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Neurology: Stroke + TIA Flashcards

1
Q

What are the clinical features of a transient ischaemic attack (TIA)?

A

1) Sudden onset focal neurological deficit of vascular aetiology
2) Symptoms last < 1 hour
3) No evidence of acute infarct on imaging

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2
Q

What are risk factors for TIA?

A

1) Diabetes
2) Hypercholesterolaemia
3) Hypertension
4) Smoking
5) FH of cardiovascular disease/stroke
6) AF - risk for cardioembolic TIAs

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3
Q

How do patients present with a TIA?

A

1) Focal neurological deficit e.g. speech difficulty, arm/leg weakness or sensory changes
2) TIA is transient and most symptoms resolve within 1 hour
3) Absence of positive symptoms suggestive of differentials e.g. shaking preceding weakness suggesting focal motor seizure
4) Absence of headache - would suggest a differential e.g. migraine or intracranial bleeding

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4
Q

What are differentials for TIA?

A

Focal motor seizure, migraine, intracranial bleed

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5
Q

What would suggest a focal motor seizure over a TIA?

A

Shaking preceding weakness

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6
Q

What would suggest a migraine or intracranial bleed over a TIA?

A

Presence of headache

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7
Q

How do you manage a patient presenting with a TIA or recent history of TIA?

A

1) Refer patients who have had a suspected TIA immediately for assessment, to be seen within 24h of onset of symptoms

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8
Q

What is a TIA called when it affects the eye?

A

Amaurosis fugax

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9
Q

What are the clinical features of amaurosis fugax (TIA affecting the eye)?

A

1) Sudden painless monocular visual loss which suddenly resolves < 1 hour (then all findings are normal)
2) May be preceded by sudden blurring of vision
3) Normal examination findings once resolved
4) Vascular risk factors present

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10
Q

What is a stroke?

A

Sudden onset focal neurological deficit of vascular aetiology, with symptoms lasting > 24h or with evidence of infarction on imaging

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11
Q

What % of strokes are ischaemic?

A

85% (15% haemorrhagic)

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12
Q

What causes ischaemic stroke?

A

When blood supply in a cerebral vascular territory is reduced secondary to stenosis or complete occlusion of a cerebral artery

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13
Q

What is the ischaemic penumbra?

A

The cerebral area surrounding the ischaemic event where there is ischaemia without necrosis - this area is amenable to recovery with thrombolysis

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14
Q

What are the main causes of ischaemic stroke?

A

1) Intracranial small vessel atherosclerosis (25%)
2) Large vessel atherosclerosis (50%) e.g. carotid artery stenosis
3) Cardio-embolic e.g. in AF (20%)

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15
Q

How does large vessel atherosclerosis e.g. carotid artery stenosis typically cause ischaemic stroke?

A

Thrombus formation on the atherosclerotic plaque and subsequent embolism of the thrombus to a smaller cerebral artery

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16
Q

How do cardio-embolic ischaemic strokes occur?

A

In AF there is stasis of blood flow in the left atrium, predisposing to thrombus formation in the left atrium and subsequent embolisation to the brain

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17
Q

What are rare causes of ischaemic stroke?

A

1) Primary vascular causes e.g. vasculitis, arterial dissection
2) Haematological causes - prothrombotic states

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18
Q

What are strong risk factors for ischaemic stroke?

A

1) Age
2) Male sex
3) FH of ischaemic stroke
4) Hypertension
5) Smoking
6) Diabetes
7) AF

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19
Q

What are weaker risk factors for ischaemic stroke?

A

1) Hypercholesterolaemia
2) Obesity
3) Poor diet
4) Oestrogen-containing therapy
5) Migraine

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20
Q

What causes haemorrhagic stroke?

A

Rupture of a cerebrospinal artery

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21
Q

What classification is used to classify stroke?

A

Bamford/Oxford classification

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22
Q

What are the clinical features of a total anterior circulation infarct (TACI)?

A

Three features need to be present to be classified as a TACI:
1) Contralateral hemiplegia or hemiparesis
2) Contralateral homonymous hemianopia
3) Higher cerebral dysfunction e.g. aphasia, neglect

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23
Q

Which arteries does a total anterior circulation infarct (TACI) involve?

A

Anterior and middle cerebral arteries on the affected side

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24
Q

What are the clinical features of a partial anterior circulation infarct (PACI)?

A

Two of:
1) Contralateral hemiplegia or hemiparesis
2) Contralateral homonymous hemianopia
3) Higher cerebral dysfunction e.g. aphasia, neglect
OR
Higher cerebral dysfunction alone

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25
Which arteries does a partial anterior circulation infarct (PACI) involve?
The anterior OR middle cerebral artery on the affected side
26
What kind of strokes can be classified as a lacunar infarct (LACI)?
1) Pure motor stroke 2) Pure sensory stroke 3) Sensorimotor stroke 4) Ataxic hemiparesis 5) Dysarthria-clumsy hand syndrome
27
Which arteries does a lacunar infarct (LACI) affect?
Small deep perforating arteries, typically suppling the internal capsule or thalamus
28
Any of which clinical features define a posterior circulation infarct (POCI)?
1) Cerebellar dysfunction 2) Conjugate eye movement disorder 3) Bilateral motor/sensory deficit 4) Ipsilateral cranial nervy palsy with contralateral motor/sensory deficit 5) Cortical blindness/isolated hemianopia
29
Which arteries does a posterior circulation infarct (POCI) involve?
Vertebrobasilar arteries and associated branches supplying the cerebellum, brainstem and occipital lobe
30
What are four different types of posterior stroke syndromes?
1) Basilar artery occlusion 2) Lateral pontine syndrome (anterior inferior cerebellar artery occlusion) 3) Wallenberg's/lateral medullary syndrome (posterior inferior cerebellar artery (PICA) infarction) 4) Weber's/medial midbrain syndrome
31
How can basilar artery occlusion (posterior stroke syndrome) present?
1) Locked in syndrome - quadriparesis with preserved consciousness and ocular movements 2) Loss of consciousness 3) Sudden death
32
What are the clinical features of lateral pontine syndrome (posterior stroke syndrome caused by anterior inferior cerebellar artery occlusion)?
1) Similar features to Wallenberg's/lateral medullary syndrome: - Ipsilateral Horner's syndrome - Ipsilateral loss of pain and temperature sensation on the face - Contralateral loss of pain and temperature sensation over the contralateral body 2) Additional involvement of pontine cranial nerve nuclei (cranial nerves V-VIII)
33
What are the clinical features of Wallenberg's/lateral medullary syndrome (posterior stroke syndrome)?
DANVAH (dysphagia, ataxia, nystagmus, vertigo, anaesthesia, Horner's) 1) Ipsilateral Horner's syndrome 2) Ipsilateral loss of pain and temperature sensation on the face and facial numbness 3) Contralateral loss of pain and temperature sensation over the contralateral body 4) Dysphagia - choking on food 5) Ipsilateral ataxia - losing balance 6) Ipsilateral nystagmus 7) Vertigo - dizziness
34
What are the clinical features of Weber's/medial midbrain syndrome (posterior stroke syndrome)?
1) Ipsilateral oculomotor nerve palsy 2) Contralateral hemiparesis
35
Which artery is occluded in lateral pontine syndrome?
Anterior inferior cerebellar artery
36
Which arteries are occluded in Weber's/medial midbrain syndrome?
Paramedian branches of the upper basilar artery and proximal posterior cerebral arteries
37
What specific part of ABCDE management are you concerned about in ischaemic stroke and why?
A - airway protection (in patients presenting with depressed consciousness) and aspiration precautions (in patients presenting with swallowing impairment) is v important
38
What is the first investigation when someone presents with stroke symptoms?
CT head - to differentiate between ischaemic and haemorrhagic stroke
39
Which is the most sensitive test for confirming ischaemic infarct?
Diffusion weighted MRI - used if diagnosis is unclear but not normally possible in emergency setting
40
What is the are the first line and second line treatments for ischaemic stroke (hyperacute management)?
1) Thrombolysis with alteplase (tissue plasminogen activator) 2) Mechanical thrombectomy
41
When can thrombolysis be given to treat ischaemic stroke?
Patients presenting within 4.5 hours of symptom onset + no contraindications to thrombolysis
42
What are contraindications to thrombolysis?
1) Recent head trauma 2) GI or intracranial haemorrhage 3) Recent surgery 4) Severe uncontrolled hypertension 5) Unacceptable platelet count or INR 6) Massive stroke - due to high risk of haemorrhagic transformation
43
When is mechanical thrombectomy indicated for ischaemic stroke management?
1) Patients with anterior circulation strokes presenting within 6 hours of symptom onset + good baseline functional status + lack of significant early infarction on initial CT scan 2) Patients with posterior circulation strokes presenting up to 12 hours after symptom onset
44
How should patients be managed who are NOT offered hyper-acute treatments?
Aspirin 300mg orally once daily for two weeks
45
How should patients be managed who are offered hyper-acute treatments?
1) Repeat CT head 24h later to exclude any new haemorrhagic stroke 2) 24h after treatment (bc of bleeding risk) - start aspirin 300mg orally once daily for two weeks
46
What is the aim of stroke investigations in the post-acute phase?
1) To further define the cause of the stroke 2) To quantify vascular risk factors
47
What further investigations can be done to determine the cause of ischaemic stroke?
1) Carotid ultrasound - to identify critical carotid artery stenosis 2) CT/MR angiography - to identify intracranial and extracranial stenosis 3) Echocardiogram - if cardioembolic source is supected 4) In young patients further investigation e.g. a vasculitis screen or thrombophilia screen may be necessary
48
What further investigation can be done to determine the cause of haemorrhagic stroke?
Serum toxicology screen - sympathomimetic drugs e.g. cocaine are a strong risk factor for haemorrhagic stroke
49
What further investigations can be done to quantify vascular risk factors for stroke?
1) Serum glucose - all patients with stroke should be screened for diabetes with a fasting plasma glucose or OGTT 2) Serum lipids - to check for raised total cholesterol/LDL cholesterol
50
What mnemonic can be used to remember the key steps in secondary stroke prevention?
HALTSS
51
What are the components of chronic stroke management/secondary stroke prevention?
1) Hypertension - anti-hypertensives initiated 2 weeks post-stroke 2) Antiplatelet therapy 3) Lipid-lowering therapy 4) Tobacco - offer smoking cessation support 5) Sugar - patients should be screened for diabetes and managed appropriately 6) Surgery - patients with ipsilateral carotid artery stenosis > 50% should be referred for carotid endarterectomy
52
How is hypertension managed acutely in stroke and why?
No benefit in lowering BP acutely as this may impair cerebral perfusion unless there is malignant hypertension (systolic > 180)
53
What is malignant hypertension?
Systolic BP > 180 mmHg
54
When should anti-hypertensive therapy be initiated post stroke?
2 weeks post-stroke
55
What are the antiplatelet therapy options post-stroke?
1) Clopidogrel 75mg one daily for long term antiplatelet therapy (or aspirin?) 2) In patients with ischaemic stroke secondary to AF warfarin (target INR 2-3) or a DOAC e.g. rivaroxaban or apixaban) is initiated 2 weeks post-stroke
56
How is lipid-lowering therapy provided post stroke?
High dose atorvastatin 20-80mg once nightly (irrespective of cholesterol level this lowers the risk of repeat stroke)
57
When are patients referred for carotid endarterectomy post stroke?
Ipsilateral carotid artery stenosis > 50% (and worth it taking into account prognosis)
58
What are the features of rehabilitation and supportive management post stroke?
MDT approach - involvement of physiotherapy, occupational therapy, SALT and neurorehabilitation
59
When should a decompressive hemicraniectomy be considered as an intervention for stroke?
1) Patient < 60 years old 2) Severe stroke symptoms 3) Reduced consciousness 4) CT-defined infarct of at least 50% of the middle cerebral artery territory (± midline shift) Increases survival rate following stroke but may not improve their disability caused by the stroke 5) Presenting < 48h
60
Why is thrombolysis contraindicated in a massive stroke?
High risk of haemorrhagic transformation
61
What are features of an unsafe swallow?
Any of the following symptoms upon drinking water in an upright position: 1) Drooling 2) Dysphonia or a 'wet' voice 3) > 2 seconds to initiate swallow 4) Coughing during or within 1 minute of swallowing
62
How would you acutely manage a patient with an unsafe swallow?
1) Ensure patients is completely NBM with IV fluids 2) Urgently call SALT team to assess the patient's swallow 3) Switch medications to NG if possible
63
After which type of stroke is an unsafe swallow common?
Partial anterior circulation stroke (PACI)
64
How would a left midbrain lesion present?
Lesions of the left oculomotor nerve and right trochlear nerve
65
How would a left pons lesion present?
Failures of the left V, VI, VII and VIII cranial nerves
66
How would lesions of the medulla present?
Cranial nerve IX, X, XI and XII palsies
67
How would lesions of the right midbrain present?
Lesions of the right oculomotor and left trochlear nerve
67
How would lesions of the right midbrain present?
Lesions of the right oculomotor and left trochlear nerve
68
How would lesions of the right pons present?
1) Sudden complete left sided paralysis, double vision - corticospinal fibres travel through the pons and decussate later in the medulla, hence hemiparesis would be contralateral to the site of the lesion 2) Lesions of the right abducens nerve which comes out of the pons - unable to abduct right eye 3) Absent corneal reflex in right eye - utilises CN V (afferent) and VII (efferent) in the reflex, further implicating the pons
69
Cranial nerve lesions are ipsilateral except which cranial nerve?
Trochlear
70
What medication should be given for suspected TIA immediately unless contraindicated?
Aspirin 300mg (if already taking low dose aspirin 75mg this would be continued rather than giving higher dose)
71
How should patients presenting with suspected TIA be managed?
Aspirin + referral for specialist assessed required ASAP within 24h
72
Which long term antiplatelet is used following a TIA?
Clopidogrel 75mg

Stage 3 (61 decks)

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