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Neurology > Lecture 33 Cerebral Infarction (Clinical) > Flashcards

Lecture 33 Cerebral Infarction (Clinical) Flashcards

1
Q

When do majority of strokes occur

A

> 65 years

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2
Q

What fraction of stroke survivors die within 1 year

A

1/3

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3
Q

What percentage of stroke survivors are dependent on others

A

50%

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4
Q

Define Stroke

A

The sudden onset of focal or global neurological symptoms caused by ischemia or hemorrhage and lasting more than 24 hours

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5
Q

Name the 2 types of stroke and which is the most common

A

Ischaemic- most common

Haemorrhagic

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6
Q

Define TIA

A

Term used to describe symptoms of stoke that resolve within 24 hours

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7
Q

Most TIAs resolve within____

A

1-60 minutes

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8
Q

What are the causes of an ischaemic stroke

A 
Large artery atherosclerosis 
Cardioembolic
Small artery occlusion
Cryptogenic
Arterial dissection
Venous sinus thrombosis
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9
Q

What are the causes of Haemorrhagic stroke

A

Primary intracerebral (aneurysm, tumour, brain trauma) haemorrhage
SAH
Arteriovenous malformation

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10
Q

Name Modifiable risk factors of Stroke

A 
Smoking
OCP
Obesity
Lack of exercise
Lipids
Alcohol
Hypertension
Diabetes
Use of cocaine
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11
Q

Name Non-Modifiable risks of stroke

A

Previous stroke
Age
Male
Family History

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12
Q

What can be used to treat Atrial Fibrilation

A

Anti-platelets are not useful instead anti-coagulants such as Warfarin and DOACS (Apixaban, Edoxaban)

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13
Q

Describe the anterior circulation of the brain

A

• 2 x Internal carotid arteries
• 2 x Anterior Cerebral Artery (ACA)
• 2 x Middle Cerebral Artery (MCA)
•

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14
Q

Describe the posterior circulation of the brain

A
  • 2 Vertebral arteries →1 basilar
  • 3 pairs of cerebellar arteries
  • 2 Posterior cerebral arteries (PCA)
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15
Q

What are the connections found within the circulation of the brain

A
  • Circle of Willis

* Border zone Anastomoses: between peripheral branches of anterior, middle and posterior cerebral arteries

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16
Q

What vessels supplies most of the hemispheres and cortical deep white matter

A

Carotid system

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17
Q

What vessels supply the brain stem, cerebellum and occipital lbes

A

Vertebra-basilar system

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18
Q

What should the diagnosis of stroke tell you

A
  • What is the neurological deficit?
  • Where is the lesion?
  • What is the lesion?
  • Why has the lesion occurred?
  • What are the potential complications and prognosis?
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19
Q

What are the functions of the frontal lobe

A
  • High level cognitive functions ie. abstraction, concentration, reasoning
  • Memory
  • Control of voluntary eye movement
  • Motor control of speech (dominant hemisphere)
  • Motor cortex
  • Urinary continence
  • Emotion and personality
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20
Q

What are the functions of the parietal lobe

A
  • Sensory cortex
  • Sensation (identify modalities of touch, pressure, position)
  • Awareness of parts of the body
  • Spatial orientation and visuospatial information (non dominant hemisphere)
  • Ability to perform learned motor tasks (dominant)
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21
Q

What is the function of the temporal lobe

A
  • Primary auditory receptive area
  • Comprehension of speech (dominant) – Wernicke’s
  • Visual, auditory and olfactory perception
  • Important role in learning, memory and emotional affect
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22
Q

Strokes involving the ACA lead to what motor symptom

A

Leg>arm weakness

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23
Q

Strokes involving the MCA lead to what motor symptoms

A

Face and arm weakness> leg weakness

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24
Q

Small strokes in what area lead to major deficits and why

A

Internal capsule
Pyramid
Fibres are packed cloys together

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25
Q

What is the function of the cerebellum

A

Balance and coordination

26
Q

What makes up the brain stem

A

Midbrain
Pons
Medulla

27
Q

How many cranial nerves come out of the brainstem

A

10/12

28
Q

What are the major functions of the brain stem

A 
Eye movement
Breathing
Swallowing
Heart beat
Consciousness
29
Q

What is the function of the occipital lobe

A
  • Primary visual cortex
  • Visual perception
  • Involuntary smooth eye movement
30
Q

Describe the clinical presentation of stroke

A
  • Motor (clumsy or weak limb)
  • Sensory (loss of feeling)
  • Speech: Dysarthria/Dysphasia
  • Neglect / visuospatial problems
  • Vision: loss in one eye (amaurosis fugax) or hemianopia
  • Gaze palsy
  • Ataxia/ vertigo / incoordination / nystagmus
  • Dynamic phenomenon where time is brain
31
Q

What are the key things to remember about a store

A
  • The symptoms come on rapidly
  • The symptoms depend on which part of the brain is affected
  • Abnormal movements are unusual after stroke
  • Positive visual phenomena more likely to be migraine
  • Severe headache is unusual after stroke
32
Q

Name the OCP Stroke classification

A
  1. Total Anterior Circulation Stroke (TACS)
  2. Partial Anterior Circulation Stroke (PACS)
  3. Lacunar Stroke (LACS)
  4. Posterior Circulation Stroke (POCS)
33
Q

What is the criteria for TACS

A

All three:
Unilateral weakness of face, arm and leg
Homonymous hemianopia
Higher cerebral dysfunction

34
Q

What is the criteria for PACS

A

Two of the following:
Unilateral weakness (and/or sensory deficit) of the face, arm and leg
Homonymous hemianopia
Higher cerebral dysfunction

35
Q

What is the criteria for LACS

A 
One of the following:
Pure sensory stroke
pure motor stroke
Sensori-motor stroke
Ataxic hemiparesis
36
Q

What is the criteria for POCS

A

Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement -gaze palsy
Cerebellar dysfunction-ataxia, nystagmus, vertigo
Isolated homonymous hemianopia or cortical blindness

37
Q

What is the left hemisphere responsible for

A 
Sensory stimulus from right
Motor control of right
Speech, language and comprehension
Analysis and calculations
Time and sequencing
Recognition of words, letters and numbers
38
Q

What symptoms occur when there is a left hemisphere stroke

A 
Right hemiplegia
Aphasia
Speech and language
Memory problems
Slow and cautious behaviour
39
Q

What is the right hemisphere responsible for

A 
Sensory stimulus of left side of the body
Motor control of left side of body
Creativity
Special ability
Context/perception
Recognition of faces and objects
40
Q

What are the symptoms if there is a lesion in the left hemisphere

A
  • Left Hemiplegia
  • Homonymous hemianopia
  • Agnosia- inability to interpret sensations
  • Visual agnosia
  • Sensory agnosia
  • Anosognosia
  • Prosopagnosia (failure to recognise faces)
41
Q

What normally causes TACS

A

Blocked carotid artery or middle cerebral

42
Q

Basilar artery occlusion causes what in the brain

A

Ischaemia in the pons

43
Q

What signs and symptoms would you see in basilar artery occlusion

A

• Predominantly motor/oculomotor signs/symptoms
Alteration in level of consciousness common
• – may progress over 12-24hours
• May present as reduced responsiveness

44
Q

What classification of stroke has the highest mortality and which has the lowest

A

TACS- highest

LACS- lowest

45
Q

What conditions mimic strokes

A
  • Seizures
  • Syncope (hypotension)
  • Sugar (hypo or hyper)
  • Sepsis (+previous stroke)
  • Severe migraine
  • Space occupying lesions
  • Si-chological (Functional)
  • Vestibular disorders
  • Demyelination
  • Transient global amnesia
  • Mononeuropathy
46
Q

Positive symptoms of stroke

A

 excess CNS neurone electrical discharges
 visual (eg, flashing lights, zigzags, shapes, lines, objects)
 somatosensory (eg, pain, paraesthesia)
 motor (eg, jerking limb movements)

47
Q

Negative symptoms of stroke

A

 Loss or reduction of CNS neurone function
 Loss of vision
 Loss of sensation
 Loss of limb power

48
Q

What is a Migraine aura

A

• Due to cortical spreading depression (a propagating wave of depolarization of neurons and glial cells that spreads across cerebral cortex. The spreading of this wave is hypothesized to activate the trigeminal nerve afferents, causing inflammatory changes in pain-sensitive structures that create migraine headache)

49
Q

What are the features of a Migraine Aura

A
  • Classical spreading onset
  • Visual disturbances
  • scintillating scotomata
  • geometric (especially zigzag) patterns
  • positive symptoms (like a kaleidoscope, running water etc)
  • Can include sensory, motor or speech disturbance
50
Q

Define Hoover’s sign

A

Pressure is felt the paretic leg when the non-paretic leg is raised and no pressure is felt in the non-paretic leg when the paretic leg is being raised

51
Q

What causes Hoover’s Signs

A

Organic paresis

52
Q

Describe Acute Vestibular Syndrome

A
  • Common, onset can be acute
  • Can be very disabling
  • ‘True vertigo’ vs unsteadiness vs dizziness
  • Nystagmus – unidirectional, increases in intensity when patient looks in direction of fast phase
  • Vomiting
53
Q

What imagine technique can be useful for Acute vestibular Syndrome

A

MRI

54
Q

What is the time of acute ischaemic stroke therapies

A

• Restore blood supply
• Prevent extension of ischaemic damage
Protect vulnerable brain tissue

55
Q

Treatment for Stroke

A
  • IV Tissue Plasminogen Activator <3h- dissolves stroke causing clot
  • Thrombectomy <6h
  • Thrombolysis
  • Stroke units
56
Q

Name the staff members involved with a patient in a stroke unit

A 
o	Clinical staff
o	Stroke nurses
o	Physiotherapists
o	Speech and Language therapists
o	Occupational therapists
o	Dietician
o	Psychologist
o	Orthoptist
57
Q

Strict Criteria for TPA use

A
  • < 4.5 hours from symptom onset.
  • Disabling neurological deficit.
  • Symptoms present > 60 minutes.
  • Consent obtained.
58
Q

Exclusion for TPA

A 
•	Anything that increases the possibility of hemorrhage:
–	blood on CT scan
–	recent surgery
–	recent episodes of bleeding
–	coagulation problems
•	BP >185 systolic or >110 diastolic
•	Glucose <2.8 or > 22mmol/L
59
Q

What is an effective treatment for internal carotid artery stenosis

A

Carotid endarterectomy

60
Q

What investigations must be carried out while investigating stroke

A

• All/most patients
– Routine blood tests (FBC, glucose, lipids, ESR…)
– CT or MRI head scan (infarct vs. hemorrhage)
– ECG + Holter (?AF, LVH)
– Carotid doppler ultrasound (?stenosis)
• Some patients
– Echocardiogram (valves, ASD, VSD, PFO)
– Cerebral angiogram/venogram (vasculitis?)
– Hyper-coagulable blood screen

61
Q

Secondary prevention for strokes

A
  • Anti-hypertensives
  • Anti-platelets
  • Statins
  • Warfarin for AF
  • Carotid endarterectomy NNT of 3

Neurology (44 decks)

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