Stroke Flashcards

Question

What is cerebral amyloid angiopathy (CAA)?

Answer 1

* Amyloid build up on walls in the brain * Causes Alzheimer’s dementia, stroke

Answer 2

* Denotes 5 subtypes of ischaemic stroke, based on clinical symptoms as well as radiological and other investigation results 1. Large-artery atherosclerosis 2. Cardio-embolic 3. Small-vessel occlusion (lacunae) 4. Stroke of other determined aetiology 5. Stroke of undetermined aetiology

Answer 3

* Face Arm Speech Test- positive if any of the following are met * **_NEW FACIAL WEAKNESS_**: Can pt smile/ has face fallen to one side * **_NEW ARM WEAKNESS_**: Can pt raise both arms and keep them there * **_NEW SPEECH DIFFICULTY_**: Can pt speak clearly & understand what you say, is their speech slurred * Used outside hospital to screen people with sudden onset of neurological symptoms for a diagnosis of stroke or TIA * Well known within the community

Answer 4

* A variant of the FAST screening tool * Used by medical professionals to establish the diagnosis of a suspected stroke or TIA when pts are admitted into ED * Looks at: LoC or syncope, seizure activity, asymmetric facial weakness, arm weakness, leg weakness, speech disturbance, visual field defect

Answer 5

* Aspirin 300mg daily * Supplemental O2 if their O2 sats \<95% * Offer secondary prevention in addition to aspirin as soon as TIA diagnosis is confirmed * Refer to TIA clinic * After specialist assessment in TIA clinic, consider MRI to determine territory of ischaemia, or to detect haemorrhage or alternative pathologies- perform on same day as assessment * Immediate statin treatment not recommended; continue statins if they were already receiving them

Answer 6

* Indications for thrombolysis or thrombectomy * On anticoagulant therapy * Known bleeding tendency * Depressed GCS \<13 * Unexplained progressive or fluctuating symptoms * Papilledema, neck stiffness, fever * Severe headache at onset of stroke symptoms

Answer 7

* Admission to stroke unit * Revascularisation therapy (IV alteplase, within 4.5 hrs, or thrombectomy for patients with large vessel occlusion, 6hr therapy window) * Optimising physiology and surveillance, prevention and early intervention of complications * Nutritional support * Secondary prevention (antiplatelet therapy, anticoagulation, carotid endarterectomy (CEA), BP, lipid control) * Rehabilitation

Answer 8

* 999 call * Urgent paramedic assessment * FAST +ve * LRI ED- core stroke team alerted- Rapid Assessment Protocol (RAP) * The RAP team have 5 priorities 1. Clinically confirm diagnosis, that thrombolysis is indicated, get venous access, do bloods, obs, weigh, request CT scan 2. Identify contraindications (outside of imaging) 3. Complete consent/ assent (or best interest) 4. Imaging 5. Bolus and infusion

Answer 9

* Exclusion of intracranial haemorrhage * Early changes diagnostic for ischaemic stroke- * Evidence of thrombus in vessels- clotted blood is white on CT hence vessels become white * Effacement (swelling of brain cells) & loss of grey and white matter distinction * The failure of membrane transport à consequent intracellular fluid and electrolyte shifts results in brain cell swelling * Normally white matter has darkish hue on CT due to myelin, when grey matter cells absorb excess water the attenuation changes and resembles white matter à loss of grey and white matter distinction * Quantifying effacement & obscuration is the basis of the ASPECTS score

Answer 10

* Treatment is started as soon as possible within 4.5 hrs of onset of stroke symptoms * Intracranial haemorrhage has been excluded by appropriate imaging techniques

Answer 11

* Indications: * Administered within 4.5 hours from onset of stroke symptoms * Disabling impairments (NIH\>4, dysphasia, inability to self-care or mobilise independently, visual field defect, dysphagia) * No contraindication * Contraindications: see table in image attached

Answer 12

* (Alberta Stroke Programme Early CT Score) * 10 point quantitative topographic CT scan score used in patients with middle cerebral artery (MCA) stroke * Segmental assessment of the MCA vascular territory is made and 1 point is deducted from the initial score of 10 for every region involved * Used in revascularisation therapies for patient selection and outcome prediction

Answer 13

* Combination with thrombolysis (if not contraindicated & within the time window) * For ischaemic stroke * Thrombectomy involves removal of thrombus from vessel * NICE set out specific criteria for use of thrombectomy- Offer as soon as possible to people who were last known to be well between 6 and 24 hrs previously: * Who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation determined by CT or MRI, AND * If there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Answer 14

The 4Ps * Pipes- exploration of blood vessels, usually via CT and sometimes MR angiography * Parenchyma- exploration of tissue compromise in terms of cell death, usually via non contrast CT or MRI * Perfusion and penumbra- continue the theme of tissue compromise but go beyond cell death by clarifying ‘tissue at risk’

Answer 15

* Required special anticipation to address raised ICP due to haematoma expansion * Blood pressure control- offer rapid BP lowering who present within 6 hrs of symptom onset, have systolic between 150-220 * Aim for systolic target 130-140 within 1hr starting treatment & maintain this bp for at least 7 days * Correcting clotting derangements * Maintaining good glycaemic control * Coughing, constipation- straining increases abdo pressure, urinary retention causing increase in BP- all these things can contribute to increasing haematoma expansion so pay attention to addressing those * Pts with any of the following rarely require surgical intervention and should receive initial medical treatment: small deep haemorrhages, lobar haemorrhage w/o either hydrocephalus or rapid neurological deterioration, large haemorrhage and significant comorbidities before stroke, GCS \<8 unless because of hydrocephalus * Decompressive hemicraniectomy for clinical deficits suggesting MCA, decreased level of consciousness

Answer 16

* Neurosurgery as a strategy for managing raised ICP is a balance between the following: * Surgical accessibility- is it superficial and accessible to surgical evacuation or aspiration * Neurological stability- GCS, previously frail?, are they likely to survive anaesthesia or improve neurologically after surgery because raised ICP has already caused irreversible harm * If hydrocephalus develops, insert ventricular drain

Answer 17

* For management of malignant oedema in \<60years old, but otherwise biologically fit stroke pts above this cut off * Malignant oedema means a large MCA infarction * Acute brain swelling * Referrals should be made within 24 hrs & surgery completed within 48 hrs

Answer 18

* Recurrent stroke- due to unaddressed aetiological factors before cause of stroke is clarified and secondary prevention efforts optimised * Extension of stroke- due to loss of ischaemic penumbra resulting from suboptimal physiology * Raised ICP- due to haematoma expansion, malignant oedema, haemorrhagic transformation or hydrocephalus * Infections- aspiration pneumonia, UTI due to incomplete bladder emptying either from constipation or bed bound posture * Complications of immobility- VTE, constipation, bed sores * Mood & cognitive dysfunction- can affect motivation and compliance with rehabilitation * Post stroke pain – due to spasticity, joint dislocation, central/ neuropathic pain * Fatigue- due to poor sleep, medications, inherent result of brain cell damage * Spasticity, contractures, secondary epilepsy

Answer 19

* A common complication of acute ischaemic stroke * Occurs when peripheral blood extravasates across a disrupted BBB into the brain following ischaemic stroke * Usually occurs following cardioembolic strokes and is more likely with larger infarct size

Answer 20

* Excessive volume of CSF within ventricular system of brain * Symptoms of raised ICP- headache worse in morning, lying down, and during Valsalva; N&V; papilloedema; coma * Haemorrhage within brain can cause obstructive hydrocephalus due to blocking outflow of CSF * Ix- CT head is first line * Mx- external ventricular drain (EVD) is used in acute severe hydrocephalus, inserted into right lateral ventricle & drains into a bag bedside

Answer 21

* Mass effect: * Effacement/ displacement/ twisting of ventricles * Hydrocephalus * Midline shift * Cerebral herniation- subfalcine, uncal, tenting, coning * Raising ICP

Answer 22

* Surveillance * Daily review of EWS, obs, mood, chest, legs (DVT), bowel, urine function, progress of impairments * Timely bloods eg CRP- infection identification and other complications such as LFTs from statins, HB drop from antithrombin therapy

Answer 23

* Antithrombotic therapy (antiplatelet vs anticoagulation- 2 weeks of aspirin 300mg followed by clopidogrel 75mg daily) * BP control (average \<130/80) * Lipid control (commence statins 48 hrs after initiation of a stroke, avoid in cerebral haemorrhage) * Glycaemic control (HbA1C \<7) * Carotid endarterectomy (symptomatic ICA \>50% lumen reduction & NASCET 50-99%) * Lifestyle- stop smoking, weight loss, optimise sleep, exercise * Swallow and nutrition assessment * Rehabilitation- all members of MDT such as PT, OT, SALT, dietician, social worker, stroke coordinator, neuropsychologist * Palliative care- early recognition and referral for those suspected with poor outcome

Answer 24

* Smoking cessation * Maintain avg BP \< 130/80 * Glycaemic control to HbA1c\<7 * Total cholesterol \<4 and LDL \<2 * Wt loss BMI \<25 * Promotion of exercise * OSA

Answer 25

* Anticoagulation- IV or subcut heparin, warfarin, DOACs * Left atrial appendage closure- option for stroke secondary prevention in pts with AF in whom anticoagulation is contraindicated

Answer 26

* National Institutes of Health Stroke Scale * 15 item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual field loss, extraocular movement, motor strength, ataxia, dysarthria, sensory loss * A trained observer rates the pt’s ability to answer Qs and perform activities * Provides a quantitative measure of the clinical outcome in stroke * Scoring system out of 42: score \<4 is good, \>22 means a significant proportion of the brain is affected, \>26 is often a contraindication for thrombolysis

Answer 27

* Used to measure the degree of disability in pts who have had a stroke * Compared over time to check for recovery and degree of continued disability * Score of 0 is no disability, 5 is disability requiring constant care for all needs, 6 is death * 0 = no symptoms 1. No significant disability, able to carry out all usual activities, despite some symptoms 2. Slight disability, able to look after own affairs w/o assistance, but unable to carry out all previous activities 3. Moderate disability, requires some help, can walk unassisted 4. Moderately severe disability, unable to attend to own bodily needs w/o assistance and unable to walk w/o assistance 5. Severe disability, requires constant nursing care and attention, bedridden, incontinent 6. Dead

Answer 28

* Broad prognostic groups can be initially derived from NIHSS score and OCSP class * Functional prognosis- recovery trajectory. Recovery will continue until a pt reaches their functional plateau- 3 groups 1. Early, high functioning plateau – the extreme version of this is a TIA or minor stroke, signifying excellent functional prognosis. 2. Early, low functioning plateau – the extreme version of this is a TACS with no meaningful improvement in function as time passes, signifying poor functional prognosis. 3. Delayed & medium functioning plateau – this will likely define recovery in most moderate strokes. These patients will benefit from a chance at sustained rehabilitation efforts until a functional plateau is achieved

Answer 29

* GOOD * Absence of coma * Early motor recovery * Continence * POOR * Severe communication deficit * Old age * Incontinence * Neglect * No leg movement at 2 weeks * Severe upper limb weakness at 4 weeks

Answer 30

* 4 week driving restriction for standard car licenses * 1 year for HGV vehicles * Residual visual field dysfunction is subjected to separate requirements before license reinstatement

Answer 31

* Unsafe swallow function- * Tube assisted enteral feeding is temporary pending safe swallow function * Assessing swallowing- video fluoroscopy and flexible endoscopic evaluation of swallowing (FEES) * Prolonged use/ commencement of parenteral feeding is best avoided when pts are approaching end of life- no real improvement to QoL or preventing death * If patients are unable to swallow adequate food/ fluids orally by 4 weeks from stroke onset- gastrostomy feeding can be considered

Answer 32

* Mobility, ADLs, speech and cognitive therapy * Managing spasticity- including orthotic prosthesis and botulinum toxin therapy * Environmental modifications

Answer 33

* Hypoglycaemia * Migraine aura * Focal epilepsy (symptoms spread over seconds & often include twitching & jerking) * Hyperventilation * Retinal bleeds * Rare mimics- malignant htn, MS, intracranial tumours, peripheral neuropathy, phaeochromocytoma, somatization

Answer 34

* Dysarthria- peripheral vocal apparatus, facial/tongue/ throat muscles * Vertigo- vestibular dysfunction (rather than cerebellum) * Diplopia- external ocular muscles, peripheral cranial nerve dysfunction (rather than pons) * Peripheral motor/ sensory dysfunction- eg in dermatomal distribution- can be sudden, focal, predominantly negative but won’t fit into a cerebral vascular territory

Answer 35

* BPPV * Positive Dix-Hallpike test will confirm diagnosis * Epley manoeuvre is a therapeutic procedure, additional vestibular exercises

Answer 36

* Vestibular neuronitis- common presentation of sudden onset vertigo that may bring suspicion of stroke * Head thrust test confirms diagnosis

Answer 37

* Transient global amnesia – dysfunction of episodic memory which is the memory of event. 3 steps to episodic memory: registration, storage, retrieval * When something first happens, brain registers the events = registration * The brain stores the memory it has registered = storage * If after a week, you can remember certain things eg recognise a voice = retrieval * Other types of memory are preserved eg biographic memory (who you are, where you are), procedural memory (eg making cup of tea) * During TGA they are unable to register events hence ask the same questions again and again * It can last a few hours

Answer 38

* This is migraine with aura * Visual, sensory, cognitive, speech aura all present in this pt * The physiological phenomenon underlying migranous aura is cortical spreading depression and the brain location undergoing CSD explains the nature of the aura. The spreading nature explains why migraine aura are gradual in evolution and separate auras tend to evolve sequentially as CSD moves from one brain location to another

Answer 39

* Physiologically characterised by cortical spreading depression or aura activity * Hence gradual onset, migratory and sequential onset of migraine aura symptoms * CSD involves altered but continuing brain cell activity- TIA involves cessation of action potentials * +/- headache * Visual aura (occipital lobe) is the most common but others are possible- tinnitus & dysphasia (temporal lobe), pines and needles/ transient cognitive disturbance (parietal lobe), unsteadiness/ dizziness/ collapse/ hemiparesis (cerebellum, brainstem) * Explore triggers

Answer 40

* Functional neurological disorder describes neurological symptoms such as limb weakness, tremor, numbness, blackouts * Caused by a problem with the functioning of the nervous system * Symptoms- * Motor dysfunction- eg functional limb weakness/ paralysis, movement disorders including tremor, spasms (dystonia), myoclonus (jerky movements), gait disorder, dysphonia * Sensory dysfunction- eg altered sensation, visual symptoms including loss of vision or diplopia * Episodes of altered awareness- eg blackouts, non-epileptic seizures * Exact cause is unknown * Mx- holistic approach: physiotherapy for motor symptoms, CBT, occupational therapy, speech therapy

Answer 41

* Chameleons- when stroke syndrome presentations deviate from the typical presentation * Venous infarcts- gradual onset, preponderance for seizure activity * Small cortical strokes- peripheral nerve lesions * Limb shaking TIA- can appear like a focal seizure- classically due to carotid low flow * Occipital strokes- predominant confusion, unexplained delirium- rule out other causes of delirium (should be visual field loss) * Stroke amnestic syndromes * Stroke mimicking vestibular dysfunction

Answer 42

* The meninges cover the brain and the spinal cord- there are three layers * Dura mater (outermost) * Arachnoid mater * Pia mater (innermost- tightly adhered to surface of brain & spinal cord, followed gyri & fissures)

Answer 43

* Underneath the arachnoid mater * Contains cerebrospinal fluid- cushion to brain * Arachnoid mater projections (arachnoid granulations\_ allow CSF to re-enter the circulation via dural venous sinuses

Answer 44

* Acute presentation, young men, 90% have skull fracture * Limited by sutures, bi-convex, hyperdense * Outer layer (periosteum) lacerates, inner layer (meningeal) is intact * Blood collects between naked bone and inner layer of dura mater

Answer 45

* Meningeal vessels * Dural sinus

Answer 46

* Dissection of subdural space- haematoma spreads around the brain, between arachnoid and dura- arachnoid intact * Convex, not crescentic * Sources of bleed- torn bridging veins * Classic presentation- middle age, severe trauma, bleeding can be rapid, localised, hyperdense

Answer 47

* Contralateral hemiparesis and sensory deficits * Lower extremities affected worse than upper

Answer 48

* Contralateral hemiparesis and sensory loss * Upper extremities affected worse than lower * Contralateral homonymous hemianopia may be present * Aphasia may be present

Answer 49

* Contralateral homonymous hemianopia with macular sparing * Visual agnosia

Answer 50

* Branches of the posterior cerebral artery that supply the midbrain become blocked * Ipsilateral CN III palsy * Contralateral weakness of upper and lower extremity

Answer 51

* AKA ***_Wallenberg syndrome_*** * Most commonly due to blockage of the ***_posterior inferior cerebellar artery,_*** causing ischaemia of the lateral part of the medulla oblongata in the brainstem * Ipsilateral facial pain and temperature loss * Contralateral limb/ torso pain and temperature loss * Ataxia and nystagmus * Loss of temperature sensation and pain from the involvement of the lateral spinothalamic tract

Answer 52

* = Lateral pontine syndrome * Symptoms similar to lateral medullary syndrome- this artery supplies the pons and the cluster of signs is known as the lateral pontine syndrome * In addition to the findings of lateral medullary syndrome, ipsilateral facial paralysis and deafness would be expected

Answer 53

* Amaurosis fugax

Answer 54

* Basilar artery

Answer 55

* Lesion of the inferior frontal gyrus * Expressive aphasia where the patient’s speech is non-fluent and halting, repetition is impaired * They can comprehend commands as language comprehension remains relatively intact * Caused by infarcts to the superior division of the left MCA * Broca sounds like ‘broken’ as the patient’s word flow is broken

Answer 56

* Affecting the arcuate fasciculus, the connection between Wernicke’s and Broca’s area * Speech fluent, repetition poor * Comprehension relatively intact

Answer 57

* Lesion of the superior temporal gyrus * Speech fluent, comprehension abnormal, impaired ability to repeat back phrases * = Receptive aphasia * Commonly secondary to an ischaemic stroke affecting the inferior left MCA * Word salad

Answer 58

* Both Wernicke’s and Broca’s areas are damaged * Impairment of language production, comprehension and repetition * Poor stuttering word flow with poor comprehension * May be able to communicate w/ facial gestures or movements

Answer 59

* Either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia * Strong association with hypertension * Common sites include the basal ganglia, thalamus and internal capsule

Answer 60

* Non-contrast CT head scan * The Question to answer is is this an ischaemic stroke or a haemorrhagic stroke * Rarely a third pathology such as a tumour may be detected * This allows us to decide whether to thrombolyse the patient

Answer 61

* Acute ischaemic stroke * May show areas of low density in the grey and white matter of the territory * These changes may take time to develop * Other signs include the hyperdense artery sign corresponding with the responsible arterial clot * This tends to be visible immediately * Acute haemorrhagic stroke * Typically show areas of hyperdense material (blood) surrounded by low density (oedema)

Answer 62

* To rule out intracerebral haemorrhage * Adding contrast is unnecessary and could make any haemorrhages less easy to see * A contrast CT scan would therefore NOT be done in the acute investigation of stroke

Answer 63

* Blood sugar * Hypoglycaemia can lead to focal neurological symptoms * Especially important in diabetic pts

Answer 64

* Similar to stroke but features resolve within ~1hr * Unilateral weakness or sensory loss * Aphasia or dysarthria * Ataxia, vertigo or loss of balance * Visual problems * Amaurosis fugax * Diplopia * Homonymous hemianopia

Answer 65

* Tissue-based- a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, w/o acute infarction * (Used to be time-based)