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Yr 3 neuro > stroke > Flashcards

stroke Flashcards

1
Q

def of stroke

A

rapid permanent neurological deficit from cerebrovascular insult

defined clinically as focal or global impairment of CNS function developing rapidly and lasting >24hr

subdivided by location (anterior circulation or posterior circ), or be path process ie infarction/haemorrhage

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2
Q

aetiology of stroke infarction

A

80%

thrombosis

  • elderly - atherosclerosis in cerebral vessels affecting small vessels ->lacunar infarcts; less commonly large vessels eg middle cerebral art
  • prothrombotic states eg dehydration or thrombophilia
  • cerebral microangiopathy

emboli

  • intimal flap of carotid dissection
  • atheromatous plaques in carotid - atherothromboembolism
  • from heart eg AF, endocarditis, MI
  • rarely from venous circ - pass through R-L heart defet eg VSD

hypotension - If below the autoregulatory range maintaining cerebral blood flow, infarction results in the watershed zones between different cerebral artery territories

vasculitis

cocaine

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3
Q

haemorrhage stoke aetiology

A

10%

HTN

charcot-bouchard microaneurysm rupture

amyloid angiopathy

anteriovenous malformations

Less commonly, trauma, tumours, arteriovenous malformations, vasculitis.

anticoagulation

thrombolysis

sudden BP drop by >40mmHg - affect boundary zone between 2 vascular beds

carotid artery dissection - spontaneous/from neck trauma/fibromuscular dysplasia

vasculitis

SAH

venous sinus thrombosis

antiphospholipid syndrome

thrombophilia

fabry disease

CADASIL

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4
Q

pathology of stroke

A

ischemic brain becomes soft due to vasogenic oedema from breakdown of blood-brain barrier and prone to haemorrhagic transformation

can cause secondary damage to CNS

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5
Q

RF for stroke

A

htn

smoking

dm

heart disease - valvular, ischemic, AF

pvd

high PCV

carotid bruit

combined OCP

high lipids

high alcohol use

high clotting - high fibrinogen, low antithrombin 3

high homocysteine

syphilis

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6
Q

cardiac causes of stroke

A

non-valvular afib - risk of stroke of 4.5%/yr. Ischemic strokes in AF have a worse prognosis

CHADSVASc score - calculate risk of stroke in pts with AF. Anticoag if score 2 or more. Take bleeding risk into account - HAS-BLED score. Caution and regular review of oral anti-coag needed if HAS-BLED >3. Dont give stroke prevention if <65yrs and CHADSVASC is 0 in men or 2 in women

anti-coag from 2wks post stroke (or 7-10d if clinically and radiologically small) - DOAC or warfarin

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7
Q

cardiac sources of emboli

A

cardioversion

prosthetic valves

acute myocardial infarct with L vent wall motion abnormalities on echo

patent foramen ovale/septal defects

cardiac surgery

IE - give rise to septic emboli

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8
Q

epi stroke

A

common

annual incidence 2 in 1000

3rd most common cause of death in industrialised countries

70yrs

Young strokes (<50years merit extensive investigation).

Someone in the UK has a stroke every 3.5 minutes

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9
Q

sx of stroke

A

sudden onset - deterioration in seconds, worst at onset

Weakness, sensory, visual or cognitive impairment, impaired coordination, or consciousness.

Head or neck pain (in carotid or vertebral artery dissection).

Enquire time of onset (critical for emergency management if<4.5 h)

Enquire if history of atrial fibrillation, MI, valvular heart disease, carotid artery stenosis, recent neck trauma or pain.

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10
Q

signs of stroke

A

examine for underlying cause - AF, heart murmur, carotid bruit, fundoscopy

pointers to infarction - AF, carotid bruit, past TIA, IHD

Infarction:

  • contralateral sensory loss/hemiplegia - initially flaccid (floppy limb, falls like a dead weight) -> becoming spastic (UMN)
  • dysphasia
  • homonymous hemianopia
  • visio-spatial defect
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11
Q

anterior circulation stroke

A

anterior cerebral: lower limb weakness (motor cortex), confusion (frontal lobe)

middle cerebral: facial weakness, hemiparesis (motor cortex) hemisensory loss (somatosensory cortex), apraxia, hemineglect (parietal lobe), receptive or expressive dysphagia (language centres), quadrantanopia (superior or inferior optic radiations)

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12
Q

lacunar stroke

A

disease in the deep perforating arteries

internal capsule or pons - Pure sensory or motor deficit (or combination of both).

thalamus - loss of consciousness, hemisensory deficit

basal ganglia - hemichorea, hemiballismus, parkinsonism

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13
Q

posterior circulation stroke

A

posterior cerebral - hemianopia

anterior inferior cerebellar artery - vertigo, ipsilateral ataxia, ipsilateral deafness or tinnitus, ipsilateral facial weakness

posterior inferior cerebellar artery (lateral medullary syndrome of Wallenberg) - vertigo, ipsilateral ataxia, ipsilateral Horner’s syndrome, ipsilateral hemifacial sensory loss, dysarthria and contralateral spinothalamic sensory loss

basilar artery - combination of cranial nerve pathology and impaired consciousness = emergency

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14
Q

vascular dementia

urinary incontinence

gait apraxia (‘marche a petits pas’, shuffling small step gait with upright posture and often normal or excessive arm swing)

5 syndromes:

  • ataxic hemiparesis
  • pure motor
  • pure sensory
  • sensorimotor
  • dysarthria/clumsy hand

cognition/consciousness intact except for in thalamic strokes

A

MULTIPLE lacunar infarcts

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15
Q

brainstem infarct

A

25%

varied

quadriplegia

gaze and vision disturbances

locked in syndrome

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16
Q

signs of haemorrhage

A

pointers to bleed - meningism, severe headache, coma

intracerebral:

  • headache
  • meningism
  • focal neurological signs
  • nausea and vomiting
  • signs of raised ICP
  • seizures
  • coma
17
Q

ix for stroke

A

blood

ECG - arrhythmias that pre-dispose to embolism

echo

carotid doppler US - exclude carotid artery disease

CT head

MRI brain

CT cerebral angio

retinopathy, nephropathy, cardiomegaly - signs of HTN

CXR - enlarged LA

check for hypoglycaemia, hyperglycaemia, dyslipidaemia, hyperhomocysteinaemia

vasculitis - high ESR, ANCA, VDRL to look for active, untreated syphilis

prothrombotic states - thrombophilia, antiphospholipid syndrome

hyperviscosity - polycythaemia, sickle cell disease

thrombocytopenia and other bleeding disorders

genetic tests - CADASIL, Fabry disease

18
Q
A
19
Q

echo stroke

A

identifies cardiac thrombus, valvular endocarditis or other sources of embolism, valvular lesions in rheumatic heart disease

consider bubble contrast study for R to L shunt eg VSD

hyperkinetic segment of cardiac muscle post MI

(Transoesophageal is more sensitive than transthoracic)

20
Q

CT head stroke

A

rapid detection of haemorrhages

often normal, especially in lacunar infarcts, or very early in stroke ie <6hr

21
Q

MRI brain stroke

A

rarely available acutely

higher sensitivity for infarction

diffuse weighted imaging (DWI) - differentiate between recent strokes (<2wks) and old strokes

22
Q

ct cerebral angio stroke

A

detect artery dissection or intracranial stenosis

alternatively MRA with T1 fat saturation can be useful

23
Q

hyperacute stroke mx

A

protect airway - avoid hypoxia/aspiration

<4.5hr from onset and haemorrhage excluded on CT head, IV thrombolysis considered with alteplase - CT 24hr after to identify bleeds

NO aspirin in 1st 24hr

Follow local protocols due to very strict inclusion and exclusion criteria (NINDS andECASS3 trials, IST3 trial for thrombolysis<6 h is ongoing).

CI to thrombolysis - major infarct or haemorrhage, mild/non-disabling deficit, recent surgery/trauma/artery or vein puncture at uncompressable site, previous CNS bleed, AVM/aneurysm, severe liver disease, varices or portal HTN, seizure at presentation, blood glucose <3 or >22, stroke/serious head injury in last 3mo, GI or urinary tract haemorrhage in last 21 days, known clotting disorder, anticoag or INR>1.7, platelets <100x10(9), history of intracranial neoplasm

24
Q

acute ischemic stroke mx

A

aspirin 300mg/clopidogrel to prevent thrombosis once haemorrhage excluded on CT head

heparin considered in certain subgroups where risk of emboli recurrence or stroke progression eg carotid dissection, recurrent cardiac emboli, critical carotid artery stenosis

formal swallow assessment vital - NG tube might be necessary

close nursing and GCS monitoring

thromboprophylaxis (but no evidence of net benefit from graded compression stockings in CLOTS trial).

Hemicraniectomy may be indicated for mass effect from infarcted tissue in the first 48 h

maintain homeostasis - keep blood glucose between 4-11mmol/L, BP if HTN emergency (eg encephalopathy/aortic dissection) or thrombolysis considered (aim <110/85) - only in these cases because treating v high may impair cerebral perfusion

25
Q

intracerebral haemorrhage Mx

A

control HTN and seizures

IV mannitol and hyperventilation helps lower ICP

Evacuation of haematoma or ventricular drainage may be required.

26
Q

stroke secondary prevention

A

300mg aspirin (2wk) and slow release dipyridamole, or aspirin then clopidogrel

warfarin anticoagulation if AF

stop smoking

control HTN and hyperlipidaemia

treatment of carotid artery disease

27
Q

surgical mx stroke

A

controversial in asymptomatic disease

Carotid endarterectomy (removal of plaque) within 2 weeks of stroke or TIA reduces risk of further stroke in ECST and NASCET trials, although carries a significant peri-operative risk.

considered in:

  • symptomatic stenosis of 70–99% (ECST criteria),
  • symptomatic stenosis of 50–99% (NASCET criteria) or
  • crescendo TIAs not responding to medical treatment.

endovascular carotid artery angioplasty with stenting if unfit for surgery - this has higher peri-procedure stroke and mortality rates

thrombectomy - intra-arterial mechanical thrombectomy = additional benefit if large artery occlusion in proximal anterior circulation

28
Q

complications of stroke

A

cerebral oedema - high ICP and local compression

immobility

infections eg pneumonia, UTI, from pressure sores

CVS events - arrhythmias, MI, cardiac failure

death

29
Q

px of stroke

A

stroke - 10% mortality in 1st mo

up to 50% who survive remain dependent

1 in 4 die in a year

10% have recurrence in 1yr

poorer for haemorrhage than infarction

overall 60000/yr

drowsiness = poor prognosis

Yr 3 neuro (32 decks)

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