Stroke Flashcards
Definition stroke
Sudden global or focal neurological deficits due to spontaneous hemorrhage or infarct of CNS irrespective of clinical duration of symptoms
Why is stroke an issue in Africa
Younger population affected
Higher death toll
Pathophysiology in stroke cerebral blood flow
Loss of autre regulation
Less than 50% tissue at risk
Less than 25% electrical failure
Less than 15% membrane failure and death
Cerebrovascular disorder leading to stroke
Atherosclerosis and arteriosclerosis
Hypertension
Cerebral amyloid
Arteritis
Vasculitis
Aneurysm
Vascular malformations
Vertebral and basilar arteries supply …
Brainstem
Mid brain
Cerebellum
Anterior cerebral artery supply
Frontal lobe
Parietal lobe
Middle cerebral
Parietal lobe
Frontal lobe
Posterior cerebral
Occipital lobe
4 Strokes syndrome
ACA - frontal lobe , altered mental state , contralateral lower extremity weakness
MCA - contralateral hemiparesis m ipsilateral hemianiopa,
PCA
Vertebrobasilae
Oxford subtypes of infarctive st
Total anetrior circulation infarct
Partial anterior circulation intact
Lacunar infarct
Posterior circulation infarct
Features of posterior circulation infarction syndrome
Ipssilateral cranail nerve palsy
Contralateral motor or sensory deficits
Features of pontine hemorrhage
Features of cerebellar hemorrhage
ASCO mnemonic in infarctive stroke
ASTHEROEMBOLIC
SMASHO mnemonic in hemorrhagic stroke
Amyloid
Hypertension
Non modifiable risk factor of stroke
Male gender
Age
Race black
Previous vascular event (MI, stroke, PVD)
Family history
SCdx
High fibrinogen
Modifiable risk factors
Obesity
Diet
Alcohol
Smoking
BP
Polycytemia
Modifiable risk factors
Smoking
Alcohol
Sedentary life style
Diet
Obesity
Stress
Cholesterol
Subtypes of ischemic stroke
Large artery atherosclerosis ( embolus, thrombus )
Specific causes of stroke in developing countries
Sickle cell disease
Snake bite
Infective endocarditis
Cerebral malaria
HIV
COVID
Chagas’ disease
Path to neuronal injury in ischemic stroke
Ischemia -> energy failure ( low ATP)-> cell depolarization (sodium and water influx) -> release of neurotransmitter ( glutamate , AMPA, NMDA) -> calcium influx into neurons -> activation of destructive process by enzymes
What is penumbra
Functionally impaired but still structurally viable tissue
Differential of stroke
ALS
Bell’s palsy
Benign postural vertigo
Cauda equina
Cavernous sinus thrombosis
Cerebral venous thrombosis
Dissection syndrome
Epidural hematoma
Head injury
meningitis
Migraine
Mutilple sclerosis
Spinal cord infarction
Stroke scale defintion
Quantity measure of stroke related deficit
NIHSS
Scale of ranking stroke
0- no symptoms
1- no significant disability
2- slight disability
3- overeats disability
4- modesevere disability
5- severe disability
Imaging techniques used
Structure - CT , MRI
Function- PET SPECT , EEG , MEG
Why do Imaging in stroke ?
Hemorrhage or infarct ?
Large vessel occlusion ?
Reduced tissue perfusion ?
Irreversible damage ?
Salvageable tissue ?
Early neuroprotection in stroke
Maintain homeostasis by
Treat severe hypertension
Maintain blood sugar
Early fluid and energy replacement
Swallowing assessment
Tx fever and antipyretic
Treatment of infection
Early mobilization and rehab
Steps in anti platelet therapy
Confirm with ct scan
300-75mg aspirin in infarct
Aspirin + early mobilisation in DVT
Hypertension treatment in strok
Reduce slowly
ACEi, ARBs, diuretics
Contraindication for thrombolysis therapy in stroke
What is tPA
In early presentation of stroke patient (4-5h)
Determinants of hogh stroke mortality in Ghana
Health seeking behavior of African
Inadequate facilities
Late institution of neruoprotectine measures
Complications of stroke s
Lack of imaging facilities
Lack of multidisciplinary teams
Low awareness , treatment and control of hypertension
Primordial
Clinical Classification of strokes from anterior carotid circulation and posterior carotid circulation
Total anterior circulation stroke TACS
Partial anterior circulation stroke PACS
Lacunar stroke LACS
Posterior circulation stroke POCS
2 types of hemorrhage leading to stroke
Intracerebral hemorrhage
Subarachnoid hemorrhage
Main neuroimaging techniques used to detect stroke
CT scan (baseline )
MRI when uncertainty of diagnosis
CT angiography /CT perfusion for characterization of ischemia
Vascular imaging techniques used in stroke
Ultrasound Doppler for carotid and vertebral arteries in the neck
Transcranial Doppler
MR angiography
CT angiography
Blood tests done in stroke
Blood glucose - diabetes mellitus
TGs , cholesterol - Hyperlipidemia
FBC - polycythemia
ESR & Immunology - ANCAs for vasculitis
Genetic testing for CADASIL - cerebral autosomal dominant arteriopathy with subcortical infarct and leucoencephalopathy
Investigation technique used only in subarachnoid hemorrhage
Lumbar puncture
Cardiovascular investigation in stroke
ECG
Echocardiography
Possible neurological presentation of stroke patient
Unilateral Weakness - sudden, rapidly progressive , UMN weakness of face , increased tone
Speech disturbance - dysphasia ( frontal and parietal lobe), dysarthria
Visual deficit
Contralateral Visuospatial dysfunction
Ataxia - cerebellum damage
Headache (severe mostly in SAH )
Seizure
Coma especially in SAH or intracerebral hemorrhage
Mortality of stroke over a month
20%
Morbidity of stroke over a month
1/2with physical disability
Main cause of cerebral infarction in stroke
Secondary thromboembolic disease to atherosclerosis
Main type of secondary thromboembolic dx leading to infarctive stroke
Cardiac embolism 20%
Thrombosis in situ 20%
Rare causes - endocarditis, vasculitis , cerebral venous dx
Disease causes of intracerebral hemorrhage
Complex small vessel disease with disruption of vessel wall
Amyloid angiopathy
Impaired blood clotting
Vascular anomaly
Substance misuse
Differentials of structural stroke
Primary cerebral tumor
Metastatic cerebral tumor
Extradual / subDural hematoma
Demyelination
Peripheral nerve lesions
Cerebral abscess
Differentials of functional stroke
Todds paresis
Hypoglycemia
Migrainous aura
Focal seizures
Manières dx
Conversion disorder
Encephalitis
TACS common symptoms
Hemiparesis
Higher cerebral dysfunction
Hemisensory loss
Homonymous hemianopia
TACS commonest cause
Middle cerebral artery occlusion
PACS commonest symptoms
Isolated motor loss
Isolated higher cerebral dysfunction
Mixture of higher cerebral dysfunction and motor loss
Main cause of PACS
Occlusion of branch of middle cerebral artery or anterior cerebral artery
LACS commonest symptoms
Pure motor stroke
Pure sensory stroke
Sensory motor stroke
No higher cerebral dysfunction or hemianopia
LACS commonest cause
Thrombotic occlusion of small perforating arteries
POCS main symptoms
Homonymous hemianopia
Cerebellar dysfunction
Cranial nerve syndromes
POCS commonest cause
Occlusion in vertebral basilar or posterior cerebral artery
What is progressing stroke
Stroke with focal neurological deficit worsenin after the patient first present
What is a complete stroke
Focal deficits persists and is not progressing
1st Step in management of stroke
Bedside test swallowing for safe medications, food, hydration
Management of ischemic stroke
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