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Neurology > Presentation and Management of Stroke > Flashcards

Presentation and Management of Stroke Flashcards

1
Q

Identify all the branches of the circle of willis.

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2
Q

Identify the branches of the circle of willis on the base of the brain.

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3
Q

Identify these veins.

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4
Q

Describe the venous drainage of the brain.

A
  • Superficial veins:
    • lie within the subarachnoid space.
  • Superior cerebral veins - drain the lateral surface of the cerebral hemispheres and empty into the superior sagittal sinus.
  • Superficial middle cerebral vein - runs along the line of the lateral fissure and empties into the cavernous sinus.
  • Superior (great) anastomotic vein - drains into the superior sagittal sinus.
  • Inferior anastomotic vein - drains into the transverse sinus.
  • Note - the circular sinus is a venous circle around the hypophysis.
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5
Q

What is the definition of stroke?

What is the difference between this and TIA?

A
  • Stroke
    • Interruption of the blood supply to a focal part of the brain causing loss of neurological function.
    • Symptoms last >24 hours or lead to death with no apparent cause other than that of vascular origin.
  • Transient ischaemic attack (TIA)
    • ​Same cause
    • Symptoms last <24 hours (this is the difference)
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6
Q

What is a haemorrhagic stroke?

A
  • Hemorrhagic strokes have many causes, including hypertension, trauma, tumour, bleeding disorder, vascular malformation, amyloid angiopathy and aneurysms (weakness in the wall of a blood vessel).
  • There are two types of hemorrhagic stroke:
    • Subarachnoid
    • Intracerebral
  • Blood spilling into the surrounding brain tissue damages brain cells, while those brain regions beyond the rupture have lost their blood supply and are also damaged.
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7
Q

What is the pathology of brain haemorrhage?

A
  • Primary brain damage:
    • Site
    • Cause
  • Secondary brain damage:
    • Surrounding oedema
    • Vascular disease
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8
Q

What is an ischaemic stroke?

A
  • The majority of strokes (about 80%) are ischemic, resulting from either:
  • A blood clot forming in an artery supplying the brain – a thrombotic stroke.
  • A clot formed in another area of the body that has traveled through the circulation and become lodged in a brain artery – an embolic stroke.
  • The causes of ischaemic stroke include cardioembolism, large vessel atherothrombosis, small vessel disease, hypoperfusion, small vessel disease, carotid / vertebral dissection, watershed areas.
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9
Q

Describe the progression of ischaemic stroke.

A
  • Penumbra - some ischaemia but not actual tissue death. If you act quickly you can prevent tissue death.
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10
Q

Quantify the timeline of neural circuitry loss during acute ischaemic stroke.

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11
Q

Describe the locations of the ‘watershed’ areas.

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12
Q

Describe cerebral autoregulation.

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13
Q

Describe the anterior circulation of the brain.

A
  • Internal carotids
  • Supply:
    • Anterior 3/5 of the cerebrum
    • Diencephalon
  • Main branches:
    • Middle cerebral artery (MCA)
    • Anterior cerebral artery (ACA)
    • Striate arteries
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14
Q

Describe the posterior circulation of the brain.

A
  • Vertebrobasilar arteries
  • Supply:
    • Posterior 2/5 of the cerebrum
    • Diencephalon
    • Cerebellum
    • Brainstem
  • Main branches:
    • Posterior cerebral arteries
    • Striate and thalamus
    • Pontine
    • Cerebellar
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15
Q

If a patient presents with these symptoms, what should you remember to do?

A

REMEMBER TO CHECK THE GLUCOSE.

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16
Q

If a patient presents with these symptoms, what should you want to know?

A
  • Is it a stroke?
  • What type of stroke is it?
  • Which part of the brain is affected?
  • What caused the stroke?
  • What is the prognosis?
  • What are the risk factors?
  • What are the functional and emotional consequences?
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17
Q

What are the presenting symptoms and signs of stroke?

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18
Q

Describe the emergency room assessment of a patient with ?stroke?

A
  • Airway
  • Breathing
  • Circulation
  • Clarify the history
  • Clarify the history!!
  • Check medical background
  • Check the signs
  • ?Stroke mimics excluded
19
Q
A
20
Q
A
21
Q

Describe the examination of a patient with ?stroke in vascular neurology.

A
  • BP and pulse measurement in both arms.
  • Conscious level (GCS; document breakdown).
  • Cardiac and carotid bruits.
  • BM / blood glucose value.
  • Neck stiffness / meningism (Kernig’s / Brudzinski signs).
  • Abnormal or involuntary movements.
  • Any seizure-like activity.
  • Skin rash / infarcts (e.g. vasculitic, papular rash).
  • Specific neurological:
    • Eye movements (gaze preference, fixed deviation).
    • Gait assessment.
22
Q

Describe the Oxford Community Stroke Project classification.

A
  • Pattern at time of maximum defecit.
  • Motor / sensory pathways
    • Type 1 - total anterior circulation syndrome (TACS).
  • Visual pathways
    • Type 2 - partial anterior circulation syndrome (PACS).
  • Higher cortical functions
    • Type 3 - Lacunar syndrome (LACS).
  • Brainstem functions
    • Type 4 - posterior circulation syndrome (POCS).
23
Q

Describe LACS.

A

Pure motor, pure sensory, sensorimotor, ataxic hemiparesis.

24
Q

Describe POCS.

A

Brainstem, cerebellar and / or isolated homonymous hemianopia.

25
Q

Describe TACS.

A

Triad of hemiparesis (or hemisensory loss), dysphagia (or other higher cortical function) and homonymous hemianopia.

26
Q

Describe PACS.

A

2 of the features of TACS or isolated dysphagia or parietal lobe signs (e.g. inattention, agnosia, apraxia, agraphaesthesia, alexia).

27
Q

What is the ABCD2 assessment in TIA and risk of stroke?

A
  • 7 point score to predict early stroke risk post TIA.
  • Age (60 or above = 1 point).
  • Blood pressure (systolic >140 and / or diastolic > 90 = 1 point).
  • Clinical features (unilateral weakness = 2 points) (speech disturbance without weakness = 1 point) (other =0).
  • Duration of symptoms in minutes(≥60 = 2 points) (10-59 = 1 point) (<10 = 0).
  • Diabetes = 1 point.
  • 2-day strokes scores / risk: 0-3 (1%), 4-5 (4%), 6-7 (8%).
28
Q

What are the common stroke mimics?

A
  • The 5 ‘S’s
    • ​Seizures
    • Sepsis
    • SOL (tumour, subdural)
    • Somatisation
29
Q

What are the red flags in ?stroke?

A
  • No history
  • No risk factor
  • No image abnormality
  • Young age
  • Seizures
  • Unusyal headache
30
Q

When a patient presents with the symptoms of stroke, what are the things that are frequently overlooked?

A
  • Evolution of symptoms
  • Maximum deficit
  • Drugs:
    • Newly prescribed
    • OCP
    • Recreational
  • Visuospatial or perceptual disorder
  • Truncal ataxia
  • Apraxias
31
Q

What are the 3 initial questions in the clinical assessment of a patient with ?stroke?

A
  • Localalisation of lesion?
  • Likely vascular or non-vascular aetiology?
  • Mechanism of vascular event e.g. small vessel disease, cardioembolism, hypoperfusion?
32
Q

What are the risk factors for recurrent stroke (in mild stroke / TIA)?

A
  • Recurrent events of likely vascular aetiology.
  • Long duration of TIA (>10 minutes).
  • Concomitant vascularrisk factors.
  • High risk of cardioembolism e.g. AF.
33
Q

What investigations should be carried out in a patient with ?stroke?

A
  • Good history and examination.
  • ECG / Holter (24 hour ECG), ECHO.
  • Cholesterol / autoimmune and thrombophilia screen.
  • Carotid doppler.
  • CT brain / MRI brain.
  • Cerebral angiography.
34
Q

What are the indications for urgent head imaging?

A
  • Depressed level of consciousness.
  • Unexplained progressive or fluctuating symptoms.
  • Papilloedema, neck stifness or fever.
  • Severe headache at onset.
  • History of trauma prior to onset.
  • Indication for thrombolysis or anticoagulation.
  • History of anticoagulant treatment of known bleeding tendency.
35
Q

What information can be gathered from CT head?

A
  • Exclude a bleed.
  • May also show:
    • Cerebellar haemorrhage
    • Another cause (tumour; SDH)
    • Early ischaemia
36
Q

What are the advantages and disadvantages of CT in a patient with ?stroke?

A
  • Advantages
    • ​Can detect bleed
    • Available 24/7
    • Quick
  • Disadvantages
    • ​Lacks sensitivity
37
Q

What are the advantages and disadvantages of MRI in a patient with ?stroke?

A
  • Advantages
    • ​Sensitive
    • Diagnostic
    • Management
    • Prognostic
  • Disadvantages
    • ​Limited availability
    • Precautions
    • Slow
38
Q

Describe the management of acute stroke.

A
  • Aspirin (300mg/day) in ischaemic stroke.
  • Thrombolytic treatment with IV rt-PA if onset <4.5 hours, haemorrhage excluded by imaging, considered suitable for treatment, administered in a specialist centre.
  • Endovascular treatment / mechanical thrombectomy with clot-retrieval device in selected patients.
  • Aggressive early BP Rx in ICH; SBP <140.
  • Neurosurgical opinion for secondary hydrocephalus especially in cerebellar stroke.
  • Anticoagulation in atrial fibrillation - once bleed excluded and usually after 10-14 days of stroke.
  • In ischaemic stroke, avoid antihypertensive medications unless MAP >130mmHg.
  • In haemorrhagic stroke aim for SBP <140mmHg, especially in the first 6 hours.
  • If BP persistently elevated, treat with IV Labetolol. Important: avoid abrupt falls in BP.
  • If raised ICP: hyperventilate mechanically (pCO2: 25-30mmHg / 20 breaths per minute), mannitol, decompressive hemicraniectomy.
39
Q

Describe the investigations and management of subarachnoid haemorrhage.

A
  • CT brain / lumbar puncture if CT normal looking for bilirubin and xanthocromia. Cerebral angiogram.
  • Management:
    • Airway: intubate if severe hypoxaemia.
    • Fluid: 3L of 0.9% NaCl per 24 hours.
    • BP: keep MAP <130mmHg. If higher: IV Labetolol or esmolol or enalapril.
    • Nimodipine 60mg 6x/day (for 3 weeks).
    • Codeine or tramadol for pain (avoid NSAIDs).
    • Phenytoin if seizures have occurred.
40
Q

Describe the pharmacological secondary prevention of stroke.

A
  • Anti-thrombotics: clopidogrel or aspirin + dipyridamole. In atrial fibrillation: warfarin or NOAC (dabigatran, rivaroxaban, apixaban).
  • Blood pressure: target BP <130/80 with calcium channel blocker, thiazide diuretic (e.g. bendroflumethiazide or indapamide), ACE inhibitor (e.g. Perindopril).
  • Anti-lipids: iftotal cholesterol >4.0mmol/L (or LDL-C >2.5mmol/L, treat with statin e.g. simvistatin (but caution in ICH or history of cerebral haemorrhage).
41
Q

Describe the modified rankin scale (MRS).

A
  • 0 - no symptoms at all.
  • 1 - no significant disability despite symptoms; able to carry out usual duties and activities.
  • 2 - slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance.
  • 3 - moderate disability; requiring some help, but able to walk without assistance.
  • 4 - moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance.
  • 5 - severe disability; bedridden, incontinent and requiring constant nursing care and attention.
  • 6 - dead.
42
Q

What is secondary prevention-carotid surgery?

A
  • Carotid endarterectomy (CEA) should be considered for all symptomatic stroke / TIA patients (without severe disability; MRS<3) and with 50-99% stenosis (by NASCET method) or 70-99% (by ECST method).
  • CEA should be performed as soon as patient is stable and fit for surgery, ideally within 1 week.
  • CEA reasonable for asymptomatic stenosis > 60% provided > 5 year life expectancy and peri-operative stroke / death rate <3%.
43
Q

Describe the longer-term management of stroke.

A
  • 6 months post-stroke, over 50% of survivors need some help with their ADL; 15% communication impairment and 53% motor weakness.
  • Psychosocial and support needs reviewed on regular basis.
  • Potential issues:
    • Communication, mobility, driving, depression, pressure sores, sepsis, nutrition, post-stroke seizure, shoulder pain, cognitive impairment and behavioural problem.
  • MDT approach:
    • Physiotherapy
    • Occupational therapy
    • Social worker
    • Speech and language therapist
    • Clinical psychologist
    • Dietician
    • Stroke nursing and GP

Neurology (16 decks)

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