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CVS > Stroke > Flashcards

Stroke Flashcards

1
Q

Define stroke

A

Stroke - A blocked or ruptured blood vessel in the brain causing failure of neuronal function leading to some deficit in brain function, neurovascular unit.

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2
Q

Differentiate between stroke and transient ischaemic attack

A

Stroke - neurological deficit (loss of function), sudden onset, lasting more than 24 hours, of vascular origin.

Transient ischaemic attack - less than 24 hours

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3
Q

Common causes of stroke

A

Causes of stroke -
blockage with thrombus or clot,
disease of vessel wall,
disturbance of normal properties of blood,
rupture of vessel wall (haemorrhage).

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4
Q

Rates of stroke due to Infarction vs Haemorrhage

A

85-90% of strokes are due to infarction and 10-15% due to haemorrhage.

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5
Q

Define hemorrhagic stroke

A

Hemorrhagic stroke - haemorrhage/blood leaks into brain tissue.

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6
Q

Define Ischemic stroke.

A

Ischemic stroke - clot stops blood supply to an are of the brain.

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7
Q

Describe how large artery disease causes stroke.

A

Large artery disease - areas of bifurcation of the carotid vessels are areas of sheer force, common for atheroma to develop in these areas. If you get a clot forming on top of an atheroma it breaks off and ends up at one of the blood vessels in the brain.

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8
Q

Describe the cause Cardioembolic stroke.

A

Cardioembolic stroke is due to large vessel occlusions, atrial fibrillation is the commonest cause (clot forming in left atrial appendage). If blood breaks off from there and heads up the aorta and up the cerebral vessels you will end up again with occlusion in the vessel.

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9
Q

Describe the process of small vessel disease in causing lacunar stroke

A

Small vessel disease/Lacunar stroke - Large vessels have small branches going into brain tissue and if one of these lenticulostriate arteries occludes it will affect a small area of the brain causing a little leak.

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10
Q

Describe rare causes of stroke.

A

Rare causes - Carotid dissection, vessel tears and thrombus forms: idiopathic or trauma.

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11
Q

Summary of causes of brain infarctions.

A
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12
Q

Risk factors for Stroke.

A
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13
Q

What does a haemorrhage look like on an MRI?

A

On a scan there is a large patch of white indicating a haemorrhage

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14
Q

Pathophysiology of haemorrhage (causes)

A

Pathophysiology of haemorrhage -
Hypertension (60-70%),
Amyloid (15-20%),
excess alcohol,
hypocholesterolaemia,
haemorrhagic transformation.

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15
Q

Describe mortality early after stroke - Haemorrhage vs Ischaemic stroke

A

Haemorrhage is associated with a much higher rate of mortality early after the stroke compared to Ischaemic stroke.

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16
Q

What happens to brain tissue in ischaemic stroke.

A

Ischaemic stroke - what happens to brain tissue: thrombus occludes the vessel causing area of infarction where the tissue dies very quickly. Surrounding will be an area called the penumbra which is getting some blood supply from collateral flow, enough blood supply to not die but no proper function.

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17
Q

Describe pathophysiology of ischaemia

A

Ischaemia results from the failure of cerebral flow to a part of the brain.

Ischaemia can be transient.

Ischaemia results in varying degrees of hypoxia and hypoglycaemia.

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18
Q

Describe how hypoxia can cause further damage to brain.

A

Hypoxia stresses the metabolic machinery of brain cells, which malfunction but are still alive (esp in the penumbra).

If prolonged, the hypoxia becomes anoxia (no oxygen).

Anoxia results in infarction (complete cell death, leading to necrosis). This is a completed stroke.

Further damage can result from oedema (swelling), depending on the size and location of the stroke, or secondary haemorrhage into the stroke.

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19
Q

Describe the growth of the infarction over time.

A

The infarction grows over time - area of dead tissue increases, swelling increases and area of salvable tissue reduces.

20
Q

Describe the sudden onset and characteristics of stroke symptoms

A

Stroke symptoms come on quickly, the signs and symptoms the patient has should make sense: i.e. fit in with an artery territory and an area of the brain.

21
Q

What does the carotid system supply?

A

The carotid system supplies most of the hemispheres and cortical deep white matter.

22
Q

What does the vertebro-basilar system supply?

A

The vertebro-basilar system supplies the brain stem, cerebellum and occipital lobes

23
Q

Symptoms and signs of stroke.

A

In stroke most symptoms are loss of some function.

  • Motor (clumsy or weak limb)
  • Sensory (loss of feeling)
  • Speech: Dysarthria/Dysphasia
  • Neglect / visuospatial problems
  • Vision: loss in one eye, or hemianopia
  • Gaze palsy
  • Ataxia/ vertigo / incoordination / nystagmus
24
Q

Symptoms of ACA (anterior cerebral artery occlusion).

A
  • paralysis of contra-lateral foot and leg
  • sensory loss over contra-lateral toes, foot and leg
  • impairment of gait and stance.
25
Q

Symptoms of MCA (middle cerebral artery) occlusion

A
  • Contra-lateral paralysis of face/arm/leg
  • Contra-lateral sensory impairment
  • Contralateral homonymous hemianopia
  • Gaze paralysis to the opposite side
  • Aphasia if stroke on the dominant (left) side
  • Unilateral neglect for half of external space if non-dominant stroke (usually right side).
26
Q

Lacunar stroke symptoms/signs

A

Devoid of ‘cortical’ signs
E.g. no dysphasia, neglect, hemianopia

  1. Pure motor stroke
  2. Pure sensory stroke
  3. Dysarthria - clumsy hand syndrome
  4. Ataxic hemiparesis
27
Q

Symptoms of posterior circulation stroke and anatomy involved.

A

Anatomy involved:
Brain Stem / Cerebellum / Thalamus
Parts of occipital and temporal lobes

Symptoms of brainstem dysfunction:
- Coma, drop attacks, vertigo, nausea, vomiting, cranial nerve palsies, ataxia.
- Hemiparesis, hemisensory loss
- Crossed sensori-motor deficits
- Visual field deficits

28
Q

Describe stroke subtypes

A

TACS: Total anterior circulation stroke
PACS: Partial anterior circulation stroke
LACS: Lacunar stroke
POCS: Posterior circulation stroke

29
Q

Why is stroke important?

A

Approximately 1/3 patients will die within one year. 50% of survivors remain on others. Costs society almost £9 billion a year.

30
Q

Risk factors for stroke.

A
  • Age
  • Hypertension
  • Cardiac Disease (esp atrial fibrillation)
  • Diabetes
  • Smoking
  • Family history
  • Cholesterol
  • Bleeding disorders
31
Q

Stroke - associated diseases

A
  • Previous TIA or strokes
  • Blood pressure poorly controlled
  • Angina
  • MI
  • Peripheral vascular disease
  • Aortic aneurysm
  • Carotid bruits
  • Renovascular disease
  • (Cocaine/ alcohol abuse)
32
Q

Describe the importance of hypertension in being a risk factor for stroke

A

Hypertension is the most important modifiable risk factorfor stroke

33
Q

Describe the importance of blood pressure in being a risk factor for stroke

A

High blood pressure is particularly associated with small vessel stroke (lacunar stroke) and with haemorrhage.

34
Q

Describe the importance of smoking in being a risk factor for stroke

A

Smokers have a two-fold increased risk of ischaemic stroke. Smokers have an approximately 3-fold increased risk for sub-arachnoid haemorrhage. Some of the increased risk of stroke relates to complications of cardiac problems.

35
Q

Describe the importance of diabetes in being a risk factor for stroke

A

Diabetes mellitus increases the incidence of strokes up to 3-fold in both sexes. It is associated with small vessel, large vessel and cardioembolic stroke.

36
Q

Describe the importance of high lipid levels in being a risk factor for stroke

A

Lipids - A high plasma level of low density lipoprotein (LDL) results in excessive amounts of LDL within the arterial wall. Hypertension, cigarette smoke, and diabetes contribute to LDL-C deposition in arterial walls.

37
Q

Describe the importance of alcohol and obesity in being a risk factor for stroke

A

Alcohol - the relationship between alcohol intake and stroke is complex. Small amounts of alcohol decrease stroke risk. Heavy drinking increases the risk 2.5 fold.

Obesity - Recently identified as an independent risk factor for vascular disease including stroke.

38
Q

Describe other risk factors of stroke apart from the main ones.

A

Other risk factors:

  • Impaired cardiac function (recent heart attack, atrial fibrillation)
  • Oral contraceptives with a high estrogen content. Progesterone only is OK
  • Hyper-coagulable states: due to malignancy or genetic.
39
Q

Aim of stroke treatment

A

Aim of treatments:

  • protect the damaged brain before ischaemia becomes cell death
  • Get rid of clot
  • Prevent the clot happening in the first place
40
Q

What should acute stroke therapies do?

A

Acute stroke therapies should:

  • Restore blood supply
  • Prevent extension of ischaemic damage
  • Protect vulnerable brain tissue
  • Avoid reperfusion injury
  • Be non toxic
41
Q

Describe the use of alteplase for treatment of stroke.

A

Alteplase can be given systematically for thrombolysis. Can be given within 4 and a half hours after stroke. IV thrombolysis is highly dependant. Benefit decreases and harm increases as time after initial stroke increases.

42
Q

Describe steps taken for investigation and treatment of stroke.

A
  • pre alert
  • patient taken to stroke centre
    10 mins
  • ED/stroke physician evaluation
    10 mins
  • perform CT
    5 mins
  • Interpret CT
    5 mins
  • IV tPA
43
Q

Describe process of clot retrieval.

A

Clot retrieval:

  • Put in catheter.
  • Put up umbrella to stop clot going further up the brain.
  • Pull whole clot out.
44
Q

Describe usefulness of Clot retrieval.

A

IVT and clot retrieval is much more effective than IVT alone.

45
Q

Other treatments for stroke - similar to ischaemic heart disease.

A
  • Antiplatelets
  • Statins
  • Blood pressure management
  • Anticoagulation (apixaban, rivaroxaban)
46
Q

Describe management of haemorrhage.

A

BP management is the only viable treatment for intracerebral haemorrhage.

CVS (21 decks)

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