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Neurology > Overview of stroke > Flashcards

Overview of stroke Flashcards

1
Q

WHO definition of a stroke is what?

A

“Clinical syndrome consisting of rapidly developing clinical signs of focal [or global in case of coma] disturbance of cerebral function lasting more than 24 hours or leading to death with no other apparent cause other than vascular origin.” WHO

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2
Q

Common Sx of carotid territory stroke

A

Weakness of face, leg, arm
Amaurosis fugax
Impaired language

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3
Q

Common Sx of posterior circulation problems

A

Dysarthria, dysphagia, diplopia, dizziness, ataxia, diplegia

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4
Q

Three main types of stroke

A

ischemic [clots], hemorrhagic [bleeds], TIA

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5
Q

Which most common, ischaemic or hemorrhagic?

A

Ischaemic in 85%, hemorrhagic in 15%

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6
Q

Causes of ischemic stroke and interruption cerebral blood supply

A

embolism, thrombosis, systemic hypoperfusion

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7
Q

Early signs of a stroke

A

Face, Arms, Speech, Time to call 999

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8
Q

Vascular supply and Circle of Willis summarise

A

slide

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9
Q

What are the cerebral vascular territories?

A

slide

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10
Q

What is the Oxford Stroke [Bamford] classification for strokes?

A

Clinical classification of patterns of neurological deficit in acute ischaemic stroke
- anterior circulation infarction [partial and total]
- posterior circulation infarction
lacurnar infarction

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11
Q

What is anterior circulation infarction?

A

Anterior and middle cerebral arteries

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12
Q

Sx of anterior circulation infarction?

A 
Contralateral weakness
Contralateral sensory loss/sensory inattnetion
Dysarthria
Dysphasia [receptive, expressive]
Homonymous hemianopia/visual inattnetion
higher cortical dysfunction
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13
Q

posterior circulation infarction

A
  • Cranial nerve palsy and a contralteral motor/sensory deficit [‘crossed signs’]
  • Conjugate eye movement disorder [e.g. horizontal gaze palsy]
  • Cerebellar dysfunnction [e.g. vertigo, nystagmus, ataxia, dysarhria]
    isolated homonymous hemianopia
  • bilateral events can cause reduced GCS
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14
Q

What is a lacunar infarction?

A

Occlusion of deep penetrating arteries
Affects small volume of subcortical white matter [therefore do not present with cortical features e.g. dysphasia, apraxia, neglect, visual field loss]
Underlying process is often referred to as small vessel disease [arterial wall, disorganisatioin, microatheroma, lipohyalinosis]

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15
Q

Give examples of Lacunar syndromes

A
  • Pure motor hemiparesis
  • Ataxic hemiparesis
  • ‘Clumsy hand’ and dysarthria
  • Pure hemisensory
  • Mixed sensorimotor
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16
Q

Go through Bamford stroke classification of each main type of stroke [TACS, PACS, LACS, POCS]

A

see slides

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17
Q

After recognition of stroke [FAST], what should be done immediately?

A

ABCDE assessment + bloods, BM
brief Hx and exam [time of onset, RFs, CI to thrombolysis], BP [permit moderate HTN], NIHSS [grade severity of the stroke]

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18
Q

What is the second stage of stroke Mx

A

urgent head CT [+/- CT angiography]

19
Q

What is the third stage of stroke Mx?

A

Thromblysis +/- mechanical thrombectomy if indicted or aspirin 300mg

20
Q

What is the final stage in stroke Mx?

A

investigate the cause [history, examination, bloods, imaging]
screen and prevent Cx [dehydration, aspiration, VTEs, pressure sores, infection, depression]
Establish secondary prevnetion [lifestyle, medical, surgical]
Rehabilitation [physio, OT, SALT]

21
Q

What is the NIHSS?

A

Grade and track the severity of stroke

Monitor response to acute Tx

22
Q

Utility of CT in acute stroke pros and cons

A

pros

  • quick
  • readily available 24/7
  • sensitive for haemorrhage
  • may see a ‘hyperdense vessel’

cons

  • cannot usually Dx an infarct in the acute phase
  • less sensitive than MRI for picking up other abnormalities [demyelination, mass lesions, microhaemorrhages] and for lacunar and posterior circulation infarcts
23
Q

What is thrombolysis?

A

breaking down acute clot

24
Q

how is thrombolysis given?

A

IV plasminogen activator e.g. altepase 0.9mg/kg
Given within 4.5hrs of Sx onset [or time they were ‘last seen well’]
Diagnostic uncertainty
Potentially life-saving

25
Q

What are the contraindications for thrombylsis?

A

slides

26
Q

post thrombolysis care

A
  • more aggressive BP - monitoring
  • vigilance for Cx [bleeding]
  • 24 hour CT head [haemorrhagic transformation]
27
Q

What is mechanical thrombectomy and when is it used?

A

Mechanical recanilsation of the culprit vessel
Proximal stenosis
6 hour time-window for anterior circulation stroke [later for basilar thrombosis]
can be used alongside IV thrombolysis
Limited resource

28
Q

What is the time window for mechanical thrombectomy?

A

6 hour time-window for anterior circulation stroke [later fo basilar thromosis]

29
Q

Describe an ischaemic penumbra

A 
Penumbra:
- blood flow: 10-17 ml/100g/min
- electrical silence
- spreading depression
- reversible damage in case of recirculation
Ischaemic core:
- blood flow permanently under <7-7.14 ml/100g/min
- irreversible membrane damage
- damaged brain tissue
30
Q

4 simple stages for the management of stroke

A
  1. investigate the cause [history, examination, bloods, imaging]
  2. Screen and prevent complications [dehydration, aspiration, VTEs, pressure sores, infection, depression]
  3. Establish secondary prevention [lifestyle, medical, surgical]
  4. Rehab [physio, OT, SALT]
31
Q

Purposes of the investigations

A
  • Diagnosis
  • R/o ‘stroke mimics’
  • identify aetiology
  • Guide RF modification
  • Prevent and treat complications
32
Q

Investigations done for a stroke

A
  • Blood tests [look up slides for more detail]: FBC, ESR, U&Es, lipid profile, LFTs, CRP, clotting screen, glucose and HbA1C
  • ECG [MI, AF] +/- 72 hour tape
  • carotid doppler USS [carotid stenosis]
  • ECG [endocarditis/thrombus]
  • MRI [confirm Dx, look for multi-territory infarcts]; delayed CT head if MRI is CI
33
Q

Clues from the MRI:

  • acute/subacute infarcts [up to 2 weeks]
  • multiple infarcts same territory
  • multi-territory infarcts
  • absent flow void in vessels
A
  • same territory ?cuplrit vessel
  • multiterritory infarcts ? cardioembolic
  • absent flow void vessels: arterial occlusion/dissection
34
Q

In the young patient/atypical stroke patient, what should you consider?

A

Bloods:

  • HIV and vasculitic screen
  • Thrombophilia screen
  • Homocysteine

Cardiac investigations

  • 7 day holter recorder/implantabel loop recorder
  • transcranial dopplers
  • transoesophageal echo

Vascular imaging

  • CT angiography
  • MR angiography
35
Q

MDT approach to treatment of a stroke

A

Nursing

  • analysing clinical status and progress; blood pressure management
  • administration of medications
  • nasogastric feeding
  • preventing pressure sores

Physio

  • strength, balancing, function
  • preventing spasticity
  • chest physiotherapy in infections and sputum clearance

Occupational therapy

  • functional assessments and future needs planning
  • cognitive and mood screening

Speech and language therapy

  • swallowing impairment and prognosis
  • communicating rehabilitation in dysphasias

Dieticians

Orthoptics

36
Q

Lifestyle management of a stroke

A 
Smoking cessation
Drug and alcohol cessation
Dietary modifications
Exercise
Driving advice
37
Q

Medical management [preventing complications]

A

VTE assessment
- intermittent pneumatic compression devices

Hydration
NG feeding +/- PEG feeding
Spasticity
- physiotherapy
- botox
Monitoring for infection
38
Q

Medical management [secondary prevention]

A

Antiplatelets
- aspirin 300mg PO/PR for 2 weeks [small ARR]; clopidogrel lifelong

Anticoagulation

  • if in AF or evidence of pAF, may need to wait up to 2 weeks
  • HASBLED and CHADSVASC scores

Hypertension

  • acute: risk of hypoperfusion
  • chronic: long term blood pressure target of< 130/80

Cholesterol
- statin therapy: aim for 40% reduction in non-HDL cholsterol

39
Q

Surgical management of stroke

A

Extra-cranial carotid stenosis

  • USS carotid dopplers +/- CTA/MRA
  • ipsilateral [symptomatic] carotid stenosis: 70-99% carotid endarterectomy [CEA] recommended, 50-69% consdier CEA
  • alternative: carotid artery stenting

Malignant MCA syndrome:
- decompressive hemicraniectomy

Posterior circulation infarct

  • risk of hydrocephalus
  • EVD/posterior fossa decompression
40
Q

55-year-old right handed man, sudden severe headache, weakness of right arm and leg, drowsy and confused.

PMHx: HTNB, AF, DM, PKA
DHx: Apixaban, Ramipril, Metformin

Dx, and then Mx?

A

Management of haemorrhagic stroke 5 aspects:

  1. ABCDE - monitoring environment, regular neuro-observations [incl. GCS and pupils]
  2. Blood pressure? [140-160 systolic acutely, <130/80 long term]
  3. Bleeding tendency? [coagulation/low platelets/medication-related]
  4. underlying malformation? [tumour aneurysm, amyloid angioapthy, AVM, cavernoma]
  5. Need for neurosurgery? [useful for superficial clots, CSF obstruction causes, hydrocephalus, posterior fossa decompression]
41
Q

What is the minimum, and what is the maximum GCS score?

A

3, 15

42
Q

What GCS should you strongly consider airway protection at?

A

At, or below 8

43
Q

Ways of reversing anticoagulation

A 
Warfarin [beriplex and vitamin K]
Heparin [Protamine]
LMWH [partially reversed with protamine]
Apixaban/Rivaroxaban/Edoxaban [Beriplex is possibly effective]
Dabigatran [Idarucizumab]
44
Q

Name disorders that stroke can mimic

A

Seizures, tumours/abscess, migraine, metabolic [e.g. hypoglycaemia, hyponatraemia], functional, spinal cord/peripheral nerve/cranial nerve

Neurology (13 decks)

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