neuro strokes TIAs Flashcards
what is a TIA
focal sudden onset neurological deficit
lasting less than 24hrs
w complete clinical recovery
iscahemia without infarction
RFs for TIA
age HTN PAST TIA smoking diabetes clot disorder hyperlipidaemia vascuitis - GCA SLE
causes of a TIA
atherothromboembolism from carotid = most common
cardioembolism - AF, valvue disease
hyperviscosity - polycythaemia, sickle cell, myloma
hypoperfusion - cardiac dyssrhythmia, postural hypOtenision
what causes the cerebral dysfunctino in a TIA
lack of oxygen and nutrient to brain - resolves before irreversible cell death hence short lived symptoms
CFs TIA
sudden loss of fuction -few mins - complete recovery
ANT CIRCULATION - amaurosis fugax, hemiparesis
BOTH = Hemisensory loss
POST CIRCULATION - vom vertigo ataxia tetraparesis diplopia
what is the important buzzword in TIA
amaurosis fugax - curtain falling over one eye
Ix for TIA
no brain scan changes
carotid doppler and CT angiography
ECG - AF ? - cardio embolism?
Mx TIA
avoid stroke risk - dual antiplatelets, aaspriin -- clopidogrel HTN control Diabetes diet statins stop smokiong exercise LIFE STYLE MODIFICATIONS
how assess likelyhood of TIA –> stroke
ABCD2 Score = 6+ specialsist - REFFERRAL 4+ see in 24hrs rest = 7days Age>65 =1 Blood pressure>140/90 =1 clinical unilateral weakness =2 speech and no weakness =1 Diabetic =1 Duration of symptoms less than 1 hour =1 more than hour =2
DDX of a TIA
migraine with aura
Todds paralysis
hypoglycaemia
types of stroke and commonest
ischaemic (commonist)
heamorrhagic
other - vasculitis , arterial dissection)
what is a stroke
rapid onset symptoms over 24hrs
neurological deficit casued by focal cerebral spinal or retinal infarcition
cuses of a ischaemic stroke
cardiac emboli
atherosclerosis
hypoperfusion
causes of haemorrhagic stroke
trauma
anneurysm rupture
example of a aneurysm rupture leading to a stroke
charot bouchard anneurysm- basal ganglia
other causes of strokes
vasculitis (GCA)
hyperviscosity (sickle cell, polycythaemia)
large artery stenoisis
Rf of stroke
DM smoking previous TIA heart disease (AF- blood stasis) alcohol COCP polycythameia
CFs of ACA stroke
gait ataxia leg and truncal weakness and sensory loss oluntary leg movement incontinence akinetic mutaism
CFs of MCA stroke
unilat weakness and sensory loss face drop hemianopia contralat receptive and affective aphasia (ARMS ALSO)
CFs of PCA
Homonymous hemianopia with macular sparing
Prosopagnosia - facial recognition ish
CFs of POST circulation strooke
cerebellar syndrome - vertigo vom headache ataxia
“locked in” motor deficit - rest fine
brain stem stroke?
Stroke in lenicular region
which artery supplies this
Internal capsule is MCA supplied
Full contralateral hemiplegia, dysarthia, dysphagia
Dx of stroke
bloods - FBC - thrombocytopenia, polycythaemia
URGENT CT SCAN HEAD - BEFORE THROMBOLYSIS incase its haemorrhagic = death
ECG - AF?
Echo- patent formamen ovale? allow passage thrombi R to L – brain
Mx of strokes ischaemic
CT scan = ISCHAEMIC less than 4.5hrs thrombolysis - IV altepase \+clop later more than 4.5hrs Aspirin 2 weeks \+ clop lifelong later
Mx of strokes haemorrhagic
antithrombosis BBs / ARB's Beriplex if warfarin related (faster acting than vit K) surgey - clot evation REHAB OCC THERAPY etc
CI for thrombolysis w alteplase
operation in last 3 months
previous history of active malignancy
warfarin
low platelets
what does alteplase do and when used
tissue plasminogen activator - precursor to plasmin that degrades clots
used in thrombolysis in ischeamic strokes
which artery most common site for strokes
middle cerebral artery
brocas vs wernickes
brocas - cant speak can undertand - superior
wernickes - can speak cant understand = infereior
what is a extradural haemorrhage
rapid collection of blood in extradural space - between dura mater and bone
what causes an extradural haemorrhage
head injury
fracture of temporal/ parietal bone — rupture of middle meningeal artery
most commonly at pterion (side of temple thin and above middle meningeal artery)
what are symtpoms of extradural haemorrhage
LOC initially
then LUCID interval (hours or days)
then rapid increase in ICP - rapid deterioration
=altered conciousness
N+V seizures confusion coma headaches pappiloedema (ICP signs)
ipsilat pappilary dilatation
bilat weakness
feautures of raised ICP hedache
headache, worst at night and in mornings, worst when lie down or cough or exercise.
relieved by vomiting,
assosiated with papilloedma
signs of ICP
ipsilateral pappilary dilatation
brainstem compression signs - death
pappiloedema, lack of conciousness
how assess conciousness
glasgow coma scale
lower = less concious
decreases as ICP increase
Dx of extradural haemorrhage
CT scan - Egg shaped - EGGstra dural
biconvex hypodense haematoma
Xray - skull fracture?
NO LP- CONING - TENTORIAL HERNIATION
Tx- extradural haemorrhage
Stabilize - airway care
neurosurgery - craniotomy, clot evacuation
mannitol - decrease ICP and swelling
why no lumbar puncture in extra dural haemmohrhage
high ICP therefore removal of CSF decreases p and CSF move down pressure gradient causing tentorial herniation - death
what is sub dural haemorr
bleeding between dura mater and arachnoid mater - follows rupture of a bridging brain
Cfs of subdural haemorrhage
fluctuating symptoms gradual increase in ICP over weeks headache vom confusion seizures SIGN - papilloedema
why is presentation gradual in subdural haemorrage
days/weeks as heamotoma forms it increaes oncotic p so water moves IN from brain (low p in veins hence SLOW)
increases ICP - midline shift
DDx of subdural haemorrage
stroke
extradural haemorrage
dementia
subarachnoid haemorr
RFs of subdural haemmorage
elderly - brain atrophy= veins less suported
alcohol abuse
shaken baby syndrome
ACCEL DECEL injury (WHIPLASH)
Dx Subdural haemorrhage
CT - Sickle Shaped Subdural (SSS)
hyperdense
CAN cross suture lines
Mx - subdural haemmorrhage
neurosurgery - clot evac =1st craniotomy =2nd
IV mannitol = decrease ICP
What is subarachnoid haem
bleeding into subarachnoid space - increaste ICP and prevents blood INTO brain
(betwen arachnoid layer of meninges and pia mater
most common cause of Subarach haem
berry anneurysm rupture
where do berry anneruysms occur
and who predisposed
at bifurcation of arteries
marfans
bifurcation of aorta
PKD
Causes of subarachnoid haemmorrhage
1 berry anneuyrsm rupture
- arteriovenous malformation
- trauma
Rfs
HTN
fam Hx
anneurysm preisposed risk (Marfans, PKD, ehlers danlos)
presentation of subarachnoid haemmorrhage
THUNDERCLAP HEADACHE sudden onset (decreased ICP signs and sympotms) seizures decreased conciousness N + V MENINGISM - STIFF NECK = nuchal rigidity PRODROME = SENTINEL HEADACHE
signs of subarachnoid haemmorrhage
pos meningisms - KERNIGS sign (pain extending knee on thigh flex at hip)
neck stiffness
brudzinskis (flex neck = flex knees n hips)
CNS DEFICITS - 3rd Nerve palsy and pupil changes (post communic artery)
what is prodrome for subarachnoid haemmorrhage
sentinel headache
diagnosos of subarachnoid haemmorrhage
CT - white starshaped
LP - wait 12 hrs - xanthochromic CSF - yellow due to bilirubin
Tx of subarachnoid haemmorrhage
dexamethasone - for swelling
control HTN
neurosurgey (clipping or coiling)
nimodipine - decrease vasospasm risk = hydrocephalus
complication with subarachnoid haemmorrhage
hydrocephalus - vasospasm as blood vessels pooled in blood = decrease blood suply to brain = irritates meninges = scarriing and inflam = CSF obstruct = dilated ventricles
