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Finals: Medicine > Stroke > Flashcards

Stroke Flashcards

1
Q

Define a stroke

A

Represents a sudden interruption in the vascular supply of the brain

It is characterised by sudden onset of rapidly developing focal or global neurological disturbance, which lasts > 24 hours or leads to death

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2
Q

What is the other name for a stroke

A

cerebrovascular accident

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3
Q

Why does a loss of oxygen supply lead to irreversible damage in the brain

A

The neural tissue of the brain is completely dependent on aerobic metabolism (it cannot do anaerobic metabolism)

Hence a loss of oxygen supply lead to irreversible damage in the brain

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4
Q

There are two main types of strokes.

What are they

A

Ischaemic and Haemorrhagic

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5
Q

Why type of stroke is most common

a) Ischaemia
b) Haemorrhagic

A

Ischaemic Stroke (most common – 85%)

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6
Q

What happens in the brain for an Ischaemic stroke to occur

A

Occurs as a result of occlusion of the blood vessels that supply the brain parenchyma leading to infarction (tissue necrosis secondary to ischaemia)

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7
Q

What happens in the brain for an Haemorrhagic stroke to occur

A

The result of weakening of the cerebral vessels leading to cerebral rupture causing bleeding/haematoma formation within the brain parenchyma, ventricular system or subarachnoid space

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8
Q

What is the direct and indirect cause of he clinical deficits associated with haemorrhagic stroke

A

Clinical deficit is caused directly by neuronal injury

Indirectly by cerebral oedema (this peaks at day 5 following symptom onset)

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9
Q

Haemorrhagic stroke classification can be subdivided further.

Name these subdivision

A

Intracerebral haemorrhage (ICH) – most common

Subarachnoid haemorrhage (SAH)

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10
Q

What is the essential problem that causes an ischaemic stroke

A

‘Blockage’ in the blood vessel stops blood flow

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11
Q

What is the essential problem that causes a haemorrhagic stroke

A

Blood vessel ‘bursts’ leading to reduction in blood flow

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12
Q

What proportion of strokes are ischaemic

A

85%

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13
Q

What proportion of strokes are haemorrhagic

A

15%

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14
Q

Name some of the modifiable risk factors for stroke

A
  • Cigarette smoking
  • Obesity
  • Hypercholesterolaemia (high serum cholesterol)
  • Hypertension
  • Combined contraceptive pill
  • Sedentary lifestyle
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15
Q

Name some of the non-modifiable risk factors for stroke

A
  • Cardiovascular disease comorbidities e.g, angina, myocardial infarction and peripheral vascular disease
  • Age (>65 years old)
  • Male gender
  • Atrial fibrillation (5 x greater risk)
  • Previous stroke or TIA
  • Diabetes mellitus
  • Hypercholesterolaemia
  • Carotid artery disease
  • Thrombophilia
  • Sickle cell disease
  • Vasculitis
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16
Q

Define the term “Transient Ischaemic Attack (TIA)”

A

It is transient neurological dysfunction secondary to ischaemia without infarction

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17
Q

How long will it take for most symptoms of the Transient Ischaemic Attack (TIA) to resolve?

A

Within 1 hr

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18
Q

Define the term “ischaemia”

A

Refers to the reduction/lack of blood flow to the tissue

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19
Q

Define the term “Infarction “

A

Refers to the cellular changes that can occur as a result of reduced/no perfusion to the tissue

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20
Q

Name the four key features of stroke

A
  • Sudden weakness of limbs
  • Sudden facial weakness
  • Sudden onset dysphasia (speech disturbance)
  • Sudden onset visual or sensory loss
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21
Q

Patients with what kind of stroke are more likely to present with global features such as headache and altered mental status.

A

haemorrhagic stroke

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22
Q

Name some of the clinical features associated with haemorrhagic stroke

A
  • Headache
  • Altered mental status
  • Nausea & Vomiting
  • Hypertension
  • Seizures
  • Decrease in the level of consciousness
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23
Q

Ischaemic Strokes are classified by what classification scale

A

Bamford/Oxford classification

24
Q

Anterior cerebral artery supplies what lobes

A

Part of the frontal and parietal lobe.

25
Q

What are the clinical features associated with an anterior cerebral artery ischaemic stroke

A
  • Unilateral weakness and/or sensory deficit on the contralateral face, arms and/or legs
  • Homonymous hemianopia: visual field loss on the same side of both eyes
  • Higher cerebral dysfunction: dysphasia, visuospatial dysfunction e.g., neglect, agnosia
26
Q

What are the clinical features associated with an middle cerebral artery ischaemic stroke

A
  • Contralateral hemiparesis and sensory loss – upper extremity > lower
  • Contralateral homonymous hemianopia (visual field loss on the same side of both eyes)
  • Aphasia (inability to comprehend speech, occurs if it affects left/dominant hemisphere)
  • Visuospatial problems
  • Apraxia (inability to create speech, occurs if it affects the right/non-dominant hemisphere)
27
Q

Middle cerebral artery supplies what lobes

A

Supplies a large proportion of the lateral surface of each brain hemisphere including the internal capsule and basal ganglia

28
Q

Posterior cerebral artery supplies what lobes

A

Supplies the occipital lobe and inferior proportion of the temporal lobe as well as some deep structures (e.g. thalamus).

29
Q

What are the clinical features associated with a posterior cerebral artery ischaemic stroke

A
  • Contralateral homonymous hemianopia with macular sparing
  • Memory deficits
  • Several visual defects – lack of depth, hallucinations
30
Q

Broca’s area is responsible for ____ speech

a) Fluent
b) The understanding of

A

a) Fluent

31
Q

Wernicke’s area is responsible for ____ speech

a) Fluent
b) The understanding of

A

Wernicke’s area is responsible for the understanding of speech

32
Q

A lesion in the Broca’s area results in _____

a) Expressive dysphasia
b) Receptive dysphasia

A

A lesion in the Broca’s area results in a) Expressive dysphasia

33
Q

A lesion in the Wernicke’s area results in _____

a) Expressive dysphasia
b) Receptive dysphasia

A

A lesion in the Wernicke’s area results in b) Receptive dysphasia

34
Q

What is the name of the tool used in the community to recognise stroke

A

FAST tool

35
Q

What is the name of the tool used in the hospital to recognise stroke

A

ROSIER

36
Q

ROSIER tool to recognise stroke is based on what factors?

A

Clinical scoring tool based on clinical features and duration

37
Q

Stroke is likely if the patient scores what on the ROSIER tool

A

> 0

38
Q

What is the gold standard investigation for stroke

A

Non-contrast CT head scan

39
Q

Why is neuroimaging needed urgently if there is a suspection of stroke

A

Urgent imaging as patient may be suitable for thrombolytic therapy to treat early ischaemic strokes

40
Q

If CT scan is contraindicated for whatever reason what is the next best neuroimaging modality for stroke

A

MRI scan of head

41
Q

What are the key CT features of an ischaemic stroke

A

May appear normal in the first few hours of the stroke - areas of low density in the grey and white matter will develop over time

42
Q

What are the key CT features of a haemorrhagic stroke

A

Areas of hyperdense material (blood) surrounded by low density (oedema)

43
Q

What is the first line management for a patient with a stroke

A

ABCDE assessment - making sure they are haemodynamically stable

44
Q

At what GCS does a patient need intubated to protect their airways

A

GCS < 8

45
Q

What is the management of a haemorrhagic stroke

A

Management depends on the extent of bleeding and the suitability for neurosurgical interventions

Potentially neurosurgical input (particularly for larger bleeds)

Most small bleeds, there is no requirement for neurosurgical intervention.

Managing underlying risk factors (see secondary prevention of stroke)

46
Q

What are the potential neurosurgical interventions for managing a large haemorrhagic bleed

A

Includes use of decompressive hemicraniectomy in those meeting specific clinical criteria or suboccipital craniotomy for posterior fossa bleeds

47
Q

What is the initial management of an ischaemic stroke

A

Loading dose aspirin (300mg) and consider:

<4.5 hrs from symptom onset: thrombolysis

< 24 hrs from symptom onset: thrombectomy

48
Q

What drug is used in Thrombolysis of ischaemic stroke

A

Alteplase

49
Q

What is Alteplase

A

Alteplase is a tissue plasminogen activator that rapidly breaks down clots and can reverse the effects of a stroke

50
Q

Name three contraindictors against thrombolysis use in ischaemic stroke

A

Neurosurgery last 3 months

Active internal bleeding (hence done only after CT has excluded haemorrhagic stroke)

Onset of Symptoms > 4.5 hrs

51
Q

What is the thrombolysis window for ischaemic stroke

A

Onset of symptoms < 4.5 hrs

Limited benefit beyond this time with increased bleeding risk

52
Q

Name a post thrombolysis complication

A

Intracranial or systemic haemorrhage

53
Q

What is involved in thrombectomy

A

Involves mechanical removal of the clot causing the ischaemic stroke in specialist centres by the interventional neuroradiology team

54
Q

What is the timeframe in which thrombectomy can be used in the management of patients with ischaemic stroke

A

Not used after 24 hours from the onset of symptoms

55
Q

Name some of the secondary preventions for strokes

A
  • Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily)
  • Atorvastatin 80mg should be started but not immediately
  • Carotid endarterectomy or stenting in patients with carotid artery disease
  • Treat modifiable risk factors such as hypertension and diabetes
56
Q

Following a stroke, patients who drive a car or motorcycle should be advised to stop driving for how long?

A

One month

57
Q

Name the 5 parts of managing a patient with a stroke

A

Part 1: Stablising the patient (ABCDE assessment)

Part 2: Imaging with non contrast CT head scan

Part 3: Intervention

Haemorrhagic stroke - consider neurosurgical intervention

Ischaemic stroke - loading dose aspirin (300mg) and:

<4.5 hrs from symptom onset: thrombolysis

< 24 hrs from symptom onset: thrombectomy

Part 4: Secondary prevention

Part 5: Stroke rehabiliation

Finals: Medicine (91 decks)

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