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STROKE Flashcards

1
Q

Define stroke

A

Stroke is defined as an acute neurological deficit lasting more than 24 hours with infarction

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2
Q

ISCHAEMIC vs HAEMORRHAGIC STROKE %

A

ischaemic - 80
haemorrhagic 20

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3
Q

What is ischaemic stroke caused by

A
  • Reduction in cerebral blood flow due to arterial occlusion/ blockage or stenosis. Typically divided into lacunar , thrombotic and embolic
  • Sites such as carotid, verebral and basilar arteries - mostly carotid
  • Infarcted area dies causing permanent deficit
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4
Q

Aetiology of ischaemic stroke

A
  • Atherothromboembolism
  • Cardioembolism - AF, post MI, IE
  • Vasculitis
  • Fat emboli
  • Hyperviscosity syndrome - blood becomes too thick
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5
Q

What is an embolic stroke usually caused by

A
  • usually a blood clot but fat ,air or clumps of bacteria
  • atrial fibrilation
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6
Q

What are thrombotic strokes usually caused by

A
  • thrombosis from large vessels
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7
Q

Primary investigations for stroke

A
  • 1st line- non contrast CT head - to allow exclusion of haemorrhage
  • Diffusion weighted MRI- gs to confirm after CT
  • ECG- asses for AF or MI
  • Bloods; hba1c, lipids, clotting screen, FBC (RBC), ESR (vasculitis), cholesterol
  • CTA
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8
Q

What are haemorrhagic strokes caused by

A
  • ruptured bv
  • berry aneurysm rupture
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9
Q

What can haemorrhgaic strokes further be divided into

A
  • intracerebral - bleeding within brain parenchyma
  • subarachnoid- bleeding between pia mater and arachnoid mater
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10
Q

Stroke in ACA

A

ACA- weakness of feet and legs with maybe sensory loss, incontinence, drowsiness, Truncal ataxia

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11
Q

Stroke in MCA

A

MCA (contralateral) - speech comprehension and understanding, hands and arms weakness, dysphasia, aphasia, Homonymous hemianopia,

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12
Q

Stroke in PCA

A
  • PCA - visual problems,
  • Propagnosia - inability to recognise faces,
  • Visual agnosia - cannot interpret visual ino
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13
Q

What happens if vertebrobasilar artery is infarcted

A
  • Quadriplegia - symptom of paralysis that affects all a person’s limbs and body from the neck down
  • Dysarthria
  • Vertigo
  • N/V
  • Drowsiness
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14
Q

Stroke in either hemisphere would exhibit ?

A

Hemiparesis
Hemisensory loss
Visual field defect

CONTRALATERAL

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15
Q

Lacunar infarct

A

Deep branches of MCA that feed the basal ganglia , damaged vessels form cysts due to hyaline arteriosclerosis

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16
Q

FEAUTURES of stroke in dominant hemisphere

A
  • usually left
  • Language dysfunction
  • Expressive dysphasia
  • Receptive dysphasia
  • Dyslexia
  • Dysgraphia
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17
Q

non dominant hemisphere stroke features

A
  • Anosognosia
  • Neglect of paralysed limb
  • Denial of weakness
  • Visuospatial dysfunction
  • Geographical agnosia
  • Dressing apraxia
  • Constructional apraxia
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18
Q

Key diagnostic factors for stroke ?

A
  • unilateral weakness or paralysis in the face, arm or leg
  • dysphasia
  • ataxia
  • visual disturbance
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19
Q

posterior circulation symptoms

A
  • Unsteadiness
  • Visual disturbance
  • Slurred speech
  • Headache
  • Vomiting
  • Others e.g. memory loss, confusion
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20
Q

Risk factors

A
  • older age
  • family history of stroke
  • history of ischaemic stroke or TIA
  • hypertension
  • Smoking
  • Male
  • diabetes
  • Vasculitis
  • Hyperlipidaemia
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21
Q

What do haemorrhagic strokes tend to show ..

A

increased intracranial pressure

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22
Q

What is ROSIER

A

Recognition of Stroke in the Emergency Room

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23
Q

DD for stroke

A
  • Hypoglycaemia
  • Hyponatraemia
  • Hypercalcaemia
  • Uraemia
  • Hepatic encephalopathy
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24
Q

increase in intracranial pressure is likely to cause ..?

A

midline shift

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25
Management of ischaemic stroke
- immediate aspirin 300mg until 2 weeks after symptoms - thrombolysis with IV alteplase ( tissue plasminogen ) to restablish blood flow - 4.5 hours within symptom onset - contraindcations of Thrombolysis
26
prevention of ischaemic stroke
- clopidogrel daily life long - aspirin 75mg daily - manage RF
27
What would you need before doing a thrombectomy
Confirmation of stroke requires CTA or MR angiogram prior to thrombectomy
28
thrombectomy for Proximal anterior circulation stroke?
offer thrombectomy within 6 hours with IV thrombolysis (if within 4.5 hours), or within 6 to 24 hours without IV thrombolysis if there is potential to salvage brain tissue
29
Haemorrhagic stroke management ?
- neurosurgery referral - intense monitoring of ICP
30
Epidemiology of stroke
- third leading cause of mortality in the US - stroke rates higher in asian and black
31
Cause of a TIA
- thrombosis - emboli- eg from AF - small vessel occlusion
32
What is a transient ischemic attack
- sudden onset focal neurological deficit that is temporary , lasts less than 24hrs WITHOUT INFARCTION - Acute loss of cerebral ocular function with sudden symptoms lasting less than 24 hours
33
How long does a TIA typically last
5-15 mins
34
What is the pathophysiology of a TIA
- type of cerebral ischaemia - lack of oxygen and nutrients to the brain resulting in cerebral dysfunction
35
RF for TIA
Same as IHD - smoking - dm - obesity - HTN - AF
36
TIA symptoms in carotid territory symptoms - more common here
- Amaurosis fugax - Aphasia - Hemiparesis - Hemisensory loss - Hemainopic visual loss
37
Symptoms of a TIA if in ACA
Weak numb contraletral leg
38
Symptoms of a TIA if in MCA
- Weak numb contralateral side of body - face drooping with forehead spared - dysphasia
39
General clinic presentation of a TIA
- sudden loss of function lasting for minutes - complete recovery - focal neurological deficit - no sign of infarction
40
What percentage of TIA affect the anterior or posterior circulation
anterior -90% posterior - 10%
41
What is amaurosis fugax and how can it be caused Otherwise known as transient visual disturbance
- sudden transient loss of vision in one eye - occlusion/ reduced blood flow to retina through opthalmic, retinal ciliary artery - signals that a stroke is impending
42
What is todds paralysis
transient weakness of arm, hand , leg after a seizure
43
Investigations for TIA
- 1st line - Diffusion weighted CT/MRI - Carotid imaging with doppler sound then MR/CT angiogrpahy if stenosis found - Bloods - Glucose, ESR, INR, U&E - ECG- AF - Echo
44
How to diagnose TIA
- based mostly on description - FAST - FACE ARM SPEECH TIME
45
When are patients at a high risk of an early stroke
- AF - more than one TIA in a week - TIA whilst on anticoagulant
46
What visual problems may occur in a TIA
- sudden transient loss of vision in one eye (amaurosis fugax) - diplopia - homonymous hemianopia
47
Immediate management of TIA
aspirin 300mg
48
for what reasons would you not give aspirin right away after a TIA
1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage) 2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist 3. Aspirin is contraindicated: discuss management urgently with the specialist team
49
What imaging is used in TIA and why
- MRI to determine the area of ischaemia , or to detect haemorrhage
50
What would a carotid bruit indicate
Carotid artery stenosis
51
Secondary prevention of stroke ?
- Clopidogrel 75mg once daily - Atorvastatin 80mg should be started but not immediately - Carotid endarterectomy or stenting in patients with carotid artery disease - Treat modifiable risk factors such as hypertension and diabetes
52
if clopidogrel is contraindicated in TIA what would you offer instead
- aspirin + dipridamole
53
what stroke has the poorest prognosis
anterior circulation stroke
54
what are the car or motorcycle rules for those who have had a stroke
- Patients must not drive for 1 month after a TIA or stroke - Driving may resume after 1 month if there has been satisfactory clinical recovery - Patients may not need to inform the DVLA if there is no residual neurological deficit beyond 1 month - Multiple TIAs over a short period requires no driving for 3 months and the DVLA must be notified
55
Heavy goods vehicle license rules?
- Patients must not drive for 1 year after a TIA or stroke and the DVLA must be notified - Relicensing may be considered after 1 year if there is no significant residual neurological impairment and no other significant risk factors
56
rules of thumb for stroke criteria
- ABRUpt DEFICIT - NEGATIVE quality - the maximal deficit at the start
57
rules of thumb for non stroke
- gradual onset - predominantly non-focal - positive - increases w time
58
dd for stroke
- epileptic seizure - positive history - space occupying lesion- gradual, headache, confusion - infection- gradual, fever
59
less common dd for stroke
- metabolic (hyponatraemia, hypoglycaemia) - multiple sclerosis- young sub acute progression - functional neurological disorder - migraine- history of previous attacks
60
common sites of atheroma
- LARGE AND MEDIUM VESSELS - carotid artery - confluence of arteries
61
small vessel ischaemic stroke involves ?
- Small deep perforator arteries blocked - Caused by high blood pressure, diabetes, smoking, age - In situ microatheroma or lipohyalinosis - At postmortem small holes + “cobweb” mesh - Hence term “lacunes”
62
Dissection stroke of carotid or vertebral artery
Causes 25% ischaemic strokes in <45 yo Risk factors - trauma or cervical manipulation - vigorous physical activity (eg weightlifting) - vasculopathy (fibromuscular dysplasia, Marfan’s) - sympathomimetic drug abuse - Often painful
63
rare causes of stroke
vasculitis venous thrombosis
64
Other Investigations over first few days after a stroke
- Blood tests can include vasculitis screen - ECG +- 72 hour tape - CT head - MRI brain with diffusion weighted imaging - Carotid Doppler - ECHO - CT or MR angiogram

Neuro (19 decks)

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