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Year 4 - Special Senses > Neurology - Stroke > Flashcards

Neurology - Stroke Flashcards

1
Q

What is a stroke?

A

A sudden interruption in the vascular supply of the brain, resulting in irreversible damage to neural tissue.

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2
Q

Types of stroke.

A
  • ischaemic (85%)
  • haemorrhagic (15%)
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3
Q

Subtypes of ischaemic stroke.

A
  • thrombotic stroke (ie. thrombosis from large vessels)
  • embolic stroke (atrial fibrillation is risk factor)
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4
Q

Risk factors for ischaemic stroke.

A
  • age
  • hypertension
  • smoking
  • hyperlipidaemia
  • diabetes mellitus
  • atrial fibrillation
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5
Q

Subtypes of haemorrhagic stroke.

A
  • intracerebral haemorrhage (bleeding within the brain)
  • subarachnoid haemorrhage (bleeding on the surface of the brain)
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6
Q

Risk factors for haemorrhagic stroke.

A
  • age
  • hypertension
  • arteriovenous malformation
  • anticoagulation therapy
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7
Q

Stroke by anatomy.

Anterior cerebral artery infarct.

A

Contralateral hemiparesis

Sensory loss (more pronounced in lower extremities)

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8
Q

Stroke by anatomy.

Middle cerebral artery infarct.

A

Contralateral hemiparesis

Sensory loss (more pronounced in upper extremities)

Contralateral homonymous hemianopia.

Aphasia.

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9
Q

Stroke by anatomy.

Posterior cerebral artery infarct.

A

Contralateral homonymous hemianopia (macula sparing)

Visual agnosia

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10
Q

Stroke by anatomy.

Posterior inferior cerebellar artery infarct.

A

Ipsilateral:
- facial pain
- temperature loss

Contralateral:
- limb / torso pain
- temperature loss

Ataxia / nystagmus

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11
Q

Stroke by anatomy.

Anterior inferior cerebellar artery.

A

Ipsilateral:
- facial paralysis / pain
- deafness

Contralateral:
- limb / torso pain
- temperature loss

Ataxia / nystagmus

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12
Q

Stroke by anatomy.

Basilar artery infarct.

A

Locked in syndrome:

The body and most of the facial muscles are paralysed, but consciousness remains.

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13
Q

Types of stroke (Oxford Stroke Classification)

A
  • total anterior circulation infarcts (TACI)
  • partial anterior circulation infarcts (PACI)
  • posterior circulation infarcts (POCI)
  • lacunar infarcts (LACI)
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14
Q

Features of TACI.

A

MCA and ACA affected, causing all of:
- contralateral hemiparesis
- contralateral homonymous hemianopia
- dysphasia

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15
Q

Features of PACI.

A

Branches of the ACA / MCA are affected, causing two of:
- contralateral hemiparesis
- contralateral homonymous hemianopia
- dysphasia

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16
Q

Features of POCI.

A

Vertebrobasilar arteries affected, causing one of:
- cerebellar or brainstem syndromes
- loss of consciousness
- contralateral homonymous hemianopia (macular sparing)

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17
Q

What areas of the brain do the lacunar arteries supply?

A
  • internal capsule
  • thalamus
  • basal ganglia
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18
Q

Features of LACI.

A

Involves perforating arteries around the internal capsule, thalamus and basal ganglia, causing one of:
- unilateral weakness
- pure sensory stroke
- ataxic hemiparesis

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19
Q

Which symptoms of stroke are more suggestive of haemorrhagic stroke?

A
  • reduced consciousness
  • headache
  • nausea and vomiting
  • seizure
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20
Q

BEFAST mnemonic for stroke.

A

Positive predictive value of 78%.

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21
Q

Imaging for stroke.

A

Non-contrast CT head scan is the first line investigation for a suspected stroke.

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22
Q

CT findings.

Ischaemic stroke.

A
  • areas of low density
  • hyperdense artery sign
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23
Q

CT findings.

Haemorrhagic stroke.

A
  • hyperdense material (blood)
  • oedema
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24
Q

When is thrombolysis for acute ischaemic stroke indicated?

A

Thrombolysis with alteplase is given if:
- administered within 4.5 hours of onset of stroke symptoms
- haemorrhage has been excluded

25
Q

Absolute contraindications to thrombolysis of an acute ischaemic stroke.

A
  • previous intracranial haemorrhage
  • seizure at onset of stroke
  • intracranial neoplasm
  • active bleeding
  • pregnancy
  • oesophageal varices
  • malignant hypertension
26
Q

When is thrombectomy for acute ischaemic stroke indicated? (6 hours)

A

Offer thrombectomy within 6 hours of symptom onset, alongside IV thrombolysis, to people who have:
- acute ischaemic stroke
- confirmed occlusion of the proximal anterior circulation

27
Q

How can occlusion of the proximal anterior circulation be confirmed?

A

Computed tomographic angiography (CTA) or magnetic resonance angiography (MRA).

28
Q

When is thrombectomy for acute ischaemic stroke indicated? (24 hours)

A

Offer thrombectomy within 24 hours of symptom onset to people who have:
- confirmed occlusion of proximal anterior circulation
- potential to salvage brain tissue

29
Q

How is the potential to salvage brain tissue by thrombectomy decided?

A

CT perfusion scan of the head.

30
Q

When is carotid artery endarterectomy performed?

A

Recommended if a patient has suffered a stroke or TIA in the carotid territory and has performance status <3, where carotid stenosis is severe.

31
Q

Management of haemorrhagic stroke.

A

Surgical management where deemed appropriate (PS).

Supportive management.

32
Q

What is a transient ischaemic attack (TIA)?

A

A transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia, without acute infarction.

33
Q

Clinical features of TIAs.

A

Similar clinical features to a stroke, with resolution within an hour.

34
Q

What is the role of the ABCD2 score?

A

Estimates the risk of stroke after a TIA.

35
Q

Management of TIA.

A
  • 300mg aspirin immediately
  • continue aspirin until specialist review
36
Q

Imaging for TIA.

A

MRI used to determine the territory of ischaemia.

37
Q

Secondary prevention of stroke.

A
  1. Clopidogrel
  2. High intensity statin
38
Q

What is a subarachnoid haemorrhage?

A

An intracranial haemorrhage that is defined as the presence of blood within the subarachnoid space.

39
Q

Causes of subarachnoid haemorrhage.

A
  • head injury
  • intracranial berry aneurysm
  • infective aneurysm
40
Q

Presentation of subarachnoid haemorrhage.

A
  • severe, thunderclap headache (occipital)
  • nausea and vomiting
  • meningism
  • coma
  • seizure
41
Q

Why are ECG changes seen in subarachnoid haemorrhage?

A

ECG changes including ST elevation may be seen, secondary to:
- autonomic neural stimulation from hypothalamus
- elevated levels of circulating catecholamines

42
Q

Investigations of subarachnoid haemorrhage.

A
  • non-contrast CT within 6 hours
  • lumbar puncture if CT not performed within 12 hours
43
Q

Role of lumbar puncture in subarachnoid haemorrhage.

A

Perform LP 12 hours following the onset of symptoms to allow the development of xanthochromia (billirubin 2° haemolysis).

Xanthochromia helps distinguish true SAH and traumatic tap.

44
Q

Management of subarachnoid haemorrhage.

A

Supportive:
- bed rest
- analgesia
- VTE prophylaxis
- reverse anticoagulation

Refer to intervention neuroradiology for coil fitting.

45
Q

Complications of subarachnoid haemorrhage.

A
  • re-bleeding
  • hydrocephalus
  • vasospasm
  • hyponatraemia
  • seizures
46
Q

Predictive factors in subarachnoid haemorrhage.

A
  • conscious level on admission
  • age
  • amount of blood visible on CT scan
47
Q

Types of traumatic brain injury following trauma.

A
  • extradural haematoma
  • subdural haematoma
  • subarachnoid haemorrhage
  • intracerebral haematoma
48
Q

Features of extradural haematoma.

A

Rupture of middle meningeal artery results in bleeding into the space of the dura mater and the skull.

Patients often exhibit a lucid interval of a few hours.

49
Q

Features of subdural haematoma.

A

Bleeding into the outermost meningeal layer, most commonly occuring around the frontal and parietal lobes.

Slower onset of symptoms than an extradural haematoma, with fluctuating consciousness.

50
Q

Features of a intracerebral haematoma.

A

A collection of blood within the brain parenchyma causes patient to present similarly to ischaemic stroke.

51
Q

Signs of raised intracranial pressure.

A

NB: hypertension occurs as when ICP is above MAP, brain can no longer receive oxygen. This activated sympathetic nervous system to raise blood pressure.

52
Q

Pupillary findings in head injury.

Unilateral dilated pupil with sluggish light response.

A

Oculomotor nerve compression secondary to tentorial herniation.

53
Q

Pupillary findings in head injury.

Unilateral dilated pupil with cross-reactive light response.

A

Optic nerve injury

ie. constricts when light shone in contralateral eye; no response when light shone in dilated pupil.

54
Q

Pupillary findings in head injury.

Bilaterally dilated pupils with sluggish light response.

A
  • poor CNS perfusion
  • bilateral oculomotor nerve palsy
55
Q

Pupillary findings.

Bilaterally constricted pupils.

A
  • opiates
  • pontine lesions
  • metabolic encephalopathy
56
Q

Pupillary findings.

Unilateral constricted pupils with preserved light response.

A

Sympathetic pathway disruption.

57
Q

Indications of CT head within 1 hour following head injury.

A
  • GCS <13 on initial assessment
  • suspected open or depressed skull fracture
  • signs of basal skull fracture
  • post-traumatic seizure
  • focal neurological deficit
  • episodes of vomiting
58
Q

Signs of base of skull fracture.

A
59
Q

Indications of CT head within 8 hours following head injury.

A
  • age >65 years
  • anticoagulant use
  • history of bleeding / clotting disorders
  • dangerous mechanism of injury
  • > 30 minutes retrograde amnesia of events before the head injury

Year 4 - Special Senses (17 decks)

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