Stroke Flashcards
Is a headache a symptom of an ischaemic stroke?
no, only focal neurology. Haemorrhagic strokes e.g. SAH can present with a headache
What is the window for thrombolysis in stroke?
<4.5 hr
Which investigations should be carried out in stroke?
CT, ECG, CXR, blood sugar!!!, swallow assessment!!, routine bloods, Hba1C and lipids long-term
How would a dense MCA sign appear on CT?
central white lesion
What are the four types of ischaemic stroke?
- embolic
- plaque
- hypoperfusion/hypovolaemic
- venous sinus thrombosis
A 24 y/o with no co-morbidities presents with stroke symptoms. She takes the combined oral contraceptive pill. Which type of ischaemic stroke are you worried about?
venous sinus thrombosis
Which classification is used to divide stroke?
oxford classification
Name three contraindications for thrombolysis
recent thrombolysis, warfarin/DOAC, very high BP, haemorrhagic stroke
What is the management of stroke?
thrombolysis +
- aspirin and clopidogrel
- PPI
- Statin
- ACEi
- consider anticoag
Why is omeprazole not used as PPI treatment in stroke? Which PPI is used instead?
lanzoprazole. omeprazole interacts with clopidogrel
which is the scoring system for TIAs?
ABCDD- age, BP, clinical features of TIA, duration of syx, diabetes
Why would you conduct a carotid doppler in stroke?
to look for stenosis
Name three key considerations that ensue after someone has had a stroke
- Swallow/nutrition
- Driving status
- R/L handed (Rehab)
- Depression/low mood
Name five risk factors for stroke
infective endocarditis, diabetes, alcohol, smoking, M>F, HTN, coagulopathy, obesity, stroke, syndromes
What is CADASIL?
inherited form of cerebrovascular disease, risk fx for stroke
Which classification is used for stroke
Bamford/oxford stroke classification
What are the components of the Bamford stroke classification
Total anterior circulation stroke TACS
Partial anterior circulation stroke PACS
lacunar syndrome LACS
posterior circulation syndrome POCS
Which arteries are affected in TACS
middle and anterior cerebral arteries
Which arteries are affected in PACS
part of anterior circulation?
Name two parts of the brain that are affected in POCS?
cerebellum and brainstem
What are the criteria for TACS?
All of the following three are required:
- Unilateral weakness +- sensory deficit of the face, arm, and leg
- Homonymous hemianopia
- Higher cerebral dysfunction- dysphasia, visuospatial disorder
What are the criteria for PACS?
Two of the following:
- Unilateral weakness +- sensory deficit of the face, arm, and leg
- Homonymous hemianopia
- Higher cerebral dysfunction- dysphasia, visuospatial disorder
(same criteria for TACS)
What are the criteria for POCS
One of the following:
- Cranial nerve palsy and a contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (e.g. horizontal gaze palsy)
- Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
- Isolated homonymous hemianopia
Which vessels are affected in lacunar stroke?
subcortical small vessels
What are the criteria for lacunar stroke?
One of the following:
- Pure sensory stroke
- Pure motor stroke
- Sensory-motor stroke
- Ataxic hemiparesis
Patient has contralateral homonymous hemianopia. Which artery is affected?
middle cerebral artery
Name two causes of a positive romberg’s sign?
vestibular- merniere’s, brainstem lesion, viral labyrinthisis
Proprioceptive loss- peripheral neuropathy, dorsal column (B12 deficiency)
Define stroke
rapid onset, focal neurological deficit due to a vascular lesion lasting >24hr
State two types of ischaemic stroke
atheroma and embolus
State three causes of haemorrhagic stroke
trauma aneurysm rupture anticoagulation thrombolysis increased BP
State four risk factors for stroke
HTN AF, valvular disease Peripheral vascular disease PMH Smoking DM FH
State four cardiac causes of stroke
AF Prosthetic valves Cardiac surgery Acute MI Valve vegetations
What is a differential for stroke?
- head injury +- haemorrhages
- space occupying lesion
- infecious: encephalitis, abscess
- Drugs: opiate overdose
- Hypo/hyperglycaemia
- Migraine
What is the medical management of stroke?
Alteplase <4.5 hr
Aspirin 300mg once haemorrhagic stroke excluded +- PPI
If patient is aspirin sensitive, which drug can be administered in stroke?
clopidogrel
Primary prevention strategies for stroke?
Control risk factors: HTN, hyperlipidaemia, smoking, DM, cardiac disease
Consider life-long anticoag in AF (CHADVASC2)
Carotid endarterectomy if symptomatic and 70% stenosis
Exercise!
Which is an important aspect of history in stroke?
DRIVING!! R/V law on driving following stroke
Secondary prevention for stroke?
- Risk factor control
- Aspirin initially, switch to clopidogrel after 3 weeks
- Carotid endarterectomy
- Statins
Which scoring system predicts stroke following TIA?
ABCD2 score
Difference between TIA and stroke?
blockage is temporary and blood flow is restored spontaneously
Pt has left hemiplegia and facial drop, language is intact, neglect of left side. What is the cause of stroke?
Right middle cerebral artery
What is a lacunar stroke?
occlusion of the small arteries of the brain, affecting mostly white matter, not penetrating cortex
Why should you not give food or drink to stroke patient?
need to assess swallow reflex, otherwise there will be a high aspiration risk
When are CT scans with contrast helpful?
to identify aneurysms, and tumours
What are the contraindications for tPa?
haemorrhage, coagulopathy, high BP, recent surgery, significant hypoglycaemia
Name two roles of imaging in acute stroke?
- ID haemorrhagic or ischaemic stroke 2. ID ischaemic penumbra and therefore areas of reperfusion 3. ID site of thombus (requires angiography)
What are the five mechanisms of cellular death following stroke?
- Excitoxicity 2. Apoptosis 3. Oxidative stress 4. Inflammation 5. Peri-infarct depolarisation
Patient with no cortical signs or hemianopia has had stroke, left side hypoasethesia in face, arm, and leg. No movement in left arm and leg against gravity. Classify this stroke and which vessels are affected?
lacunar syndrome, small vessels
Which investigations other than blood tests should be performed in acute stroke?
BP, ECG, brain imaging- CT or MRI, vascular imaging- CT angiogram
What is the first line long-term management for TIA or ischaemic stroke?
clopidogrel, atrovastatin after 48 hr
Patient presents with acute ischaemic stroke within 4 hours. CT shows ischaemic lesion in R hemisphere wit no evidence of haemorrhage. What is the next step?
thombolysis AND throbectomy (2019 guidelines) within 4.5 hours. Thrombectomy decision based on rankin score<3 and NIHSS >5.
