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Year 4 Integrated Care > Stroke > Flashcards

Stroke Flashcards

1
Q

Name three examinations you would do on first presentation of stroke

A

GCS
A to E
NIHSS

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2
Q

NIHSS is used to quantify the severity of stroke, the first response of each category is measured. Give an example of 6 parameters.

A 
Level of Consciousness
Blink Eyes and Squeeze Hands
Horizontal Ocular Movements 
Visual Fields
Facial Palsy 
Inattention
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3
Q

What do the NIHSS scores mean?

A

<4 shows a good prognosis

>26 thrombolysis is CI

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4
Q

What specific things are you looking for on a systems examination

A

CVS - Sources of Emboli, BP, Arrhythmias, Bruits
Resp - Aspiration Pneumonia, Swallow risk, O2 sats
Abdo - ?Palpable bladder, Liver Cirrhosis, Pregnancy
Cranial Nerves

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5
Q

Outline a peripheral nerve exam

A 
Inspection 
Tone 
Power (Out of 5)
Reflex
Sensation 
Coordination
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6
Q

How is Power of limbs rated out of 5

A 
1 - Trace of Contraction 
2 - Movement if no gravity 
3 - Active against gravity 
4 - Active against gravity and resistance 
5 - Normal
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7
Q

Describe the non imaging investigations for Stroke

A
  • Urine Dip
  • Blood Glucose
  • Bloods (looking for damage from long lie, or underlying cause)
  • ECG
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8
Q

Describe the imaging for Stroke

A

If suspecting - Non Contrast Head CT in one hour (eg if GCS<13, known bleeding tendency, severe headache)

If going for thrombectomy - CT Angio indicated

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9
Q

How can Stroke Mimics be classified?

A

1 - Readily identifiable on imaging (eg MS, Subdural Haematomas)
2 - Syndromically distinguishable on clinical grounds after medical assessment
3 - Exclusion requires specialist stroke assessment (eg focal seizures, migraine with aura)

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10
Q

Name five Stroke Mimics

A 
Transient Global Amnesia
Migraine with Aura 
Functional Syndrome 
Hypoglycaemia
Amyloid Spell
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11
Q

What is Transient Global Amnesia?

A

During the episode, patient is unable to make new memories but old memories are retained
Can last up to 10 hours
Can be triggered (e.g sudden immersion in hot/cold, pain)

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12
Q

What is Migraine with Aura?

A
  • Typically positive symptoms
  • Headache may be absent or minimal
  • Can have cortical spreading depression (wave of depolarisation causing spreading of aura)
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13
Q

What is an Amyloid Spell?

A

Presents similarly to Migraine with Aura but lasts less than 10 minutes
MRI shows cerebral amyloid angiopathy

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14
Q

What is Functional Syndrome?

A

Presence of genuine neurological signs that cannot be attributed to an underlying cause

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15
Q

How can a Stroke Mimic be differentiated from a Stroke?

A

Onset
Stereotyping (same vessel is unlikely to be repeatedly occluded)
ROSIER score

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16
Q

What is an exception to using stereotyping to differentiate?

A

Capsular Warning Syndrome in Lacunar Arteries

Intermittent Hypoperfusion over minutes to hours

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17
Q

ROSIER score is important tool to recognise stroke. What are the parameters?

A 
LOC
Seizure
Face/Arm/Leg Weakness
Speech Disturbance
Visual Symptoms
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18
Q

What do ROSIER scores mean?

A

From -2 to +5

> 0 means that stroke is likely

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19
Q

What are Stroke Chameleons

A

The opposite of mimics

Strokes that look like other conditions

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20
Q

Name five Stroke Chameleons

A 
Venous Infarcts 
Small Cortical Strokes
Limb Shaking TIA
Occipital Strokes
Intracranial Stenosis
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21
Q

How do Venous Infarcts present?

A

Gradual Onset
Seizure Activity
Treated with Heparin

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22
Q

How does Intracranial Stenosis Present?

A

Atherosclerosis in a vessel where each time there is hypoperfusion, patient gets symptoms
Leads to stereotyping
Confirmed with CT Angio

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23
Q

How do Small Cortical Strokes present?

A

Peripheral Nerve Lesions/Palsies

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24
Q

How do Occipital Strokes present?

A

Predominantly confused
Visual Field Defects
Vestibular Dysfunction

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25
Q

How can Cerebral Ischaemia transform into Cerebral Infarction?

A

1) Tissue Hypoperfusion
2) Na+K+ reversal
3) Cytotoxic Oedema
4) BBB break down (allowing RBCs and Macromolecules in)

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26
Q

Describe the four stages of infarct

A

Hyperacute - first 6h
Acute - up to 7d
Subacute - up to 4m
Chronic - after 4m

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27
Q

Causes of Ischaemic Stroke can be classified using the TOAST tool. What are the 5 types?

A 
Large Artery Atherosclerosis 
Cardioembolic (confirmed by ECG)
Small Vessel disease only (eg Lacunar Stroke, <1.5cm)
Other Determined
Undetermined
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28
Q

The main aim of Non Contrast Head CT is to rule out Haemorrhagic Stroke. What are the early features of ischaemic?

A

Hypoattenuation
Sulcal Effacement
Loss of great white matter differentiation

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29
Q

What is ASPECT?

A

10 point CT scan for MCA stroke

Used for revascularisation and patient outcomes

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30
Q

Describe the use of MRI for Ischaemic Strokes

A

Shows infarct from 2h to 3wks

Very sensitive

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31
Q

Describe the use of Perfusion CT in Ischaemic Strokes

A

Uses iodinated contrast, and takes repeated images of the same level as contrast flows

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32
Q

How can the perfusion CT scans be used?

A

A curve of Arterial input and Venous outflow can be plotted

Can overlay maps of cerebral blood flow and cerebral blood volume

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33
Q

Describe the features of the Overlayed CT Perfusion Scans

A

Infarct Core (Red) - Reduced venous flow, indicating infarction

Ischaemic Penumbra (Green) - Ischaemic region characterised by reduced blood flow but maintained drainage. This is the only region that will benefit from thrombolysis

34
Q

What is the risk of thrombolysing a large Infarct Core?

A

Haemorrhagic Transformation

35
Q

When can you manage Stroke by Thrombolysis with Alteplase?

A

If <4.5h
Haemorrhagic Stroke Excluded
No Haemorrhagic Risk Factors

36
Q

Name three absolute contraindications to Thrombolysis

A

Stroke in the last two weeks
Surgery/Trauma in the last two weeks
Active Internal Bleeding

37
Q

Name three complications of Thrombolysis

A

Extracerebral Haemorrhage
Seizure
Evolution causing raised ICP

38
Q

When should Thrombectomy be carried out?

A
  • Within 6h alongside Thrombolysis is acute ischaemic stroke with occlusion of proximal anterior circulation (confirmed by angiography)
  • Within 6-24h if confirmed anterior circulation infarct with potentially salvagable tissue (limited core infarct)
  • up to 24h alongside thrombolysis if confirmed occlusion of posterior circulation (with limited core infarct)
39
Q

What other medication should be started within 24h of an Ischaemic stroke?

A

300mg Asparin Orally (alongside PPI)

Continued for 2w before switching to Clopidogrel

40
Q

How is Central Venous Thrombosis managed?

A

Full dose Heparin and then Warfarin

41
Q

Name two other managements which might need to be considered in Ischaemic Stroke

A

Decompressive Hemicraniotomy (for Malignant MCA)

End Arterectomy (if >50% atherosclerotic occlusion)

42
Q

CHADS-VASc and HAS BLED are two scores used to determine the need for anticoagulation in AF. Describe CHADS-VASc

A 
CHF
HTN
Age (>75 - 2p)
Diabetes
Stroke (2p)
Vascular disease 
Age (60-74)
Sex Category (Female)
43
Q

CHADS-VASc and HAS BLED are two scores used to determine the need for anticoagulation in AF. Describe HAS BLED

A 
HTN
Abnormal Liver/Renal
Stroke
Bleeding Predisposition
Labile INR 
Elderly (>65)
Drugs/Alcohol
44
Q

What is a Watershed Stroke?

A

Infarcts occurring during systemic hypotension at the boundaries of vascular supply (affecting those furthest from it)

Can be Cortical (between ACA/MCA/PCA territories) or Deep (between ACA/MCA/PCA and perforating Lenticulostriate)

45
Q

Define TIA

A

Transient Neurological Dysfunction characterised by focal neurological dysfunction without evidence of acute infarct

USed to be time based (<24h) but is now tissue based

46
Q

How is TIA managed?

A

300mg Asparin STAT and refer to TIA clinic

47
Q

What happens at a TIA clinic?

A 
ECG
BP
Bloods
Smoking Cessation and Lifestyle advice 
DVLA information (can't drive for a month)

May require MRI or Carotid Doppler

48
Q

What is ABCD2?

A

Risk of stroke after TIA

Age>60 
BP>140/90 
Clinical features (Speech - 1, Unilat weakness - 2)
Duration (<60 - 1, >60 -2)
Diabetes
49
Q

Haemorrhagic Strokes account for 15% of strokes. What are they?

A

Bleeding inside and around leading to hypoperfusion

50
Q

What are some clinical clues that would point towards Haemorrhagic Stroke?

A
  • Possible underlying PMH
  • Reduced consciousness at admission
  • Hx of headaches
  • Seizures
51
Q

Name two causes of PRIMARY Haemorrhagic Stroke

A

Hypertension

Cerebral Amyloid Angiopathy

52
Q

Name five causes of SECONDARY Haemorrhagic Stroke

A 
Haemorrhagic Transformation 
Tumour 
Aneruysm/AVM
Coagulopathy/Anticoagulation 
Cocaine/Alcohol
53
Q

Initially a Haemorrhagic stroke presentation depends on extent and duration. As it continues to expand, what changes occur?

A

Midline Shift
Twisted Ventricle
Intracranial Herniation

54
Q

Name four predictors of Poor Outcome

A

> 30ml
Affecting Deep Basilar or Brainstem
GCS<9
80y

55
Q

Name the 5 Subtypes of Haemorhagic Stroke

A 
Extradural Haemorrhage
Subdural Haemorrhage
SAH
Intraparenchymal 
Intraventricular Haemorrhage
56
Q

Describe the aetiology of Extradural Haemorrhage

A

Separation of the bone from the Periosteal Layer of Dura
90% associated skull fracture
Often bleeding from MMA

57
Q

How do Extradural Haemorrhages present?

A

Classic LOC immediately, then lucid interval, then further deterioration as haematoma expands

Associated cranial nerve examinations, headache, nausea and vomiting

58
Q

How do Extradural Haemorrhages present on CT?

A

Biconvex bleed limited by suture lines

59
Q

How are Extradural Haemorrhages managed?

A

Small - observation and conservative management
Raised ICP - Hypertonic Saline/Mannitol
Surgically manage if GCS<14 or clot>40ml

60
Q

What is a Subdural Haemorrhage?

A

Bleeding between arachnoid and pia matter

Sources of blood - torn bridging veins (acceleration, deceleration, senile atrophy, alcoholism, NAI)

Can be Acute, Subacute (3-7d) or Chronic (2-3 weeks)

Can be Simple (no parenchymal injury) or Complicated (Parenchymal Injury - eg Contusion)

61
Q

How do Subdural Haemorrhages present?

A

Acute - lucid interval then deterioration

Chronic - progressive anorexia, nausea and vomiting, neurological deficits , headache

Raised fontanelle in infants

62
Q

How are Subdural Haemorrhages investigated?

A

Bloods

CT - Convex shape, as it ages intensity decreases

63
Q

How are Subdural Haemorrhages managed?

A

Small - observation and conservative management
Raised ICP - Hypertonic Saline/Mannitol
Surgically manage if GCS<14 or clot>40ml

64
Q

How are SAH imaged?

A

CT - Hyperdensity around Circle of Willis/ Basal Cisterns

MRI - good for imaging reactive vasospasm

65
Q

How are Intraparenchymal Bleeds managed?

A 
Stop and Reverse Anticoagulation 
Maintain Systolic at 90-130 (for CPP)
BP Control (Labetolol, Nimodipine)

May require decompressive hemicraniotomy or EVD

66
Q

What is Cerebral Amyloid Angiopathy?

A

Pathological deposition of amylid in tunica media/adventitia of vessels

Fibrinoid degredation and microaneurysms

Association with Alzheimers

Scored on imaging using Boston Criteria CT

67
Q

Name five complications of stroke

A 
Complications of immobility (pressure sores etc)
Raised ICP
Infection 
Mood/Cognition Changes 
Post Stroke Pain
68
Q

What are the 5 R’s of Stroke Rehabilitation?

A 
Realisation of Potential
Reablement (functional independence)
Resettlement (safe transfer of care)
Role Fulfillment
Readjustment
69
Q

Where do patients go after a Stroke?

A

Either: Stroke Rehab Unit (medically stable, established NG) OR Early supported Discharge

70
Q

What is required for Early Supported Discharge?

A

Can transfer independently or with carer
Suitable home
Willing to participate
Identified goals

71
Q

When does peak Stroke recovery occur

A

Between 1-3 months due to Neuroplasticity

72
Q

Name three good prognostic factors in Stroke

A

No coma
Continence
Early motor recovery

73
Q

What is the Amber Care Bundle?

A

Patient is very unwell and unsuitable for rehab

Advanced Care Planning

74
Q

Describe the different types of Stroke Prevention

A

Primordial - Public Health Campaigns
Primary - for at risk (treat high BP etc)
Secondary (reduce disease progression - Asparin in TIA)
Tertiary - reduce disease progression in establushed

75
Q

What is the target threshold for Cholesterol

A

Total <4

76
Q

What things can be discussed with the patient in terms of Secondary prevention

A

Smoking Cessation
Diet and Exercise
Treating BP/AF
Maintaining BGC

77
Q

What is the Modified Rankin Score?

A

Assesses post stroke baseline function

0 - no symptoms
to
6 - dead

78
Q

What is a Stroke of unknown aetiology known as?

A

Cryptogenic Stroke

79
Q

What does the LACS criteria require?

A

Symptoms in two areas

If in only one area - PACS

80
Q

How would you investigate intracranial venous thrombosis?

A

MRI Angiography

Year 4 Integrated Care (5 decks)

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