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Yr4 - Neuro + SS > Stroke > Flashcards

Stroke Flashcards

1
Q

Define subarachnoid haemorrhage

A

Bleeding into the subarachnoid space

- between the arachnoid mater and pia mater

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2
Q

Epidemiology of subarachnoid haemorrhage

A

6-8 cases per 100,000
Average onset 50-55
Higher incidence in men and black people

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3
Q

Risk factors for subarachnoid haemorrhage

A

Hypertension
Smoking
FHx
Autosomal dominant polycystic kidney disease

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4
Q

Pathophysiology of subarachnoid haemorrhage

A

Most commonly spontaneous rupture of berry aneurysms - commonly in the anterior circle of Willis
AV malformation
Arterial dissections
Use of anticoagulants

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5
Q

Presentation of subarachnoid haemorrhage

A 
Sudden onset, thunderclap headache
Photophobia
Loss of consciousness
CN III palsy - posterior communicating artery aneurysm compressing the ipsilateral CN III
N+V
Meningism
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6
Q

Ix for subarachnoid haemorrhage

A

CT head - hyperdense areas in basal cisterns, major fissures and sulci
FBC - leucocytosis
Clotting profile - may show coagulopathy - elevated INR, prolonged PTT
Troponin I - elevated in 1/4 of cases
LP - presence of RBCs or xanthochromia in 3 consecutive samples

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7
Q

Mx of subarachnoid haemorrhage

A

Cardiopulmonary support
- intubation, mechanical ventilation and sedation with benzodiazepines
- labetalol to keep systolic BP < 160
Surgical clipping/coil embolisation
Calcium channel blockers - vasospasm prophylaxis

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8
Q

Define extradural haemorrhage

A

Collection of blood between inner surface of skull and periosteal dura mater
Usually secondary to traum / skull fracture

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9
Q

Presentation of extradural haemorrhage

A

Loss of consciousness normally followed by transient recovery with ongoing headache
- caused by striping of dura from bone by expanding haemorrhage
Rapidly decreasing consciousness - haematoma enlarges increasing ICP
CN palsies - brain structures herniate

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10
Q

Ix for extradural haemorrhage

A

CT scan - bleeding limited by suture lines of skull

  • hyperdense lemon shape
  • midline shift away from bleed
  • compression of ventricles
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11
Q

Mx of extradural haemorrhage

A

Prognosis good with early intervention
A-E assessment and neuro exam
Small - observe and manage conservatively
Large - urgent referral to neurosurgery for craniotomy and clot evacuation

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12
Q

Complications of extradural haemorrhage

A 
Permanent brain damage
Coma
Seizures
Weakness
Pseudoaneurysm
Arteriovenous fistula formation
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13
Q

Define subdural haematoma

A

Collection of blood between meningeal dura mater and arachnoid mater
Acute < 3 days
Subacute 3-21 days
Chronic > 21 days

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14
Q

Pathophysiology of subdural haematoma

A

Bleeding occurs due to shearing forces on corticla bridging veins with sudden change in velocity of head
Normally due to trauma
- may be spontaneous in anticoagulated patients

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15
Q

Presentation of subdural haematoma

A

Headache
Acute - severely depressed GCS, pupillary abnormalities
Chronic - insidious onset of confusion and cognitive decline

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16
Q

Ix for subdural haematoma

A

CT scan

  • bleed does not cross midline due to falx cerebri
  • banana shape
  • midline shift away from bleed
  • loss of cerebral architecture on affected side
  • chronic bleed appears darker
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17
Q

Mx of subdural haematoma

A

Prognosis relatively poor - full recovery in 20% of patients
Small chronic - serial imaging to monitor progression
Acute - neurosurgical intervention to relieve raised ICP

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18
Q

Define stroke

A

Sudden onset of focal neurological deficit due to vascular cause

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19
Q

Types of strokes

A 
Haemorrhagic - vascular rupture
- intracerebral
- subarachnoid
- subdural
Ischaemic - vascular occlusion or stenosis
20
Q

Types of haemorrhagic strokes

A

Lobar
- cortex or subcortical white matter of cerebral hemispheres
Deep hemispheric
- supratentorial deep grey matter structures
- most commonly putamne and thalamic nuclei
Brain stem
- mainly pons
Cerebellar
- mostly dentate nucleus

21
Q

Classification of ischaemic strokes

A

TOAST classification
Large artery atherosclerosis
- infarction in perfusion of extracranial or intracranial artery with > 50% stenosis
Cardioembolism
- infarction in presence of one cardiac condition
- AF
Small vessel occlusion
- infarction < 1.5cm in diameter in perfusion territory of small penetrating blood vessel
Stroke of other determined aetiology
- vasculitis, arterial dissection, hypercoagulable states
Stroke of indeterminate aetiology

22
Q

Epidemiology of stroke

A

3rd leading cause of death and major disability
180 per 100,000
Ischaemic = 87%

23
Q

Risk factors for stroke

A 
Older age
Fhx
PMHx
Hypertension
Smoking
DM
AF
Comorbid cardiac conditions 
- MI, decreased left VEF, valvular disease, cardiomyopathy
Carotid artery stenosis
Sickle cell disease
Dyslipidaemia
Obesity
Alcohol abuse
Oestrogen-containing therapy 
Illicit drug use
Migraine
Hypercoagulable state
Haemophilia
Anticoagulation
24
Q

Pathophysiology of stroke

A

Ischaemic
- blood supply in cerebral vascular territory critically reduced
- thrombosis risk increased by Virchow’s triad
Haemorrhagic
- vascular rupture with bleeding into brain parenchyma
- expanding haematoma may shear neighbouring arteries -> futher bleeding
- mass effect -> increased ICP, reduced cerebral perfusion, ischaemic injury

25
Q

Presentation of stroke

A 
Visual loss or visual field deficit
- commonly in patients with posterior circulation ischaemia
- unilateral - carotid or vertebrobasilar ischaemia
- bilateral - vertebrobasilar ischaemia
Weakness
- complete or partial loss of muscle strength in face/arms/kegs
- all three suggests deep hemispheric involvement
Aphasia
- expressive or receptive
Ataxia
- cerebellar pathology
Sudden onset
Diplopia
Sensory loss
Dysarthria
Gaze paresis
Neck pain 
Miosis, ptosis facial anhidrosis
Altered level of consciousness
Photophobia and headache
26
Q

Define stroke chameleons

A

Presentations which resemble other conditions but are actually stroke
Venous infarcts - impaired drainage and gradual onset
Small cortical strokes - peripheral nerve lesions
Limb shaking TIA
Occipital stroke - present with confusion and delirium - visual field defects

27
Q

Ix for stroke

A 
Non-enhanced CT - within 1 hour
- ischaemic - CT normal in first few hours, hyperattenuation of relevant vessel due to clotted blood, loss of grey-white matter differentiation, hypodensity of cortical tissue
- haemorrhagic - hyperdense lesion
CT with contrast angiography - if thrombectomy indicated
CT perfusion imaging or MRI alternative
Serum glucose - exclude hypogylcaemia
Serum electrolytes 
Urea + creatinine - renal failure may be contraindication to mx
Cardiac enzymes - concomitant MI
ECG - exclude arrhythmia or ischaemia
FBC
Clotting screen
Carotid USS - carotid stenosis
28
Q

Oxford classification of ischaemic strokes

A

Total Anterior Circulation Stroke - TACS
- usually cardiac emboli
- affects area of brain supplied by middle and anterior cerebral arteries
Partial Anterior Circulation Stroke - PACS
- usually large vessel disease
- less severe form or TACS
Posterior Circulation Syndrome - POCS
- involves damage to area of brain supplied by the posterior circulation - occipital lobe, cerebellum or brainstem
Lacunar Syndromes - LACS
- usually atheroma in situ
- subcortical stroke that occurs secondary to small vessel disease
- no loss of higher cerebral functions

29
Q

Classification of Total Anterior Circulation Stroke

A

All 3 must be present

  • unilateral weakness of face, arm and leg
  • homonymous hemianopia
  • higher cerebral dysfunction - dysphasia, visuospatial disorder
30
Q

Classification of Partial Anterior Circulation Stroke

A

2 of the following present

  • unilateral weakness of face, arm and leg
  • homonymous hemianopia
  • higher cerebral dysfunction - dysphasia, visuospatial disorder
31
Q

Classification of Posterior Circulation Syndrome

A

One of the following

  • cranial nerve palsy and contralateral motor/sensory deficit
  • bilateral motor/sensory deficit
  • conjugate eye movement disorder - horizontal gaze palsy
  • cerebellar dysfunction - vertigo, nystagmus, ataxia
  • isolated homonymous hemianopia
32
Q

Classification of Lacunar Syndrome

A

One of the following present

  • pure motor stroke - lenticulostriate artery
  • pure sensory stroke - thalamoperforator artery
  • sensorimotor stroke
  • ataxic hemiparesis
33
Q

Assess the severity of stroke

A 
National Institutes of Health Stroke Scale
Level of consciousness
o   Level of alertness (0-3)
o   Verbal (0-2)
o   Visual and motor (0-2)
·       Best gaze (0-2)
·       Visual fields (0-3)
·       Facial Palsy (0-3)
·       Arm motor (0-4)
·       Leg motor (0-4)
·       Limb ataxia (0-2)
·       Sensory (0-2)
·       Best language (0-3)
·       Dysarthria (0-2)
·       Extinction and inattention (neglect) (0-2)
0 – no stroke symptoms
1-4 – minor stroke
5-15 – moderate stroke
16-20 – moderate to severe stroke
21-42 – severe stroke
34
Q

Define ROSIER

A

Used in A+E for stroke diagnosis

35
Q

Stages of ROSIER

A

Exclude hyperglycaemia first
Loss of consciousness or syncope = -1
Seizure activity = -1
New, acute onset of asymmetrical face weakness = +1
New, acute onset of asymmetrical arm weakness = +1
New, acute onset of asymmetrical leg weakness = +1
New, acute onset of speech disturbance = +1
New, acute onset of visual field defect = +1
A stroke is likely if the score is > 0

36
Q

Mx of ischemic stroke

A 
Emergency
- IV alteplase
- thrombectomy
Conservative
- admission to stroke unit to optimise physiology and monitor
Medical
- aspirin 300mg daily for 2 weeks
- clopidogrel 75mg TD after aspirin finished
Surgical
- carotid endarterectomy
37
Q

How does alteplase work

A

Activates plasminogen to form plasmin

- degrades fibrin and breaks up thrombi

38
Q

Indications for alteplase

A

Clinical diagnosis of ischaemic stroke

  • NIHSS 4
  • aphasia
  • binocular visual field deficit
  • swallowing deficit
  • unable to walk or self-care independtly
39
Q

Absolute contraindications for alteplase

A 
BP > 185/110 after 2 attempts to reduce
Surgery or trauma within last 14 days
Active internal bleeding
Haematology abnormalities - INR>1.7 or APTT > 40
Arterial puncture at non-compressible site or LP in last 7 days
Symptoms of subarachnoid haemorrhage
IE, pericarditis
Childbirth in last 4 weeks
Acute pancreatitis
Severe liver disease
40
Q

Conservative mx of stroke

A 
Admission to stroke unit to optimise physiology
- Maintain good glycaemic control
- Ensure BP doesn't drop
- Ensure good sleep
- Monitor O2 sats
- Nutritional support
- Rehabilitation
Lifestyle modifications
- Smoking
- Weight
- Alcohol
- Diet
- Exercise
41
Q

Mx of underlying stroke pathologies

A 
Anticoagulation if has AF - balance bleeding and clot risk
- CHADVASC - warfarin
- HASBLED - DOACs
Antihypertensives - target of 130/80
- ACE inhibitors
- CCB
- Thiazides
Statins for hypercholesterolaemia
Glycaemic control for diabetes
42
Q

Mx of haemorrhagic stroke

A 
Neurosurgical evaluation
Airway protection
Blood pressure control
- labetalol
- nicardipine
43
Q

Complications of stroke

A 
Dysphagia may lead to aspiration
Prolonged immobility
- DVT
- Pressure ulcers
- Constipation
    - urinary retention
Seizures - abnormal glial activity
Recurrent strokes
Raised ICP
- malignant oedema
- hydrocephalus
- haemorrhagic transformation
Cognitive issues
Mood changes
Fatigue
Pain
Alteplase-related orolingual oedema
44
Q

Features of TIA

A

Symptoms lasting less than 24 hours

Refer to TIA clinic within 24 hours

45
Q

Screen for subsequent stroke post TIA

A

ABCD2 score

  • A - age > 60
  • B - blood pressure > 140/90
  • C - clinical features - unilateral weakness = 2, dysphasia without weakness = 1
  • D - duration - >60mins = 2, 10-60mins = 1
  • D - diabetes
46
Q

Mx of TIA

A

< 3 = specialist assessment within week
> 3 = specialist assessment in 24 hours
Start aspirin 300mg OD and simvastatin 40 mg OD

Yr4 - Neuro + SS (9 decks)

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