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Cardiovascular > Stoke > Flashcards

Stoke Flashcards

1
Q

What is a stroke?

A

Neurological deficit of sudden onset which lasts more than 24 hours
Also of vascular origin

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2
Q

What is a transient ischaemic attack?

A

Less than 24 hours
Neurological deficit (loss of function)

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3
Q

What happens to cause a stroke?

A

A blocked or ruptured blood vessel causing a failure of neuronal function leading to some deficit in brain function
Death to neurovascular unit

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4
Q

What are the causes of stroke?

A

Blockage by thrombus or clot
Disease of vessel wall
Disturbance of normal properties of blood
Rupture of vessel wall - haemorrhage

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5
Q

What are the 2 types of stoke?

A

Haemorrhagic stroke - blood leaks into brain tissue Ischaemic stroke - occlusion causing cell death as lack of blood supply

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6
Q

What are types of large artery disease?

A

Carotid stenosis
Carotid disease - plaque ruptures
Cardioembolic stroke - atrial fibrillation is the commonest cause

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7
Q

Describe lacunar stroke

A

Small vessel stroke
Affects very small areas of the brain and is associated with hypertension
Blockage or rupture in medial and lateral lenticulostriate arteries

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8
Q

What is a rarer cause of stoke?

A

Carotid dissection - idiopathic or trauma
Lining of blood vessel tears and causes thrombosis which breaks off and travels to brain vessels

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9
Q

What are the causes of brain infarction?

A

Intracranial atherosclerosis, carotid plaque with arthritogenic emboli, aortic arch plaque, cardiogenic emboli, valve disease, atrial fibrillation, carotid stenosis and penetrating artery disease

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10
Q

Why does haemorrhage happen?

A

Hypertension, amyloid, excess alcohol, hypocholesterolaemia and haemorrhagic transformation

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11
Q

Is haemorrhagic stroke or ischaemic stroke more deadly?

A

Haemorrhagic

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12
Q

Explain penumbra

A

Area of brain which surrounds ischaemic brain tissue but is getting enough blood to not die but not enough to carry out function
Still some supply from collateral vessels

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13
Q

What is lost every minute in a patient with large vessel ischaemic stroke?

A

1.9 million neurons
13.8 billion synapses
12km of axonal fibres

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14
Q

What does ischaemia result in?

A

Varying degrees of hypoxia and hypoglycaemia

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15
Q

What hours of a stroke are essential for threshold of preservation?

A

First 2-3 hours

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16
Q

What does prolonged hypoxia lead to?

A

Hypoxia stresses metabolic machinery of brain cells
Becomes Anoxia (no oxygen)

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17
Q

What is the result of anoxia?

A

Results in infarction and this is a completed stroke
Further damage can be result of oedema, size and location of stroke and haemorrhage

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18
Q

Explain oedema in the brain

A

Oedema can push parts of brain and damage rest of brain tissue because of pressure
Vessels can move and midline can be shifted

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19
Q

How is lactic acid produced in brain?

A

Lack of O2 and glucose means brain cells lose ability to make energy
Cells in affected area switch to anaerobic metabolism so lesser ATP production and lactic acid production

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20
Q

What does lactic acid do in the ischaemic cascade?

A

Acts as an irritant which has potential to destroy cells by disruption of normal acid-base balance in the brain

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21
Q

Describe the influx of Ca2+ and efflux of potassium in the ischaemic cascade?

A

ATP-reliant ion transport pump fails so membrane depolarises, influx of Ca2+ and efflux of K+
Intracellular calcium level become too high and trigger release if excitatory amino acid neurotransmitter glutamate

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22
Q

What is the role of glutamate in the ischaemic cascade?

A

Stimulates AMPA receptors and Ca-permeable NMDA receptors which leads to more Ca influx into cells
Excess Ca entry overexcites cells and activates proteases, lipases and free radical formed in process called excitotoxicity

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23
Q

What happens when the cells membrane is broken down by phospholipids?

A

Becomes more permeable so more ions and harmful chemicals enter cells
Mitochondria break down and release toxins ad apoptotic factors into cell so cells undergo apoptosis

24
Q

What happens when a cell dies through necrosis?

A

Release glutamate and toxic chemicals into environment.
Toxins poison nearby neurons and glutamate overexcites them

25
Q

What does loss of structural integrity result in?

A

Breakdown of protective blood brain barrier and contributes to central oedema which can cause secondary progression of brain injury

26
Q

Explain the extension of infarction over time in a stroke?

A

First tiny area of dead tissue and large penumbra
Then as time increases, dead tissue increases and area of salvageable tissue decreases
Swelling also increases with time

27
Q

What symptoms does a patient get with a stroke?

A

Motor - clumsy or weak limb, Sensory - loss of feeling, Speech - dysarthria/ dysphagia, visuospatial problems, gaze palsy, loss in one eye, hemianopia, ataxia, vertigo, incoordination

28
Q

Describe the vascular supply of the brain

A

Carotid system supplies most of the hemispheres and cortical deep white matter
Vertebra-basilar system supplies brainstem, cerebellum and occipital lobes

29
Q

What is hemianopia?

A

Both eyes can only see left side as right side is blacked out

30
Q

What is ataxia?

A

Cant control movement
Impaired coordination

31
Q

What is dysarthria?

A

Slow or slurred speech as weakened muscles

32
Q

What are the symptoms of anterior cerebral artery occlusion?

A

Paralysis of contra-lateral foot and leg, sensory loss over contra-lateral toes, foot and leg, and impairment of gait and stance

33
Q

What are the symptoms of middle cerebral artery occlusion?

A

Contra-lateral paralysis of face/arm/leg, sensory impairment and homonymous hemianopia
Gaze paralysis to opposite side, aphasia if on dominant side (left) and unilateral neglect for half of external space if non-dominant

34
Q

What are some lacunar stroke syndromes?

A

Lack of cortical signs
Pure motor stroke
Pure sensory stroke
Dysarthria - clumsy hand syndrome
Ataxia hemiparesis

35
Q

Where will a small stroke cause major deficit?

A

At internal capsule and pons
Fibres are packed together very closely

36
Q

What is the anatomy involved in posterior circulation?

A

Brainstem, cerebellum, thalamus, parts of occipital and temporal lobes

37
Q

What are symptoms of brainstem dysfunction?

A

Coma, drop attacks, vertigo, nausea, vomiting, cranial nerve palsies and ataxia
Hemiparesis, hemisensory loss, crossed sensory-motor deficits and visual field deficits

38
Q

What are the stroke subtypes?

A

TACS - total anterior circulation stroke
PACS - partial anterior
LACS - lacunar stroke
POCS - posterior circulation stroke

39
Q

Which stroke subtype has highest mortality and recurrence rate?

A

Mortality is highest after a year in TACS
Recurrence rate is highest in POCS and PACS (part of MCA)

40
Q

What are the risk factors of stroke?

A

Age, hypertension, cardiac disease, diabetes, smoking, Family history, cholesterol (apoA and apoB) and bleeding disorders
Obesity

41
Q

What are some associated disease with strokes?

A

Previous TIAs or strokes, angina, MI, blood pressure poorly controlled, PVD, aortic aneurysm, carotid bruits and renovascular disease
Possible cocaine or alcohol abuse

42
Q

What is the most important modifiable risk factor for stroke?

A

Hypertension - associated with small vessel stroke and haemorrhage

43
Q

Describe diabetes and strokes

A

Diabetes mellitus increases incidence of stroke up to 3-fold
Small vessel, lagre vessel and cardioembolic strokes

44
Q

Describe smoking and strokes

A

Have a 2 fold increased risk of ischaemic stroke

45
Q

Describe lipids and strokes

A

High plasma level of low density lipoprotein results in excessive amounts of LDL within arterial wall
Hypertension, cigarette smoking and diabetes contribute to LDL deposition on arterial walls

46
Q

What are some other less common risk factors?

A

Impaired cardiac function, oral contraceptives with high oestrogen content and hypercoagulable states (malignancy and genetic)

47
Q

What is the aim of stroke treatment?

A

Protect the damaged brain before ischaemia becomes cell death, get rid of clot and prevent the clot happening in the first place

48
Q

Why are stroke units important?

A

Physiotherapy, aspirin and can get imaging done fast
Also specialised staff

49
Q

What shoulds acute stroke therapies do?

A

Restore blood flow, prevent extension of ischaemic damage, protect vulnerable brain tissue, avoid reperfusion injury and be non-toxic

50
Q

What medication if given for strokes?

A

Thrombolysis - alteplase
Try give in 30 mins of arriving at hospital
Has risk of bleeding but has more benefits

51
Q

Describe the acute stroke triage

A

Pre-alert, stroke centre, ED/stroke physician initial evolution, perform CT and IV tPA

52
Q

What investigation is first choice in ED?

A

Plain CT
MRI are good for areas of infarction but take longer

53
Q

What are some advanced imaging that will help is available?

A

Perfusion CT, CT angiogram, MRA, Diffusion CT

54
Q

Explain fast field cycling MRI

A

Lower magnetic field
PUFFINS trial
Ultra low magnetic field
Assesses new contrast mechanisms based onT1 dispersion
Infarct is clearer at lowest magnetic field

55
Q

Explain clot retrieval

A

Catheter pulls clot out safely
Trials show positive outcomes with clot retrieval
Challenges are no thrombectomies in Scotland right now

56
Q

What are some other treatments for strokes?

A

Antiplatelets, statins, blood pressure management and anticoagulation if atrial fibrillation

57
Q

What is the treatment for primary intracerebral haemorrhage?

A

BP management to <140mmHg

Cardiovascular (33 decks)

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