Stroke Flashcards
Stroke definition: _____ onset with focal neurological signs due to disrupted _____, with symptoms lasting longer than ____ hours
Stroke definition: ACUTE onset with focal neurological signs due to disrupted BLOOD SUPPLY, with symptoms lasting longer than 24 hours
TIA definition: symptoms last less than ____ hours, ischaemia without infarction
TIA definition: symptoms last less than 24 hours, ischaemia without infarction
What is a crescendo TIA?
2 or more TIAs within 1 wk
Give 5 differentials for a stroke
- Metabolic eg hypoglycemia
- SOL
- Intoxication
- Wernicke’s encephalopathy
- Bell’s palsy
- Demyelination
- Herpes encephalitis
- Post ictal eg Todd’s paresis
- Traumatic head injury
- Hemiplegic migraine
“The ability of the brain to remodel itself, allowing other areas of the brain to take over the function of the lost cells” is the definition of what
Neuroplasticity
What are the 2 types of strokes? What percentage of strokes to each represent?
85% ischemic
15% haemorrhagic
What is the classification system for ischaemic stroke? Name each type of stroke within the classification system
TOAST
- Large vessel
- Small vessel
- Cardioembolic
- Other
- Cryptogenic
Large vessel ischaemic strokes are due to ______. Do they effect cortex or deep brain? Would they cause an anterior or posterior circulation stroke?
Large vessel strokes due to atherosclerosis, effect cortex (therefore cause cortical signs), cause anterior circulation strokes
Small vessel ischaemic strokes are also called what? Do they effect cortex or deep brain? What type of vessels are involved?
Small vessel strokes = lacunar strokes. Effect deep brain (therefore no cortical signs), effect perforator arteries (small branches of large vessels, don’t communicate with each other)
Name 3 causes of cardioembolic strokes
AF, endocarditis, mechanical heart valve
What is a paradoxical embolism?
Right to left shunt through septal defect or patent foramen ovale
(Associated with anterior circulation strokes)
What is a watershed infarct?
Due to hypoperfusion eg sudden drop in BP in sepsis
What type of stroke can be due to neck trauma, fibromuscular dysplasia or occur spontaneously?
Carotid artery dissection
Does antiphospholipid syndrome and thrombophilia cause arterial or venous clots?
APS = arterial and venous Thrombophilia = venous
Vasospasm strokes occur as a result of what?
Post SAH (after 4-10 days)
Haemorrhagic strokes can be divided into 2 types, name them
SAH and intracerebral haemorrhage
What type of stroke are the following things risk factors for?-AF
- Blood thinners
- ADPKD
- Cavernous malformation
- Bleeding disorder
- Metabolic syndrome
- AF = ischaemic
- Blood thinners = haemorrhagic
- ADPKD = haemorrhagic
- Cavernous malformation = haemorrhagic
- Bleeding disorder = haemorrhagic
- Metabolic syndrome = ischaemic
What are the criteria for TACS total anterior circulation stroke?
Homonymous hemianopia + motor + higher cortical deficit
(Motor = 2/3 of arm/face/leg)
Higher cortical deficit could be: dysphagia, dysphasia, dyscalculia, dyspraxia, personality change, hemispatial neglect, new cognitive impairment, agnosia etc)
(these are large vessel strokes)
What are the criteria for PACS partial anterior circulation stroke?
2/3 of: homonymous hemianopia OR motor OR higher cortical deficit
OR isolated higher cortical deficit
What are the criteria for LACS lacunar syndrome?
Purely motor OR purely sensory OR purely sensorimotor or ataxic hemiparesis
(No cortical signs)
(Often face/hand)
What type of stroke has the worst prognosis?
TACS
A stroke that causes a pure hemiparesis is difficult to distinguish the cause because ….
Could be small vessel internal capsule (MCA branches) or large vessel primary motor cortex
(If just leg/arm = cortical, if face / hand = lacunar)
A stroke effect the pons would be the result of TACS or PACS or LACS or PACS …?
LACS
Pons supplied by pontine arteries (branches of basilar artery)
What is the criteria for POCS?
Brainstem infarct or isolated homonymous hemianopia
Brainstem disturbance: vertigo, dysarthria, ataxia
Carotid bruit and a past TIA both point to [haemorrhagic or ischaemic] stroke
Pointers towards ischaemic stroke: carotid bruit, AF, past TIA, IHD
Low GCS, papilledema, progressive symptoms point to [haemorrhagic or ischaemic] stroke?
Pointers towards haemorrhagic stroke: low GCS, signs of raised ICP, meningism, progressive symptoms, known RF eg anticoagulant, bleeding disorder
How do you differentiate ischaemic v haemorrhagic strokes?
The only way to definitely differentiate is by imaging
What is the name of the assessment tool use for determining stroke likeliness in the assessment room?
ROSIER
1st line investigation for stroke?
Gold standard investigation for stroke?
1st line non-contrast enhanced CT
Gold standard diffusion weighted MRI
The NICE guidelines say ever stroke patient should get a CT within 24 hours, but what are the criteria for urgent CT?
- If thrombolysis considered
- If suspicion haemorrhagic stroke
- Signs of meningism
- GCS <13
- Severe HA
What additional investigation would you perform for anterior circulation strokes?
Carotid doppler
What additional investigation would you perform if you suspect endocarditis or patent foramen ovale?
Echo
What are the 3 aims of stroke management?
- Regain reversible losses
- Maximise residual function
- Prevent further stroke
Blood pressure should not be lowered in the acute management of a stroke, why is this?
Since will reduce cerebral perfusion
What drug should you give stat when you suspect a stroke? What dose? Continue for how long? What exception?
Once haemorrhagic stroke excluded give 300mg aspirin stat (continue for 2 wk then switch to antithrombotic either antiplatelet or anticoagulant depending on if cardioembolic)
What are the criteria for thrombolysis i.e. who is suitable?
If onset <4.5hr ago ischaemic stroke
What are the risks of thrombolysis?
Bleeding - so CT after 24hr to identify bleeds
What drug is thrombolysis for stroke?
Alteplase tissue plasminogen activator tPA
What are the contraindications for thrombolysis?
- Major infarct on CT
- Haemorrhage on CT
- Non disabling deficit
- Recent trauma / surgery
- On anticoagulant
- INR >1.7
- BP >220/130
- Aneurysm
- AVM
- Cirrhosis/varices/portal HTN
- Seizures at presentation
Is thrombectomy done as an alternative or an adjunct to thrombolysis? How many hours after onset should it be performed in?
Adjunct
Within 6hr of onset
How do you reverse warfarin?
Vitamin K + prothrombin complex concentrate
Every stroke patient should be admitted to a specialist stroke unit - T or F
True (in NICE guidelines)
Patients with a TIA should be seen within __ hours by a stroke specialist
24 hours (NICE guidelines)
What is the management of a TIA?
300mg aspirin stat (continue daily) + secondary prevention
What are the criteria for carotid endarterectomy?
If >70% stenosis in ipsilateral artery +
<14d since stroke/TIA +
Symptomatic
What is the secondary prevention for a cardioembolic ischaemic stroke?
Anticoagulant + statin + antihypertensive
Statin atorvastatin 80mg
What is the secondary prevention for a non-cardioembolic ischaemic stroke?
Antiplatelet + statin + antihypertensive
Antiplatelet clopidogrel 75mg
What is the secondary prevention for a haemorrhagic stroke?
Antihypertensive
Receptive aphasia is cause by a lesion where?
Wernicke’s area in left parietal lobe
Expressive aphasia is caused by a lesion where?
Broca’s area in left frontal lobe
Gerstmann syndrome is caused by a lesion where?
Angular gyrus - junction of pareital/temporal lobe
Expressive aphasia in the absence of other symptoms would be what type of stroke?
PACS
Contralateral hemiparesis + hemisensory loss (mainly face + hand) + contralateral VFD would be cause by occlusion of what vessel?
MCA superior division
