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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

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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6
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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7
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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8
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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9
Q

Name five Stroke Mimics

A 
Transient Global Amnesia
Migraine with Aura 
Functional Syndrome 
Hypoglycaemia
Amyloid Spell
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10
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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11
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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12
Q

What is Functional Syndrome?

A

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

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13
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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14
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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15
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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16
Q

What do ROSIER scores mean?

A

From -2 to +5

> 0 means that stroke is likely

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17
Q

What are Stroke Chameleons

A

The opposite of mimics

Strokes that look like other conditions

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18
Q

Name five Stroke Chameleons

A 
Venous Infarcts 
Small Cortical Strokes
Limb Shaking TIA
Occipital Strokes
Intracranial Stenosis
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19
Q

How do Venous Infarcts present?

A

Gradual Onset
Seizure Activity
Treated with Heparin

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20
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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21
Q

How do Small Cortical Strokes present?

A

Peripheral Nerve Lesions/Palsies

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22
Q

How do Occipital Strokes present?

A

Predominantly confused
Visual Field Defects
Vestibular Dysfunction

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23
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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24
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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25
Causes of Ischaemic Stroke can be classified using the TOAST tool. What are the 5 types?
``` Large Artery Atherosclerosis Cardioembolic (confirmed by ECG) Small Vessel disease only (eg Lacunar Stroke, <1.5cm) Other Determined Undetermined ```
26
The main aim of Non Contrast Head CT is to rule out Haemorrhagic Stroke. What are the early features of ischaemic?
Hypoattenuation Sulcal Effacement Loss of great white matter differentiation
27
What is ASPECT?
10 point CT scan for MCA stroke Used for revascularisation and patient outcomes
28
Describe the use of MRI for Ischaemic Strokes
Shows infarct from 2h to 3wks Very sensitive
29
Describe the use of Perfusion CT in Ischaemic Strokes
Uses iodinated contrast, and takes repeated images of the same level as contrast flows
30
How can the perfusion CT scans be used?
A curve of Arterial input and Venous outflow can be plotted Can overlay maps of cerebral blood flow and cerebral blood volume
31
Describe the features of the Overlayed CT Perfusion Scans
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
32
What is the risk of thrombolysing a large Infarct Core?
Haemorrhagic Transformation
33
When can you manage Stroke by Thrombolysis with Alteplase?
If <4.5h Haemorrhagic Stroke Excluded No Haemorrhagic Risk Factors
34
Name three absolute contraindications to Thrombolysis
Stroke in the last two weeks Surgery/Trauma in the last two weeks Active Internal Bleeding
35
Name three complications of Thrombolysis
Extracerebral Haemorrhage Seizure Evolution causing raised ICP
36
When should Thrombectomy be carried out?
- 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)
37
What other medication should be started within 24h of an Ischaemic stroke?
300mg Asparin Orally (alongside PPI) Continued for 2w before switching to Clopidogrel
38
How is Central Venous Thrombosis managed?
Full dose Heparin and then Warfarin
39
Name two other managements which might need to be considered in Ischaemic Stroke
Decompressive Hemicraniotomy (for Malignant MCA) End Arterectomy (if >50% atherosclerotic occlusion)
40
CHADS-VASc and HAS BLED are two scores used to determine the need for anticoagulation in AF. Describe CHADS-VASc
``` CHF HTN Age (>75 - 2p) Diabetes Stroke (2p) Vascular disease Age (60-74) Sex Category (Female) ```
41
CHADS-VASc and HAS BLED are two scores used to determine the need for anticoagulation in AF. Describe HAS BLED
``` HTN Abnormal Liver/Renal Stroke Bleeding Predisposition Labile INR Elderly (>65) Drugs/Alcohol ```
42
What is a Watershed Stroke?
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)
43
Define TIA
Transient Neurological Dysfunction characterised by focal neurological dysfunction without evidence of acute infarct USed to be time based (<24h) but is now tissue based
44
How is TIA managed?
300mg Asparin STAT and refer to TIA clinic
45
What happens at a TIA clinic?
``` ECG BP Bloods Smoking Cessation and Lifestyle advice DVLA information (can't drive for a month) ``` May require MRI or Carotid Doppler
46
What is ABCD2?
Risk of stroke after TIA ``` Age>60 BP>140/90 Clinical features (Speech - 1, Unilat weakness - 2) Duration (<60 - 1, >60 -2) Diabetes ```
47
Haemorrhagic Strokes account for 15% of strokes. What are they?
Bleeding inside and around leading to hypoperfusion
48
What are some clinical clues that would point towards Haemorrhagic Stroke?
- Possible underlying PMH - Reduced consciousness at admission - Hx of headaches - Seizures
49
Name two causes of PRIMARY Haemorrhagic Stroke
Hypertension | Cerebral Amyloid Angiopathy
50
Name five causes of SECONDARY Haemorrhagic Stroke
``` Haemorrhagic Transformation Tumour Aneruysm/AVM Coagulopathy/Anticoagulation Cocaine/Alcohol ```
51
Initially a Haemorrhagic stroke presentation depends on extent and duration. As it continues to expand, what changes occur?
Midline Shift Twisted Ventricle Intracranial Herniation
52
Name four predictors of Poor Outcome
>30ml Affecting Deep Basilar or Brainstem GCS<9 >80y
53
Name the 5 Subtypes of Haemorhagic Stroke
``` Extradural Haemorrhage Subdural Haemorrhage SAH Intraparenchymal Intraventricular Haemorrhage ```
54
Describe the aetiology of Extradural Haemorrhage
Separation of the bone from the Periosteal Layer of Dura 90% associated skull fracture Often bleeding from MMA
55
How do Extradural Haemorrhages present?
Classic LOC immediately, then lucid interval, then further deterioration as haematoma expands Associated cranial nerve examinations, headache, nausea and vomiting
56
How do Extradural Haemorrhages present on CT?
Biconvex bleed limited by suture lines
57
How are Extradural Haemorrhages managed?
Small - observation and conservative management Raised ICP - Hypertonic Saline/Mannitol Surgically manage if GCS<14 or clot>40ml
58
What is a Subdural Haemorrhage?
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)
59
How do Subdural Haemorrhages present?
Acute - lucid interval then deterioration Chronic - progressive anorexia, nausea and vomiting, neurological deficits , headache Raised fontanelle in infants
60
How are Subdural Haemorrhages investigated?
Bloods | CT - Convex shape, as it ages intensity decreases
61
How are Subdural Haemorrhages managed?
Small - observation and conservative management Raised ICP - Hypertonic Saline/Mannitol Surgically manage if GCS<14 or clot>40ml
62
How are SAH imaged?
CT - Hyperdensity around Circle of Willis/ Basal Cisterns MRI - good for imaging reactive vasospasm
63
How are Intraparenchymal Bleeds managed?
``` Stop and Reverse Anticoagulation Maintain Systolic at 90-130 (for CPP) BP Control (Labetolol, Nimodipine) ``` May require decompressive hemicraniotomy or EVD
64
What is Cerebral Amyloid Angiopathy?
Pathological deposition of amylid in tunica media/adventitia of vessels Fibrinoid degredation and microaneurysms Association with Alzheimers Scored on imaging using Boston Criteria CT
65
Name five complications of stroke
``` Complications of immobility (pressure sores etc) Raised ICP Infection Mood/Cognition Changes Post Stroke Pain ```
66
What are the 5 R's of Stroke Rehabilitation?
``` Realisation of Potential Reablement (functional independence) Resettlement (safe transfer of care) Role Fulfillment Readjustment ```
67
Where do patients go after a Stroke?
Either: Stroke Rehab Unit (medically stable, established NG) OR Early supported Discharge
68
What is required for Early Supported Discharge?
Can transfer independently or with carer Suitable home Willing to participate Identified goals
69
When does peak Stroke recovery occur
Between 1-3 months due to Neuroplasticity
70
Name three good prognostic factors in Stroke
No coma Continence Early motor recovery
71
What is the Amber Care Bundle?
Patient is very unwell and unsuitable for rehab Advanced Care Planning
72
Describe the different types of Stroke Secondary Prevention
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
73
What is the target threshold for Cholesterol
Total <4
74
What things can be discussed with the patient in terms of Secondary prevention
Smoking Cessation Diet and Exercise Treating BP/AF Maintaining BGC
75
What is the Modified Rankin Score?
Assesses post stroke baseline function 0 - no symptoms to 6 - dead
76
What is a Stroke of unknown aetiology known as?
Cryptogenic Stroke
77
What does the LACS criteria require?
Symptoms in two areas If in only one area - PACS

OPIC (6 decks)

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