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OPIC > Stroke > Flashcards

Stroke Flashcards

1
Q

What are the different mechanisms of stroke?

A
  • Ischaemic - due to occlusion of blood vessels, 85% - thrombosis, emboli or dissection
  • Haemorrhagic - from bleeding inside or around brain tissue, 15%, ICH or SAH
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2
Q

What are the RFs of stroke?

A
  • HTN
  • Smoking
  • DM
  • Hypercholesterolaemia
  • Obesity
  • Afib
  • Carotid artery disease
  • Age
  • Thrombophilic disorders eg. antiphospholipid syndrome
  • Sickle cell
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3
Q

Draw the circle of Willis

A

Find answers in anki flashcards

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4
Q

What is the blood supply of the brain divided into?

A

Ant circulation - blood vessels arising from the carotid arteries
Post circ - blood vessels arising from the vertebrobasilar arteries

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5
Q

What are the 3 main cerebral arteries?

A
  • Ant cerebral artery
  • Middle cerebral artery
  • Post cerebral arter
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6
Q

What does the ant cerebral artery supply?

A

Midline structures of the front 2/3 of the brain
Part of the ant circ.

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7
Q

What does the middle cerebral artery supply?

A

Lateral structures of frontal, temporal and parietal lobes inc internal and basal ganglia, occipital pole
Part of the ant circ.

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8
Q

What does the post cerebral artery supply?

A

Occipital lobe and inf temporal lobe and thalamus.
Part of the post circ.

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9
Q

What is the Bamford/Oxford classification of stroke?

A

TACS - total ant circ stroke, ACA or MCA
PACS - partial ant circ stroke, ACA or MCA
LACS - lacunar stroke, deep perforating arteries
POCS - post circ stroke, vertebrobasilar arteries

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10
Q

What are the features of an ant cerebral artery stroke?

A
  • Contralateral weakness and sensory problems in the lower limb - lower limb more medial in cortex
  • Urinary incontinence if para central lobules affeccted
  • Split brain/alien hand syndrome if corpus callosum affected
  • Frontal lobe features eg. personality change, apraxia
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11
Q

What are the features of a proximal middle cerebral artery stroke?

A
  • Contralat sensory problems in face and arm, upper body more lateral on cortex
  • Contralat hemiparesis - int capsule affected
  • Contralat hemianopia w/o macular sparing
  • Aphasia if L sided occlusion
  • Contralat hemispatiel neglect if R sided lesion
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12
Q

What are the features of a sup distal MCA stroke?

A
  • Broca’s aphasia = expressive aphasia
  • Contralat weakness to face and arm
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13
Q

What are the features of a inf distal MCA stroke?

A
  • Contralat sensory probs in face and arm
  • Wenicke’s aphasia = fluent aphasia
  • Quandrantopia or homonomous hemianopia w/o macular sparing
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14
Q

What are the features of a PCA occlusion?

A
  • Contralateral homonomous hemianopia w macular sparing (MCA = back up blood supply to macula)
  • Contralat sensory probs due to damage to thalamus
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15
Q

What are the criteria of a TACS?

A
  • Contralat hemiplegia or hemiparesis
  • Contralat homonymous hemianopia
  • Higher cerebral dysfunc eg. aphasia and neglect
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16
Q

What are the criteria of PACS?

A

Two of the TACS criteria or higher cerebral dysfunc alone

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17
Q

What are the criteria of LACS?

A
  • Pure motor or pure sensory or sensorimotor signs
  • Affects lenticulostriate arteries which supply int capsule and basal ganglia
  • Face, arm and leg affected equally because of damage to int capsule not homonculus
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18
Q

What are the criteria of POCS?

A

One of:
- Cerebellar dysfunc
- Conjugate eye movement disorder
- Bilat motor/sensory deficit
- Ipsilateral CN palsy w contralat motor/sensory deficit
- Cortical blindness

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19
Q

What are the ix into suspected stroke?

A
  • CT head immediately, MRI better but slow so not suitable in emergencies, sensitive for haemorrhage but in ischaemic imaging often normal after a few hours
  • Obs, BM, ECG
  • Bloods - FBC, U+E, LFT, ESR, coag, lipids, HbA1c
  • Echo, carotid dopplers
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20
Q

What is the management of haemorrhagic stroke?

A
  • Small bleed = no requirement for neurosurgical intervention
  • Decompressive hemicraniectomy if pt meets criteria
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21
Q

What is the management of ischaemic stroke?

A
  • Alteplase: w/i 4.5 hours sx onset, NIH score >26, no thrombolysis contraindications - need to exclude ICH
  • Mechanical thrombectomy - w/i 6 hours of sx onset
  • Need to go to hyper acute stroke unit to be monitored
  • Together called stroke revascularisation therapy
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22
Q

What is ongoing management of a pt who has had a stroke?

A
  • BP control
  • BM control
  • Weight loss and smoking cessation
  • Statin started 48hrs after stroke - total cholesterol <4, LDL cholesterol <2, 80mg atorvastatin
  • 2 weeks 300mg aspirin and then 75mg clopidogrel daily for ever
  • Carotid doppler to assess - may need carotid endarterectomy, urgently if >50% stenosis, 70% if asymptomatic?
    or 75% stenosis = stent?
  • Swallow and nutrition assessment
  • Rehab at local stroke unit or palliative care
23
Q

What are the early complications of stroke?

A
  • Haemorrhagic transformation of ischaemic stroke
  • Cerebral oedema
  • Seizures
  • Infection
  • Cardiac arrhythmias
  • Venous thromboembolism
  • Death
24
Q

What are the late complications of stroke?

A
  • Mobility and sensory issues
  • Bladder and bowel dysfunction
  • Pain
  • Fatigue
  • Cognitive and visual problems
  • Emotional and psychological issues
  • Probs w swallowing = probs w hydration and nutrition
25
Q

How do you differentiate strokes from the stroke mimics?

A
  • Can differentiate on CT - SOL, MS, subdural haematoma
  • Can differentiate w clinical dx - BPPV, vestibular neuronitis, transient global amnesia
  • Subtle differences that need additional ix and specialist assessment - complicated migraine w aura, focal seizures, FND
  • Apparent neurological deficit
  • BEHIND
  • Encephalopathy
26
Q

What makes up the stroke service?

A
  • Acute stroke unit
  • TIA and outpt clinics
  • Stroke rehab services
  • Early supported discharge schemes
27
Q

What are some different stroke assessment tools?

A
  • NIHSS - assesses stroke severity, estimating prognosis, recovery and suitablity for diff therapies
  • ASPECTS - CT scan score for MCA stroke
  • OCSP - POCS, TACS etc
  • Modified Rankin scale - assess baseline, evaluate outcomes and treatment impact
  • Rosier scale - stroke vs stroke mimics
  • CHADVASC in AF
  • Barthel - funcitonal capacity
28
Q

What does BEHIND stand for?

A

Differentials for stroke mimics:
Brain - mass, haemorrhage, contusion
Epilepsy
Hyponatraemia, Hypoglycaemia
Intoxication and infection
Neuro - migraine, MS
Dissection, disc prolapse

29
Q

How do you assess the prognosis of a pt w stroke?

A
  • 20-30% of pt die w/i. amonth
  • 5 year risk of recurrent stroke is 30-40%
  • Good factors - absence of coma, early motor recovery, continence
  • Poor factors - severe communication defecit, old age, incontinence esp faecal incontinence, no leg movement at 2 weeks, severe upper limb weakness at 4 weeks
30
Q

What are the criteria for rehab transfer?

A
  • Medically stable
  • On <24% O2
  • NG feeding w no risk of refeeding syndrome
  • Stroke consultant review twice a week
  • Not awaiting echo
31
Q

What is the difference between ischaemia and infarction?

A

Ischaemia = not enough blood flow = cerebral hypoxia, this can then lead to death of brain tissue which is cerebral infarction
Ischaemia = reversible
Infarction = irreversible

32
Q

TIA vs stroke

A

TIA - brief episode of neuro dysfunc due to focal brain ischaemia, sx typically last less than 1 hour, no evidence of infarction
Stroke - neuro dysfunc due to cerebral ischaemia, >24 hours

33
Q

What are some of the thrombolysis contraindications?

A
  • Haemorrhagic stroke
  • ICH/recent head injury - need to exclude haemorrhage before give thrombolysis
  • Cerebral malignancy - primary or mets
  • Aortic dissection
  • Recent surgery
  • Ischaemic stroke < 3 months
  • On DOAC or high dose LMWH
  • Abnormal APTT or INR
  • Acute pancreatitis
  • Child birth w/i 4 weeks
34
Q

What imaging is used in suspected stroke?

A
  • Non contrast CT head - effacement, loss of grey/white matter distinction, increased density of blood vessel = signs of early cerebral ischaemia, increased attenuation = ICH
  • MRI head - good for looking at acute infarction
  • and can try CT angiogram and CT perfusion studies and CT venogram
34
Q

What in the hx indicates a stroke is more likely to be haemorrhagic than ischaemic?

A
  • Underlying cause - HTN, aneurysm, vasculitis, cocaine, warfarin, aspirin, tumour
  • Reduced level of consciousness at admission
  • Hx of headache - transient or thunderclap
  • Seizures
  • Features of raised ICP
  • N+V
35
Q

What are some features of typical stroke syndrome?

A
  • Sudden onset
  • Focal
  • Negative sx eg. weakness, visual loss, numbness
  • Vascular territory hypoperfusion can explain all sx
  • Sx don’t migrate over time
  • Episodes don’t stereotype - no identical recurrent episodes, if so unlikely to be stroke
36
Q

What is the management of ICH?

A

IX - CT MRI head

  • Small bleed = no need for neuro surgical intervention
  • Decompressive hemicraniectomy
  • Intra ventricular shunting in hydrocephalus
  • Control BP <140.80
  • Anticonvulsants to prevent seizures
37
Q

What is capsular warning syndrome?

A

Recurrent lacunar TIAs affecting the int capsule, associated w high risk of complete stroke

38
Q

What are the criteria for decompressive hemicraniectomy?

A
  • W/i 48 hours of sx onset
  • NIHSS >15 and clinical defecits suggesting infarction in MCA territory
  • Decreased level of consciousness
  • Signs on CT of infarct w 50%+ of MCA territory
39
Q

What is the stroke rehab pathaway?

A

Acute stroke unit - early supported discharge
Acute stroke unit - stroke rehab unit - supported discharge

40
Q

What is early supported discharge?

A

40% of stroke pt eligible - hospital level therapy at home. Prevents hospital related complications eg. infection, delirium and DVT. Increased pt satisfaction.

41
Q

How does stroke rehab work?

A
  • Brain plasticity - neuro recovery at peak from 1-3 months
  • Initial phase - reperfusion of hypoxic brain and reduction of brain oedema
  • Late phase - brain remodelling
42
Q

How do you manage impaired swallowing?

A
  • Immediate dietician referral
  • Consideration for alt fluids
  • SALT assessment
  • Consider for NG tube w/i 24 hours - avoid malnutrition
  • Gastronomy if unable to tolerate NG tube and not able to swallow adequately at 4 weeks post stroke
43
Q

What is the management of incontinence?

A
  • Need to treat urine incontinence as increases skin breakdown = pressure ulceration
  • Timed toileting
  • Review caffeine intake
  • Bladder retraining
  • Pelvic floor exercises
  • Constipating drugs/oral laxatives
  • Med review
44
Q

What is the management of spasticity?

A
  • Simple measures - positioning, passive movement, analgesia inc treating neuropathic pain
  • Focal spasticity - IM botulinum injection
  • Generalised spasticity - skeletal muscle relaxants eg. baclofen
45
Q

What is the management of anxiety and depression post stroke?

A
  • Very common
  • Increased social interaction
  • Increased exercise
  • Psychosocial education groups and support groups
46
Q

What is ischaemic penumbra?

A

Tissue at risk that hasn’t yet become infarct, is salvageable

47
Q

What is ASPECTS score?

A

Used to assess the prognosis of a stroke, mostly for MCA, take 1 point from 10 for every vascular region involved
<7 - worse functional outcome at 3 months and symptomatic haemorrhage

48
Q

What are the complications of thrombolysis?

A

Extracerebral haemorrhage - thin pulse, malaena, distended abdo
Intracerebral haemorrhage - neuro decline, new headache, rising BP, N+V

49
Q

What is ROSIER score?

A

Recognition of Stroke In Emergency Room:
-1 seizure activity
-1 LOC
+1 asymmetrical face weakness
+1 asymmetrical arm weakness
+1 asymmetrical leg weakness
+1 speech difficulty
+1 visual field defect

50
Q

Wernicke’s vs Broca’s aphasia

A

Wernicke’s - fluent aphasia, L sup temporal gyrus affeced
Broca’s - non fluent, L inf frontal gyrus

51
Q

AICA vs PICA strokes

A

Ant inf cerebellar - vertigo and vom, ipsilat facial paralysis and deafness
Post inf cerebellar - lat medullary syndrome = nystagmus, ataxia, ipsilat face pain and temp loss, contralateral limb pain and temp loss

52
Q

What are the ix into a TIA?

A

Diffusion weighted MRI head

OPIC (5 decks)

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