Ischemic/Hemorrhagic stroke, TIA, Bells Palsy, Ramsay Hunt Flashcards
Stroke
-subtypes
Sudden interruption of blood supply in brain
Ischemic (85%)
-thrombosis of large vessels (carotid)
-embolic from clot/fat/air/septic
Haemorrhagic (15%)
-intracerebral
-subarachnoid
Risk factors for stroke and TIA
-ischemic
-hemorrhagic
General
-HTN
-age
-hypercoagulability - APS, migraine with aura, postpartum, sickle cell
Ischemic
-smoking
-hyperlipidemia, carotid artery disease
-DM
-AF, infective endocarditis
Hemorrhagic
-AVM
-ADOKD
-AC
Symptoms of stroke
ACUTE SUDDEN FOCAL NEURO LOSS
-unilateral weakness/paraesthesia in face, arm, leg
-dysarthria, expressive/receptive dysphasia
-vision problems
-headache (sudden, severe, unusual)
-ataxia
-vertigo/loss of balance
Symptoms of stroke mimics
Neuro symptoms that are gradual in onset, progressive, migratory
-POSITIVE neurological symptoms (flashing lights, tingling, jerking, shaking limbs)
-cognitive impairment
-resp, abdominal or other abnormal signs
Stroke and TIA mimics
Migraine with aura - positive marching in minutes
Epilepsy - focal, acute, positive sensorimotor spread in minutes.
Stereotypic attacks
TGA - short term acute anteroretrograde amnesia, resolves in hours
Bells palsy
Facial palsy
Facial palsy/Bells palsy
-presentation
-how does this differ from a stroke
Weakness/paralysis of facial muscles
Forehead sparing in UMN/stroke
Forehead not spared in facial palsy
Bells palsy
-presentation
-investigations
-management
Idiopathic, but related to recent viral infections/stress
Painless unilateral LMN facial weakness, in hours
-cannot close eyes or cry
-increased sensitivity to sound
-metallic taste
Clinical diagnosis
-serology to rule out RHS
Supportive eye care - eye pathc, lubricating drops
Medical - PO steroids within 72hrs + antivirals
Surgical if no change or not Bells
If no change within 3wks => urgent neuro referral
Ramsay Hunt Syndrome
-pathophysiology
-presentation
-investigations
-management
Reactivitation of HZV
Ear pain => facial palsy, ipsilateral vertigo, increased sensitivity to sound, blisters on VII region
Clinical diagnosis
Medical - PO pred (5 days) + aciclovir (7 days)
Stroke patterns - Anterior cerebral artery
CL M+S loss
L limbs > U limbs
Stroke patterns - Middle cerebral artery
CL M+S loss
U limb > L limbs
CL HH
Aphasia if dominant hemisphere affected
Spatial neglect if non dominant hemisphere affected
Stroke patterns - Posterior cerebral artery
CL HH with macular sparing
Visual agnosia
Stroke patterns - Branches of PCA that supply midbrain
Weber’s syndrome
IL CN3 palsy
CL UL, LL weakness
Stroke patterns - Posterior inferior cerebellar artery
Lateral medullary syndrome
Wallenburg syndrome
Spinothalamic - temp/pain loss
IL facial
CL limb/torso
Ataxia, nystagmus
Stroke patterns - Anterior inferior cerebellar artery
Lateral pontine syndrome
Spinothalamic - temp/pain loss
IL facial
CL limb/torso
IL FACIAL PARALYSIS and DEAFNESS
Stroke patterns - retinal artery
Amaurosis fugax
Stroke patterns - basilar artery
Locked in syndrome
Difference between TIA and stroke
TIA - brief neurological deficit due to focal brain, spinal cord, retinal ischemia without acute infarction
Stroke - acute infarction of focal, brain, spinal cord, retinal ischemia => neurological deficit
Management of suspected ischemic stroke
-secondary management
Carotid endarterectomy if
-stroke/TIA in carotid region and not severely disabled
-stenosis 50 or 70%+ depending on criteria used
Presentation of hemorrhagic strokes (SAH)
Thunderclap occipital headache
-peak severe pain almost instantly
-may be history of less severe headaches leading up to presentation
N+V
Meningism - photophobia, neck stiffness
Seizures
May have ST elevation on ECG
-from autonomic neural stimulation from hypothalamus/elevated levels of circulating catecholamines
TIA
-what is it
Transient neurological deficit caused by focal cerebral ischemia without CT evidence of infarction
Symptoms last U24hrs, bit similar to stroke
Bamford and Oxford classification of strokes
POCS
Posterior circulation infarct - cerebellum and brainstem
-homonymous hemianopia
-dizzy
-drowsy
-dysarthria
-diplopia
-dysphagia
Bamford and Oxford classification of strokes
TACS vs PACS
Total anterior circulation infarct - ACA + MCA
INVOLVEMENT OF WEAKNESS/SENSORY LOSS + VISION + SPEECH
All 3 of
-unilateral weakness/sensory deficit of face, arm, leg
-homonymous hemianopia
-higher cerebral dysfunction (aphasia or spatial neglect)
PACS - smaller arteries of anterior circulation involved
2 of the 3 criteria from above
Bamford and Oxford classification of strokes
Lacunar
Lacunar infarct - no loss of higher cerebral function
1 of
-pure sensory
-pure motor
-sensorimotor
-ataxic hemiparesis
Stroke differentials
-acute
-chronic
Acute
-seizure
-migraine + aura
-peripheral neuropathy - Bells
-trauma
-hypoglycemia, hypoxia
-syncope
-meningitis, encephalitis, vasculitis
-delirium
-drug, alcohol, Wernicke’s
Chronic
-tumour
-subdural
-asbcess
Initial investigations for suspected stroke or TIA
History
Clinical examination
-neuro
-cardiovascular
-RULE OUT HYPOXIA AND HYPOGLYCEMIA
Quick screening tools
-FAST
-ROSIER
Suspect stroke if
-sudden onset focal neurological deficit, ongoing/persisted for longer than 24hrs
Suspect TIA if
-sudden onset neurological deficit has resolved within 24hrs
Blood glucose
ECG - AF?
CT HEAD TO ASSESS FOR HEMORRHAGE
Managament of ischemic stroke
-immediate
-secondary prevention
A-E stabilisation
ASPIRIN 300mg for 2 weeks
Non contrast CT head
-may not see anything
-may have hypodense tissue + (hyperdense artery sign from clot)
U4.5hrs since onset - alteplase thrombolysis
U6hrs since onset - mechanical thrombectomy for proximal anterior circulation
-can use with thrombolysis if applicable
6-24hrs => thrombectomy if there is potential to salvage brain tissue
-Yes = proximal anterior circ
-Maybe = proximal posterior circ
2 week follow up
1st line - long term clopidogrel 75mg + PPI
2nd line - aspirin 75mg + MR dipyridamole 200mg BD
3rd line - aspirin 75mg OD
4th line - MR dipyridamole 200mg BD
Lifestyle changes
-smoking cessation
-reduce alcohol
-increase physical activity
-diet modification
Management of hemorrhagic stroke
STOP AC, AP
Rapid reduction in high BP => target 130-140 within 1 hour of treatment, maintain for 7 days
UNLESS
-underlying structural cause - tumour, AVM, aneurysm
-GCS U6
-early neurosurgery to evacuate hematoma
-massive hematoma with poor prognosis
Surgery
SAH - coil, craniectomy and clipping
ICH - craniotomy/craniectomy with evacuation of hematoma
Hydrocephalus - temporary ext ventricular drain or long term ventriculoperitoneal shunt
LowNa from SIADH
Seizures
Investigations and management
-subarachnoid hemorrhages
Non contrast CT head immediately to assess for ischemic or haemorrhagic
If U6hrs + normal => alt diagnosis
If 6hrs+ + normal => LP at least 12hrs from onset
-xanthochromia = identify true SAH from traumatic tap
-normal/high opening pressure
Evidence of hemorrhagic stroke
-hyperdense blood surrounded by hypodense edema
=> NEUROSURGERY REFERRAL and CT intracranial angio to identify cause
Fluid resuscitation
PO nimodipine => prevent vasospasm
Reduce BP!
Management of TIA
-initial
-ongoing
Referrals
-Current => emergency admission, imaging to exclude hemorrhagic
-Multiple TIAs => discuss admission with stroke specialist
-Within week => assessment within 24hrs
-More than 1 week => assessment within the week
Immediate
300mg aspirin unless
-has bleeding disorder or on AC/AP => immediate admission for imaging to exclude haemorrhage
-can’t take aspirin
-TIA caused by AF => take DOAC/warfarin
Imaging - MRI
-determine ischemic area/hemorrhage
Aspirin for 2 weeks => clopidogrel 75mg
Statin 40mg
Lifestyle modification
Do not drive until driving advice given by specialist team
Carotid doppler - if candidate for carotid endarterectomy (stenosis 70%+)
If U55
-thrombophilia and AI screening (ANA, APL. ACL, LA)
-coagulation factors
-ESR
-homocysteine
-syphilis
