Stroke Flashcards
How common is stroke?
11% of all deaths in England
What are different types of stroke and their prevelances?
- Ischaemic: 87%
- Haemorrhagic: 10%
- Subarachnoid haemorrhage: 3%
What is ischaemic stroke?
- syndrome not disease
2. reduction in cerebral blood flow due to arterial occlusion or stenosis
What is a haemorrhagic stroke?
spontaneous intracerebral haemorrhage
What are RF for ischaemic stroke?
- Older age
- FHx of stroke
- Hx of ischaemic stroke
- Hypertension
- Smoking
- DM
- AF
- Sickle cell
- Dyslipidaemia
What are RF for haemorrhgaic stroke?
- Hypertension
- Older age
- Male sex
- Asian
- Heavy alcohol use
- Fhx
- Haemophilia
- Anticoagulation
- Etc
What are common causes for haemorrhagic stroke?
- Long standing hypertension
- Cerebral amyloid Angiopathy
- Sympathomimetic drugs of misuse e.g. cocaine and amphetamine
Where in the brain are infarct of stroke commonly?
Cerebral infarcts: 50%
Brainstem infarct: 25%
Lacunar infarcts:25%
What are common signs and symptoms of an ischaemic stroke?
- Unilateral weakness or paralysis in face, arm or leg
- Dysphasia
- Ataxia
- Visual disturbance
- Headache
- Numbness
What are common signs and symptoms of haemorrhagic stroke?
- Unilateral weakness or paralysis in face, arm or leg
- Dysphasia
- Dysarthria
- Visual disturbance
- Headache
- Photophobia
- Ataxia
What are possible DDx for stroke?
- Intracerebral haemorrhage
- TIA
- Hypertensive encephalopathy
- Hypoglycaemia
- Complicated migraine
- Seizure
- Wernicke’s encephalopathy
- Brain tumour
What is the first line investigation for stroke?
immediate non-contrast head CT
What would a non-contrast CT head show in ischaemic stroke?
- hypoattenuation (darkness) of brain parenchyma
- loss of grey matter-white matter differentiations and sulcal effacement
- hyperattentuaton (brightness) in an artery indicates clot within vessel lumen
What would non contrast CT head show in haemorrhagic stroke?
hyperattenuation (brightness), suggesting acute blood, often with surrounding hypoattenuation (darkness) due to oedema
What bloods would you do for stroke and why?
- Serum glucose
- Serum electrolytes
- Serum U and E
- Cardiac enzyme
- FBC
- ECG
- PT and PTT with INR
Why are you checking clotting factors?
to see if coagulopathy
What is the management of ischaemic stroke?
- ABCDE
- Admit everyone within 4hr presentation
- IV alteplase: 0.9mg/kg within 4.5 hrs of onset and intracranial haemorrhage excluded
What else is added to the treatment of ischaemic stroke?
- Mechanical thrombectomy performed in some within 6-24hrs of symptoms onset
- Antiplatelet agent ASAP e.g. aspirin 300mg
What is the treatment of ischaemic stoke after 4.5hr?
- Supportive care + monitoring + antiplatelet agent + VT prophylaxis + high-intensity statin
- Consider mechanical thrombectomy
What is the 1st line treatment for haemorhagic stoke?
1st line: supportive care and monitoring + neurosurgery assessment
- rapid BP control
- urgent reversal anticoag
- Vt prophylaxis
What are complications of ischaemic stroke?
- DVT
- Haemorrhagic transformation of ischaemic stroke
- Alteplase-related orolingual oedema
- Depression
- Aspiration pneumonia
What are the complications of a hameorrhgaic stroke?
- Infection
- DVT
- seizures
- Delirium
- Aspiration pneumonia
What acronym is used for assement of stroke?
- ROSIER in A and E
- FAST in community
What is the mortality of stroke?
haemorrhagic High mortality 35%-40% than ischaemic stroke
What does the anterior cerebral artery (ACA) supply?
- Medial and superior parts of frontal lobe
2. Anterior parietal lobe
What are the associated signs in a ACA stroke?
- Contralateral hemiparesis to more lower limbs > upper limbs/face
- Behavioural changes
What does the middle cerebral artery (MCA) supply?
Lateral parts of frontal, temporal and parietal lobes
What are the associated signs in a MCA stroke?
- Contralateral hemiparesis: upper limbs/face > lower limbs
- Contralateral hemisensory loss
- Apraxia
- Aphasia
- Quadranotopias
What is Broca’s area responsible for?
Responsible for speech production
What does a stroke in Brocca’s area result in?
expressive aphasia
B for ‘buccal’ or ‘bouche’ (your mouth is where speech is produced)
What is Wernicke’s area responsible for?
Responsible for speech comprehension
What does a stroke in Wernicke’s area result in?
receptive aphasia
W for “What do you mean?”
What would a lesion at parietal upper optic radiation mean?
contralateral homonoygous inferior quadranopia
What would a lesion at temporal lower optic radiation
Contralateral homonymous superior quadranopia
What does the posterior cerebral artery (PCA) supply?
- Occipital lobe
2. Inferior part of temporal lobe
What are the associated signs in a PCA stroke?
- Contralateral homonymous hemianopia
2. Visual agnosia (difficulty recognising familiar objects/faces)
What would a lesion at the occipital visual cortex lead to?
contralateral homonymous hemianopia (macular sparing)
What would a lesion at the optic tract lead to?
contralateral homonymous hemianopia
What would a lesion at the optic chiasm lead to?
bitemporal hemianopia
What would lesion of optic nerve result in?
ipsilateral monocular visual loss
What would a posterior circulation stroke lead to?
- damage in the brainstem
2. (don’t confuse with posterior cerebral artery with contralateral signs)
What signs does a cerebllar lesion give?
ipsilateral signs
DANISH
What are the signs of a cerebllar stroke?
- Dysdiadochokinesia
- Ataxia (gait and posture)
- Nystagmus
- Intention tremor
- Slurred, staccato speech
- Hypotonia/Heel-shin test
+ Decreased consciousness
What is the rosier score?
RISK OF STROKE IN EMERGENCY ROOM
Why do you measure serum glucose?
hypoglycaemia may minimic stroke
Why do you measure serum U+Es?
exclue hyponatremaia
Why do you measure cardiac enzymes?
eg. troponin → exclude concomitant myocardial infarction
Why do you measure FBC?
Check for anaemia or thrombocytopenia prior to possible initiation of thrombolysis or anticoagulant
Does a normal CT rule out ischaemic stroke?
no
What is the management plan for an iachamic stroke less than 4.5 hours from symptoms onset?
- Thrombolysis - IV alteplase
(Recombinant tissue plasminogen activator, r-tPA) - Then give aspirin (300 mg, oral)
- Note: Endovascular interventions can be beneficial in large vessel occlusions
What is the management plan for an ischamic stroke more than 4.5 hours from symptoms onset or thrombolysis contraindictaed?
Aspirin (300 mg, oral)
What are contraindications for thrombolysis?
- Symptom onset > 4.5 hours
- CT reveals acute trauma or haemorrhage
- Symptoms suggestive of subarachnoid haemorrhage
- High INR, APPT, PT
What is done at stroke unit?
- Swallowing assessment -aspiration pneumonia, choking
- VTE prophylaxis
- GCS monitoring
- Early mobilization and rehabilitation
- MDT approach
What further investigations may be done for iachameic stroke?
- find cause
1. CT angiogram
2. Carotid doppler
What can CT angiogram show?
performed in all patients with acute ischaemic stroke and suspicion of a large vessel occlusion who would be candidates for endovascular thrombectomy
When is a carotid doppler used?
- Checks for carotid artery stenosis
- If >70% occlusion, carotid endarterectomy recommended
What is the surgical option after ischaemic stroke?
carotid endarterectomy
What is the secondary prevention for ischaemic stroke?
antiplatelets
What antiplatelets are given for AF patients?
Warfarin prophylaxis
What antiplatelets are given for non-AF patients?
- Continue 75mg aspirin for 2 weeks
2. Then switch to lifelong 75 mg clopidogrel
What lifestyle changes are reccomended for stroke patient?
- Avoid heavy drinking
- Glucose control
- Maintenance of healthy BMI
- Aerobic activity
- Reduce salt intake
How is haemorrhgaic stroke managed?
- ICU or surgery
- Important NOT to administer thrombolysis or aspirin in suspected haemorrhagic strokes
- Review anticoagulant medications
Why do you need to review anticoagulant medication for haemorrhgic stroke?
- Anticoagulants and antithrombotic drugs can make bleeding worse
- Discontinued or reverse
- Contact GP to change medications
