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BDS3 Diseases of Human Systems > Stroke > Flashcards

Stroke Flashcards

1
Q

What is the definition of a stroke?

A

An acute focal neurological deficit resulting from cerebrovascular disease and lasting more than 24 hours or causing earlier death

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2
Q

What happens during a stroke?

A
  • blockage of blood delivery of oxygen to tissues
    • no local cerebral blood flow
    • cell death = death of brain tissue
      • infarction of tissue
      • haemorrhage into brain tissue
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3
Q

What is a TIA?

A

Transient Ischaemic Attack
- temporary ischaemia

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4
Q

What is the acronym FAST in relation to stroke?

A

F - facial drooping
A - arm weakness
S - speech difficulty
T - time

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5
Q

What feature of TIAs differs from strokes?

A
  • recovery time
    • full recovery after 24 hours
    • many experience full recovery in 30 minutes
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6
Q

Why do TIAs only have a temporary effect?

A
  • ischaemia is cleared
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7
Q

How are TIAs thought to occur?

A
  • platelet emboli from neck vessels block blood supply to brain tissues
  • ischaemia caused by emboli
  • emboli cleared by circulation
  • no permanent damage caused
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8
Q

What do TIAs increase the risk of?

A
  • full stroke
  • myocardial infarction
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9
Q

What are the risk factors for stroke?

A

Major:
- hypertension
- smoking
- ischaemic heart disease

Minor:
- alcohol
- atrial fibrillation
- diabetes mellitus

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10
Q

What level of hypertension increases the risk of stroke?

A
  • diastolic >110mmHg
    • 15x increase
  • borderline hypertension still carries risk
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11
Q

Why does atrial fibrillation increase the risk of stroke?

A
  • associated with emboli from abnormally contracting atria
  • emboli pass through ventricle into cerebral circulation
  • ischaemia caused
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12
Q

What are the incidences of the different types of strokes?

A

infarction - 85%
haemorrhage - 10%
subarachnoid haemorrhage - 5%
venous thrombosis - <1%

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13
Q

What is the cause of ischaemia stroke?

A
  • uncertain
  • usually narrowing of vessels and plaque formation
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14
Q

What is the cause of haemorrhagic stroke?

A
  • inter cranial bleed
    • usually from aneurysm rupture
    • weak point in vessel fails
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15
Q

What are the causes of embolic strokes?

A
  • embolism from left side of heart
    • atrial fibrillation
    • heart valve disease
    • recent MI
  • atheroma of cerebral vessels (TIA or full)
    • carotid bifurcation
    • internal carotid artery
    • vertebral artery
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16
Q

What type of stroke can be seen on CT scans?

A
  • haemorrhage
    • visible as radiopaque mass
17
Q

What type of stroke can be seen on an MRI?

A
  • infarction
    • shows inflammatory change around bleed
18
Q

What are potential causes of stroke?

A
  • venous thrombosis
    • oral contraceptive pill use
    • polycythaemia (high Hb)
    • thrombophilia (increased clotting)
  • borderzone infarction
    • poor brain perfusion over period of time
    • resulting brain injury
    • severe hypotension, cardiac arrest etc.
  • vasculitis
    • narrowed vessels to brain
    • limited oxygen delivery
19
Q

How can stokes be prevented?

A
  • reduction of risk factors
    • quit smoking
    • improve diabetic control
    • control hypertension
  • anti-platelet action
    • only as secondary prevention
    • aspirin (NSAID)
    • dipyridamole (anti-platelet)
    • clopidogrel (anti-platelet)
  • anticoagulants
    • less commonly used
    • appropriate for embolic risk (e.g. AF, LVT)
    • warfarin
    • apixiban
  • carotid endarterectomy
  • preventative neurosurgery
20
Q

What is carotid endarterectomy and when is it used?

A

Used in case of:
- severe stenosis
- previous TIAs
- under 85s

  • incision of vessel containing large atherosclerosis
  • collateral circulation of head and brain compensate
  • atherosclerosis can be removed to increase patency
  • 7.5% mortality rate
21
Q

What are examples of preventative neurosurgery?

A
  • aneurysm clips
  • AV malformation correction
22
Q

How can strokes be investigated and what are the advantages and disadvantages of each method?

A
  • CT scan
    • quick and easy
    • poor for ischaemic stroke detection
  • MRI scan
    • cannot be done quickly
    • shows haemorrhagic and ischaemic
    • good for visualising early damage
    • MRA (angiography) is best for brain circulation
  • Digital Subtraction Angiography (DSA)
    • if MRA not available
  • Assessment of risk factors
    • carotid ultrasound
      - evidence of atherosclerosis
      - carotid artery
    • cardiac ultrasound
      - formation of thrombi
      - left ventricle
    • ECG
      - arrhythmias
      - particularly AF
    • blood pressure
      - hypertension
    • diabetes screen
      - assess control
    • thrombophilia screen
      - younger patients
      - increased clot formation
23
Q

What are the effects of stroke?

A
  • loss of functional brain tissue
    • immediate nerve cell death
    • nerve cell ischaemia in penumbra
    • nerve cells will die if not protected
    • loss dependent on type/volume of damage
  • gradual or rapid loss of function
    • stroke can evolve over hours or minutes
  • inflammation In tissue surrounding infarct/bleed
    • penumbra (survivable ischaemia)
    • size depends on time before treatment
    • inflammation can cause further function loss
    • final loss assessed after several days
24
Q

What are the complications of stroke?

A
  • motor function loss
    • cranial nerve or somatic (opposite side)
    • autonomic in brainstem lesions
  • dysphonia
    • changes to speech
  • aphagia/dysphagia
    • aspiration of food/saliva
    • increased risk of pneumonia
  • sensory loss
    • cranial nerve or somatic (opposite side)
    • body perception altered
    • neglect (patient does not look after area)
    • phantom limbs (less common than neglect)
  • cognitive impairment
    • appreciation of special sensation
    • processing of speech and language
    • difficulty understanding information
    • memory impairment
    • emotional lability and depression
25
Q

How is the acute phase of stroke managed?

A
  • limit damage
    • improve blood flow/oxygenation
      - thrombolysis within 3 hours
      - maintain perfusion pressure to brain
    • normoglycemia
      - hypo/hyper is harmful
      - glucose is sole energy store of brain
      - abnormalities may increase damage
    • preserve penumbra
      - calcium channel blockers (nimodipine)
  • reduce further risk
    • manage penumbra to reduce loss of function
    • institution of treatment
      - 300mg aspirin daily
      - anticoagulation if AF or LFT (after 2 weeks)
  • removal of haematoma for subarachnoid haemorrhages
26
Q

How is the chronic phase of stroke managed?

A
  • rehabilitation
    • immobility support
      - prevention of bed sores
      - physiotherapy to prevent contractures
    • speech and language therapy
      - communications
      - swallowing and eating
    • occupational therapy
  • reduce further risk
27
Q

What are the dental considerations of stroke?

A
  • impaired mobility and dexterity
    • more challenging to attend appointments
    • difficult to maintain adequate oral hygiene
  • communication difficulties
    • dysphonia (abnormal/hoarse voice)
    • dysarthria (difficulty speaking)
    • cognitive difficulties
  • risk of cardiac emergencies
    • MI
    • further stroke
  • loss of protective reflexes
    • aspiration
    • saliva management (anticholinergic drugs)
  • loss of sensory information
    • difficult to adapt to new oral environment
  • stroke pain
    • CNS generated pain perception
    • e.g. pain reported as a result of peripheral stimuli

BDS3 Diseases of Human Systems (13 decks)

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