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Stroke Flashcards

1
Q

Left MCA syndrome

A

Right hemiparesis (face/arm > leg)
Aphasia
Right sensory/visual inattention
Right hemianopia

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2
Q

Right MCA syndrome

A

Left hemiparesis (arm/face > leg)
Dysarthria
Left sensory/visual inattention
Left hemianopia

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3
Q

Lacunar syndrome

A

Absence of cortical signs
Isolated face/arm/leg weakness or numbness
Dysarthria
Ataxic hemiparesis

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4
Q

Posterior circulation syndrome

A

Diplopia
Dysarthria
Dysphagia
Vertigo
Ataxia
Hemi/tetraparesis
Ipsilateral face/contra lateral body numbness/weakness

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5
Q

Stroke mimics

A

Migraine with aura
Seizure with Todd’s paresis
Functional
Metabolic/Sepsis

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6
Q

CT non con findings

A

Hyperdense area white) = blood or calcium
Hyperdense artery = acute thrombus
Loss of grey/white diff = infarct
Hypodensity (black) = over 4.5hr onset

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7
Q

CT perfusion findings

A

Delay in time to peak = collateral territory (penumbra)

Low cerebral blood volume = likely irreversible ischaemia

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8
Q

CT angio findings

A

Ischaemic stroke
-vessel occlusion or stenosis

ICH
-vascular malformation
-spot sign = marker of growth

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9
Q

MRI brain

A

DWI
-most sensitive

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10
Q

TIA define

A

Same pathophysiology as ischaemic stroke but clot dissolves before causing permanent injury

Now defined as no lesion on MRI DWI
(Not resolution of symptoms within 24hrs)

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11
Q

TIA evaluation and management

A

CT brain
ECG
Carotid imaging
Antiplatletes
Antihypertensives
Statin

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12
Q

Ischaemic stroke aetiology investigations

A

Arterial pathology
CT angio (arch to vertex) or carotid doppler
-atherosclerosis
-dissection
-vasculitis

Cardioembolic pathology
-AF
-Akinetic LV segment
-Endocarditis
-PFO
ECG, holter or telemetry (24hrs) TTE/TOE

Rare (young)
-thrombophilia
-vasculitis
-fabrys

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13
Q

ICH aetiology investigations

A

CT angio
-routine
-vascular malformation

CT venography
-venous sinus thrombosis

Catheter angiography
-subtle AVM or dural AVF

Delayed MRI
-routine at 8 weeks
-underlying mass, AVM, cavernoma
-microangiopathy (hypertensive/amyloid)

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14
Q

Thrombolysis indications

A

Disabling stroke (NIHSS>5) due to large vessel occlusion

<4.5hrs
or
4.5-9hrs post onset or mid point of sleep for CT perfusion selected

Prior to endovascular thrombectomy if thrombolysis indicated

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15
Q

Alteplase administration

A

Dose
0.9mg/kg up to 90mg, infuse over 60 mins with 10% bolus over 1 min

Admit to ICU

CT brain if
-severe headache
-acute hypertension
-nausea or vomiting
-worsening neurological exam

Avoid NGs, IDC, art lines

CT or MRI brain
-24hrs post
-prior to stating antiplatelets/anticoagulants

BP and neurological assessments
-every 15 mins during infusion and for 2hr post
-then every 30 mins for 6hrs
-then hourly until 24 hrs

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16
Q

Thombolysis contraindications

A

Haemorrhage on CT brain
Extensive hypodensity on CT brain
Active non compressible systemic bleeding
Recent GI/GU bleeding, surgery or trauma
BP >185/105
BGL <2.7
IE, aortic dissection, malignant brain tumour
INR > 1.7
Platelets <100
DOAC <48hrs

17
Q

Effect of alteplase 0-3 hrs post onset

A

~1/3rd improve or back to normal
~2/3rd no change
~3% worse, severely disabled or dead

18
Q

Labetalol for emergency reperfusion

A

10-20mg IV over 1-2 mins. Can repeat once

19
Q

Nicardipine for emergency reperfusion

A

5mg/hr IV, titrate up by 2.5mg/hr every 5-15 mins, max 15mg/hr

20
Q

BP targets

A

Thrombolysis
<185/105 pre and for 24hrs post

Ischaemic stroke not for thrombolysis
<220/120

ICH
-around 140 but not substantially below

21
Q

Orolingual angioedema frequency, features, management

A

Frequency
-2% overall
-5% if on ACEi

Features
-unilateral lip and tongue swelling
-contralateral to brain lesion

Maintain airway
-may require intubation
Discontinue alteplase
Cease ACEi
Give methylprednisone 125mg IV
Give diphenhydramine 50mg IV
Give ranitidine 50mg IV
Consider andrenaline 0.3mg sc or 0.5mg neb

22
Q

ICH post thrombolysis frequency and risk factors

A

Haemorrhaging transformation is almost universal
-may be associated with favourable outcome

Haematoma expansion with mass effect beyond infarct is harmful
-rate is 1.7%

Risk factors
-CT hypodensity
-Severe leukoaraiosis
-Large core and severe hypoperfusion
-Delayed reperfusion

23
Q

Symptomatic ICH post thrombolysis management

A

Stop alteplase
CT brain non con
FBC, Coags, fibrinogen, GnH
Give cryo 10u
Give TXA 1g IV
Haematology and neurosurg consult

24
Q

Endovascular thrombectomy indication

A

Ischaemic stroke caused by occlusion of
-ICA
-M1
-Tandem (cervical carotid + intracranial large artery)
-Basilar
-?M2

ICA/M1: <6hr or <24hr with CT perfusion criteria

Basilar time window unclear

Good premorbid function

No age or clinical severity limit

25
Hemicraniectomy indication
Under 60 Malignant M1 infarct
26
ICH management
Intensive BP lowering -to around 140 (not substantially below) Reverse anti coagulation -warfarin: prothrombinex + vit K -dabigatran: idarucizumab -rivaroxaban/apixaban: andexanet alfa -antiplatelets: NO platelet transfusions Surgery -posterior fossa with mass effect -possibly for supratentorial with mass effect
27
Antiplatelets regime indications
DAPT Indications -Minor ischaemic stroke (NIHSS <4) -High risk TIA (ABCD2 >3) -Not receiving thrombolysis Timing -ASAP post CT brain excludes haemorrhage -Continue for 21 days then mono therapy Aspirin mono therapy Indications -Ischaemic stroke treated with thrombolysis -Low risk TIA (ABCD2 <4) Timing -Post CT brain rules out haemorrhage -24hrs post thrombolysis
28
Anticoagulation
Indicated in AF only NOAC first line Warfarin if valvular AF or mechanical heart valve -valvular = mod-severe MS Can be commenced post CT brain for TIA Can be delayed for up to two weeks for ischaemic stroke Not to be combined with antiplatelet therapy
29
Cholesterol lowering therapy
High dose statin for all ischaemic stroke or TIA with possible atherosclerosis contribution Avoid statin in ICH Target LDH is <1.8
30
Carotid endarterectomy
Strongest indication -within two weeks (AIS, TIA, retinal ischaemia) -relevant territory -stenosis 70-99% Consider if above and stenosis 50-69%
31
AF detection
ECG Holter or telemetry for at least 24 hours Longer you look, the more you find
32
Blood pressure lowering secondary prevention
Start in all stroke and TIA with BP >140/90 Probably start if BP 120-140 Stroke risk reduction is independent of class -avoid beta blockers Ideal long term target not established
33
Stroke/TIA investigations
CT brain immediately -non con -perfusion -angio (arch to vertex) ECG BGL Bloods -FBC, EUC, CMP, CRP -GnH, coags and fibrinogen if coagulopathic or ICH Telemetry or holter for > 24 hrs Repeat CT or MRI brain at 24 hours TTE Carotid US if CT angio not done
34
Ischaemic stroke supportive care
Admit to stroke unit Oxygen -Supplemental only if sats <93% -On oxygen, aim sats 94-96% (or 88-92%) Glycemic control -Aim BGL <10 Fever -Sepsis screen -Paracetamol DVT prophylaxis -SCUDs for all (no TEDs) Head position -doesn’t matter NBM -until swallow assessed
35
NIHSS components
Level of consciousness -Alert -Minor stimulation -Repetitive stimulation -Movements to pain -Postures or unresponsive Month and age -Both right -One right -Neither right -Dysarthric, trauma, language barrier, intubated -Aphasic Language and aphasia -Normal -Some obvious changes with significant limitation -Fragmentary speech, inferences needed, cannot identify objects -Mute, coma, no usable speech or comprehension Dysarthria -Normal, intubated, unable to test -Slurring, can be understood -Unintelligible speech, mute Blink eyes and squeeze hands -Both tasks -One task -Neither task Horizontal eye movements -Normal -Partial gaze palsy or can be overcome with occulocephalic reflex -Fixed gaze deviation Visual fields -Normal -Partial hemianopia -Complete hemianopia -Bilateral hemianopia or blind Facial palsy -Normal symmetry -Flat nasolabial fold, smile asymmetry -Lower face unilateral weakness -Unilateral or bilateral upper and lower weakness Limb drift -No drift for 10 seconds, amputation, joint fusion -Drift, doesn’t hit bed -Drift, hits bed -Effort against gravity -No effort against gravity -No movement Finger nose and heel shin -No ataxia, doesn’t understand, amputation, joint fusion -Ataxia in one limb -Ataxia in two limbs Sensation -Normal -Less sharp, more dull -Compete loss, no response, coma Inattention -None -Sensory, auditory or visual inattention -Inattention to >1 modality or profound (doesn’t recognise own hand)

Neurology (7 decks)

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