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Neurology: Clinical - Stroke Flashcards

1
Q

What is ischaemia?

A

Lack of blood flow

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2
Q

What is hypoxia?

A

Lack of oxygen

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3
Q

What is the WHO definition of a stroke?

A

Focal neurological deficit due to disruption of blood supply

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4
Q

What is the overall cause of stroke?

A

Interruption of supply of oxygen and nutrients, causing damage to brain tissue

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5
Q

What is the interruption of oxygen caused by changes in?

A 
Vessel wall
Blood flow (including BP)
Blood constituents
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6
Q

What could be a change in a vessel wall that would cause a stroke?

A

Atheroma or vasculitis

Outside pressure e.g. strangulation, spinal cord compression or compression of veins

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7
Q

What could be a change in blood flow or pressure that would cause a stroke?

A

Decreased blood flow, increased blood pressure due to bursting of vessels

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8
Q

What could be a change in blood constituents that would cause a stroke?

A

Thrombosis of arteries (rarely veins)

Bleeding due to anticoagulation, reduced platelets and clotting factors

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9
Q

What are the 3 main causes of localised interrupted blood supply?

A

Atheroma and thrombosis
Thromboembolism
Ruptured aneurysm

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10
Q

What does atheroma and thrombosis ultimately cause?

A

Ischaemia

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11
Q

If there was internal carotid artery thrombosis where would you typically get ischaemia?

A

Middle cerebral artery territory

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12
Q

What kind of symptoms do you get with reversible ischaemia and how long do they last?

A

Transient symptoms

<24hrs

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13
Q

What kind of symptoms do you get with irreversible ischaemia and how long do they last?

A

Infarct (longstanding symptoms)

>24hrs

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14
Q

What happens to neurons if infarction?

A

Damage to neurons is permanent (cannot regenerate)

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15
Q

What does a regional cerebral infarct typically look like on a brain?

A 
Wedge shaped (arterial territory)
Yellow colouration
Tissue disintegration
Congested vessels
Swelling of surrounding brain tissue
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16
Q

What does an infarcted area of brain look like histologically?

A

Loss of neurons

Foamy macrophages - repair process leading to gliosis

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17
Q

What is gliosis?

A

CNS equivalent of fibrosis

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18
Q

What does thromboembolism lead to?

A

Ischaemia

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19
Q

How can aneurysms form in the cerebral arteries?

A

Weakening of the wall + hypertension

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20
Q

What does a ruptured cerebral artery cause?

A

Haemorrhage and distal ischaemia as there is decreased blood glow distally

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21
Q

Where are the 2 most common sites of ruptured vessels causing haemorrhagic stroke?

A

Basal ganglia - microaneurysms

Circle of Willis - berry aneurysms

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22
Q

What causes generalised interrupted blood supply or hypoxia in the brain?

A
  1. Low O2 in blood (hypoxia)
  2. Inadequate supply of blood
  3. Rare - inability to use O2 (cyanide)
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23
Q

When are example of low O2 in the blood causing generalised interrupted blood supply or hypoxia?

A

CO2 poisoning
Near drowning
Respiratory arrest

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24
Q

When are example of inadequate supply of blood causing generalised interrupted blood supply or hypoxia?

A

Cardiac arrest
Hypotension
Brain swelling (trauma)

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25
What are Watershed infarcts?
Zones of infarction at interface of artery perfusion territories
26
What does pure hypotension with oxygenated blood lead to?
Watershed infarcts
27
How does a cardiac arrest leading to interrupted blood supply and/or hypoxia?
No circulation to brain and no oxygen in brain
28
75yr old woman with known coronary artery disease. Suffers bout of pneumonia. Then suffers cardiac arrest and dies. What types of infarct would this patient have and due to what?
Watershed infarcts = hypotension Laminar cortical necrosis (infarction) = cardiac arrest causes no circulation and no oxygen Regional infarcts = related to poor flow through cerebral vessels narrowed by atheroma
29
What time of infarction does cardiac arrest cause?
Cortical infarction
30
What is more common: ischaemic or haemorrhagic stroke?
Ischaemic
31
What is the ischaemic penumbra?
The area surrounding an ischaemic event
32
What is the most important modifiable risk factor for stroke?
Hypertension
33
What is stroke risk related to?
Blood pressure level
34
A blockage of the ACA would result in a stroke of which part of the brain?
Medial part of whichever hemisphere is affected
35
What are the symptoms of ACA occlusion?
Contralateral: | Paralysis of foot and leg, sensory loss over foot and leg and impairment of gait and stance
36
What are the symptoms of MCA occlusion?
``` Contralateral: Paralysis of face/arm/leg Sensory loss face/arm/leg Homonymous hemianopia Gaze paralysis to the opposite side Aphasia if stroke on dominant (left) side ```
37
Sum up the main 3 features of an MCA occlusion
Hemiplagia Homonoymous hemianopia Dysphagia
38
Which part of the brain is responsible for recognising fans and where is it?
Fusiform gyrus | Broadman area 37 - occipitotemporal
39
What is prosopagnosia?
Failure to recognise faces
40
What is there is an occlusion in the right hemisphere, what could be some of the symptoms?
Left hemiplegia Homonymous hemianopia Agnosia: visual, sensory etc.
41
Which types of stroke cause damage to the basal ganglia?
Lacunar strokes
42
What are the signs of a lacunar stroke?
``` Pure motor stroke Pure sensory stroke Dysarthria - clumsy hand syndrome Ataxic hemiparesis (NO cortical signs) ```
43
What signs are lacking in a lacunar stroke?
Cortical signs
44
What structures are affected in a posterior circulation occlusion?
Brain stem, cerebellum, thalamus, occipital and medial temporal lobes
45
What are symptoms of brainstem dysfunction?
Coma, vertigo, nausea, vomiting, cranial nerve palsies, ataxia Hemiparesis, hemisensory loss Crossed sensori-motor deficits Visual field deficits
46
What should acute ischaemic stroke therapies aim to do?
Restore blood supply Prevent extension of ischaemic damage Protect vulnerable brain tissue
47
What are the treatments for stroke?
Thrombectomy IV TPA (Tissue plasminogen activator) Aspirin Stroke unit care
48
What are the different classifications of stroke (Bamford classification)?
Total anterior circulation stroke (TACS) Partial anterior circulation stroke (PACS) Lacunar stroke (LACS) Posterior circulation stroke (POCS)
49
What is the name of the system of classifying strokes?
Bamford Stroke Classification
50
Which is the worst type of stroke in the Bamford classification?
TACS
51
What do you need to be classified as having a TACS (Bamford classification)?
All 3 of the following: Unilateral weakness (and/or sensory deficit) of the face, arm and leg Homonymous hemianopia Higher cerebral dysfunction (e.g. dysphasia, visuospatial disorder)
52
What do you need to be classified as having a PACS (Bamford classification)?
Any 2 of the following: Unilateral weakness (and/or sensory deficit) of the face, arm and leg Homonymous hemianopia Higher cerebral dysfunction (e.g. dysphasia, visuospatial disorder)
53
What do you need to be classified as having a LACS (Bamford classification)?
``` One of the following: Pure motor stroke Pure sensory stroke Sensori-motor stroke Ataxic hemiparesis ```
54
What do you need to be classified as having a POCS (Bamford classification)?
One of the following: Cranial nerve palsy and a contralateral motor/sensory deficit Bilateral motor/sensory deficit Conjugate eye movement disorder (e.g. gaze palsy) Cerebellar disorder (e.g. ataxia, nystagmus, vertigo) Isolated homonymous hemianopia or cortical blindness
55
How soon do you have to administer TPA as treatment for stroke?
<4.5hours from symptom onset
56
What is the criteria for TPA use?
<4.5hours from symptom onset Disabling neurological deficit Symptoms present >60 mins Consent obtained
57
What is the exclusion criteria for IV TPA?
Anything that increases risk of haemorrhage
58
What is effective treatment in symptomatic internal carotid artery stenosis?
Carotid endarterectomy
59
What are the main causes of an ischaemic stroke?
``` Large artery atherosclerosis Cardioembolic (AF) Small artery occlusion Undetermined Rare care - arterial dissection/venous sinus thrombosis ```
60
What are the investigations for stroke?
``` Blood tests - FBC, glucose, lipids, ESR CT/MRI head scan ECG - ?AF, LVH Echocardiogram - (valves, congenital) Carotid doppler ultrasound - ?stenosis Cerebral angiogram/venogram - ?vasculitis Hyper-coagulable blood screen ```
61
What is secondary prevention treatment for stroke?
``` Anti-hypertensives Anti-platelets Lipid lowering agents Warfarin (AF) Carotid endarterectomy ```

Neurology (9 decks)

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