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Year 3 Neuroscience > Stroke > Flashcards

Stroke Flashcards

1
Q

What is a stroke?

A

Rapid, permanent neurological deficit from cerebrovascular insult, defined as focal or global impairment of CNS function developing rapidly and lasting OVER 24 hours.

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2
Q

What is the aetiology of stroke?

A
  • INFARCTION: thrombosis (atherosclerosis) affecting mainly small vessels (lacunar infarcts) and less commonly large vessels, emboli (from intimal flap of carotid dissection, atheromatous plaques), hypotension, vasculitis, cocaine
  • HAEMORRHAGE: hypertension, Charcot-Bouchard microaneurysm rupture, amyloid angiopathy, trauma, tumours, vasculitis
  • Subarachnoid haemorrhage
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3
Q

What is Charcot-Bouchard microaneurysm rupture?

A

Small aneurysms in small penetrating blood vessels

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4
Q

What are the risk factors for infarct stroke?

A

Prothrombotic states such as dehydration and thrombophilia

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5
Q

What is the epidemiology of stroke: Type?

A

Most common type is infarct.

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6
Q

What is the pathophysiology of ischaemic stroke?

A

Ischaemic brain becomes soft due to vasogenic oedema and breakdown of BBB and prone to haemorrhagic transformation. This can cause secondary damage to CNS

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7
Q

What are the lobes of the brain?

A

.

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8
Q

What is the vascular anatomy of the brain?

A

.

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9
Q

What is the structure of the motor/somatosensory cortex?

A

.

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10
Q

What are the general signs and symptoms of stroke? Onset?

A
  • Sudden onset
  • Weakness, sensory, visual, or cognitive impairment, impaired coordination, or consciousness
  • UMN signs
  • Headache and meningism in haemorrhagic events – signs of raised ICP
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11
Q

What are the signs and symptoms of ischaemic stroke: Anterior cerebral artery?

A

Contralateral lower limb weakness (hemiparesis) and sensory loss. Confusion (frontal lobe). Damage to parietal lobe leads to special neglect

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12
Q

What are the signs and symptoms of ischaemic stroke: Middle cerebral artery?

A
  • Contralateral hemiparesis and sensory loss: upper extremities and face more than lower extremities.
  • Contralateral homonymous hemianopia
  • Hemineglect from parietal lobe damage
  • Receptive or expressive dysphasia/aphasia (basically the same)
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13
Q

What are the types of aphasia that patients experience in ischaemic stroke? Aetiology of each?

A
  • BROCA: frontal lobe – production of speech – expressive aphasia. Superior division of left middle cerebral
  • WERNICKE’S: temporal lobe – comprehension of speech – receptive dysphasia. Inferior division of left middle cerebral artery. Associated with confabulations
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14
Q

Which side of the brain is associated more strongly with aphasias?

A

More affected if left hemisphere.

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15
Q

What are the signs and symptoms of ischaemic stroke: Posterior cerebral artery?

A
  • Contralateral homonymous hemianopia with macula sparing
  • Visual agnosia (cannot recognise objects)
  • Prosopagnosia (cannot recognise faces)
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16
Q

What is the PITS acronym for visual field defects?

A

Parietal lobe stroke leads to homonymous inferior quadrantanopia, temporal lobe stroke leads to homonymous superior quadrantanopia.

17
Q

What are the signs and symptoms of ischaemic stroke: Anterior inferior cerebellar artery?

A

Can lead to lateral pontine syndrome. Vertigo, ipsilateral ataxia, ipsilateral deafness, ipsilateral face weakness

18
Q

!!! What are the signs and symptoms of ischaemic stroke: Posterior inferior cerebellar artery?

A

AKA lateral medullary syndrome of Wallenberg. Same as anterior: vertigo, ipsilateral ataxia, AND ipsilateral Horner’s syndrome, ipsilateral hemifacial sensory loss, dysarthria, nystagmus, and contralateral spinothalamic sensory loss

19
Q

What are the signs and symptoms of ischaemic stroke: Basilar artery?

A

Combination of cranial nerve pathology, and impaired consciousness – emergency! Leads to locked-in syndrome

20
Q

What are the signs and symptoms of ischaemic stroke: Lacunar vessels?

A

Affecting deep perforating arteries: Isolated hemiparesis (internal capsule (part of basal ganglia) or pons), hemisensory loss (thalamus, internal capsule, or pons), or hemiparesis with limb ataxia (usually UL and a clumsy hand; basal ganglia).

21
Q

SUMMARY: Visual field defects.

A

May be worthwhile for the OSCE!

22
Q

What are the differentiating signs and symptoms between haemorrhagic and ischaemic stroke?

A

Ischaemic: visual field defect, weakness, aphasia and ataxia; haemorrhagic: meningism, history of AF or liver disease, visual changes and photophobia.

23
Q

What are the investigations for stroke? (x7)

A
  • BLOODS: clotting profile especially in young patients (thrombophilia)
  • ECG: identify arrythmias which predispose to embolism
  • ECHO: identify cardiac thrombus, valvular endocarditis or other sources of embolism
  • CT: rapid detection of haemorrhages, often normal especially in lacunar infarcts or very early in stroke (less than 6 hours)
  • DIFFUSION-WEIGHTED MRI: more sensitive for ischaemic stroke once isodense
  • CAROTID DOPPLER: screens stenotic carotids
  • CT-CEREBRAL ANGIOGRAM: to detect artery dissections or intracranial stenosis
24
Q

How is hyperacute stroke managed? Criteria?

A
  • IF LESS THAN 4.5 HOURS from onset and HAEMORRHAGE EXCLUDED on CT. Various additional criteria are used to exclude patients including NINDS and ECASS3 trials
  • IV thrombolysis and withhold aspirin until another CT head at 24 hours to ensure no subsequent haemorrhage
  • 2 weeks aspirin 300mg
  • May consider thrombectomy (endovascular) which directly removes clot through femoral artery access to brain
25
Q

How is acute ischaemic stroke managed?

A
  • ASPIRIN 300mg to prevent further thrombosis once haemorrhage excluded on CT
  • STOP ANTICOAGULANTS due to risk of haemorrhagic transformation
  • AFTER 2 WEEKS stop aspirin and start clopidogrel. Consider anticoagulant if HIGH RISK of emboli recurrence or stroke progression such as in carotid dissection
  • SWALLOW ASSESSMENT to assess need for NG tube as some have compromised function following stroke
  • May consider thrombectomy (endovascular) which directly removes clot through femoral artery access to brain
26
Q

How is ischaemic stroke management continued after acute management? (x4)

A
  • Lifelong antiplatelet prophylaxis with clopidogrel. May need warfarin if AF
  • Daily statin (highest dose, 80mg)
  • Daily ACEi/thiazide diuretic
  • Carotid endarterectomy within 2 weeks reduces risk of further stroke
27
Q

How is haemorrhagic stroke managed? (x3)

A
  • RAPID BP CONTROL: IV sodium nitroprusside or labetolol. IV mannitol/external ventricular drainage to reduce ICP.
  • REVERSAL OF ANTICOAGULANTS: Stop warfarin and consider Vitamin K/PT
  • Surgery such as craniotomy and evacuation to remove haematoma
28
Q

What is the prognosis of stroke: Which type is worse? Mortality? Recurrence?

A

Haemorrhagic prognosis worse, 10% mortality in first month, 10% recurrence in a year

29
Q

What is a TIA?

A

Transient episode of neurological dysfunction caused by focal brain or retinal ischaemia without infarction. It has sudden onset and may last between minutes and 24 hours. Most usually have complete resolution of symptoms within an hour.

30
Q

When should TIA be suspected?

A

IMPORTANT OSCE POINT: In anyone with sudden onset focal neurological deficit that has completely resolved within 24 hours on onset and cannot be explained by other conditions such as hypoglycaemia

31
Q

What is the aetiology of TIA? (x6)

A
  • IN SITU THROMBOSIS due to stenosis or unstable atherosclerotic plaque
  • CARDIOEMBOLIC EVENT: secondary to AF, endocarditis, prosthetic valve
  • Hypercoagulability
  • Dissection
  • Vasculitis
  • Vasospasm
32
Q

What is the pathophysiology of TIA?

A

Ischaemic neurological injury is associated with oedema which can be seen as a hyperintensity in MRI (white) – the same is with stroke!

33
Q

What are the signs and symptoms of TIA?

A
  • SAME AS STROKE but transient
  • Unilateral weakness or paresis in face, arm, or leg. Bilateral weakness is a feature of brainstem ischaemia
  • Dysphasia
  • Ataxia, vertigo, loss of balance
  • Loss of vision in one eye (amaurosis fugax) from thrombus in ophthalmic artery
  • Homonymous hemianopia
34
Q

What are the investigations for TIA? (x3)

A
  • BLOODS: glucose (to rule out hypoglycaemic aetiology), PT/INR to exclude coagulopathy and in case thrombolytic therapy is being considered
  • ECG: AF or arrythmias
  • CT HEAD: in patients taking anticoagulant or with bleeding disorder to exclude haemorrhage. Do not use if you JUST suspect TIA
35
Q

How are TIAs managed?

A
  • LOADING ASPIRIN (following exclusion of hypoglycaemia)
  • Refer for specialist assessment within 24 hours
36
Q

What is the prognosis of TIA?

A

Recurrence into stroke is HIGH.

Year 3 Neuroscience (14 decks)

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