Stroke Flashcards
What is another term for strokes?
Cerebrovascular Accidents
What are strokes?
They are defined as a condition in which there is an acute insult in the vascular supply of the brain
What are the two classifications of strokes?
Ischaemic Strokes
Haemorrhagic Strokes
What is the most common stroke classification?
Ischaemic Strokes
What are ischaemic strokes?
They occur when the blood supply to an area of brain tissue is reduced due to clot formation, resulting in tissue hypoperfusion
What are the two subclassifications of ischaemic strokes?
Thrombotic Stroke
Embolic Stroke
What is a thrombotic ischaemic stroke?
It is deifined as clot formation locally within a cerebral vessel within the brain
What is an embolic ischaemic stroke?
It is defined as clots mobilisation to the cerberal vessels, which originate in other regions of the body
What is the most common cause of embolic strokes?
Atrial Fibrillation
What are haemorrhagic strokes?
They occur when there is rupture of a blood vessel or abnormal vascular structure within the brain
What are the two subclassifications of haemorrhagic strokes?
Intracerebral Haemorrhage
Subarachnoid Haemorrhage
What are intracerebral haemorrhage strokes?
It is defined as bleeding within the brain secondary to a ruptured blood vessel
What are subarachnoid haemorrhage strokes?
It is defined as bleeding outside of the brain tissue, occurring between the pia mater and arachnoid mater
What are the thirteen risk factors associated with strokes?
Older Age
Stroke History
Hypertension
Atrial Fibrillation
Carotid Artery Disease
Arteriovenous Malformation
Hyperlipidaemia
Diabetes Mellitus
Vasculitis
Smoking
Alcoholism
Obesity
Drug Administration
What two drugs are associated with strokes?
Anticoagulant Therapy
Combined Oral Contraceptive Pill
What are the six clincial features of strokes?
Facial Motor Weakness
Limb Motor Weakness
Visual Field Defects
Dysphasia
Dysphagia
Ataxia
What are the four aphasia classifications?
Wernicke’s Aphasia
Broca’s Aphasia
Conduction Aphasia
Global Aphasia
What lesion results in Wernicke’s aphasia?
Superior temporal gyrus, which is supplied by the inferior division of the left middle cerebral artery
What is Wernicke’s aphasia?
‘What?’ as the patient doesn’t understand a command
It results in sentences that make no sense, word substitution and neologisms but speech remains fluent. The comprehension is impaired
What lesion results in Broca’s aphasia?
Inferior frontal lobe/gyrus, which is supplied by the superior division of the left middle cerebral artery
What is Broca’s aphasia?
Broca sounds like ‘broken’ as the patient’s word-flow is broken
It is when speech is non-fluent, laboured, and halting. The repitition is impaired. The comprehension is normal
What lesion occurs conduction aphasia ?
Arcuate fasiculus, which is the connection between Wernicke’s and Broca’s area
What is conduction aphasia?
It is when speech is fluent, however repetition is poor. They are aware of the errors they are making. The comprehension is normal
What lesion results in global aphasia?
It is defined as large lesion affecting the superior temporal gyrus, inferior temporal gyrus and arcuate fasiculus
What are the nine anatomical classifications of strokes?
Anterior Cerebral Artery Strokes
Middle Cerebral Artery Strokes
Posterior Cerebral Artery Strokes
Weber’s Syndrome
Anterior inferior Cerebellar Artery Strokes
Posterior inferior Cerebellar Artery Strokes
Ophthalmic Artery Strokes
Basilar Artery Strokes
Pontine Haemorrhages
What is global aphasia?
It is when individuals are only able to communicate through gestures
What are anterior cerebral artery strokes?
They are defined as cortical strokes affecting the areas of the brain supplied by the anterior cerebral artery
What are the two clinical features of anterior cerebral artery strokes?
Contralateral Hemiparesis
Contralateral Sensory Loss
Which extremities are affected in anterior cerebral artery strokes?
Lower Extremeties
What are middle cerebral artery strokes?
They are defined as cortical strokes affecting the areas of the brain supplied by the middle cerebral artery
What are the four clinical features of middle cerebral artery strokes?
Contralateral Hemiparesis
Contralateral Sensory Loss
Contralateral Homonymous Hemianopia
Aphasia
Which extremities are affected in middle cerebral artery strokes?
Upper Extremities
What are posterior cerebral artery strokes?
They are defined as cortical strokes affecting the areas of the brain supplied by the posterior cerebral artery
What are the two clinical features of posterior cerebral artery strokes?
Contralateral Homonymous Hemianopia & Macular Sparing
Visual Agnosia
What is another term for Weber’s syndrome?
Ventral midbrain syndrome
What is Weber’s syndrome?
It is defined as a cortical stroke affecting the areas of the midbrain supplied by the branches of the posterior cerebral artery
What are the two clinical features of Weber’s syndrome?
Ipsilateral CN III Palsy
Contralateral Upper/Lower Weakness
What are the three clinical features of CN III palsy?
Eyelid Ptosis
‘Down & Out’ Eye Restriction
Dilated, Fixed Pupil
What is another term for anterior inferior cerebellar artery strokes?
Lateral pontine syndrome
What are anterior inferior cerebellar artery strokes?
They are defined as cortical strokes affecting the areas of the brain supplied by the anterior inferior cerebellar artery
What are the six clinical features of anterior inferior cerebellar artery strokes?
Contralateral Limb Pain
Contralateral Temperature Loss
Ipsilateral Facial Paralysis
Ipsilateral Deafness
Ataxia
Nystagmus
What are another two terms for posterior inferior cerebellar artery strokes?
Lateral medullary syndrome
Wallenberg syndrome
What are posterior inferior cerebellar artery strokes?
They are defined as cortical strokes affecting the areas of the brain supplied by the posterior inferior cerebellar artery
What are the six clinical features of posterior inferior cerebellar artery strokes?
Contralateral Limb Pain
Contralateral Temperature Loss
Ipsilateral Facial Pain
Ipsilateral Temperature Loss
Ataxia
Nystagmus
What is another term for opthalmic artery strokes?
Retinal artery strokes
What are ophthalmic artery strokes?
They are defined as cortical strokes affecting the areas of the brain supplied by the ophthalmic artery – which is a branch of the internal carotid artery
What is a clinical feature of ophthalmic artery strokes?
Ipsilateral Amaurosis Fugax
What are basilar artery strokes?
They are defined as cortical strokes affecting the areas of the brain supplied by the basilar artery
What is a clinical feature of basilar artery strokes?
Locked In Syndrome
What is locked in syndrome?
It is defined as the inability to mobilise or speak, however the ability to follow eye movement commands remains intact
What are pontine haemorrhages?
They are defined as the rupture of pontine arteries, which radiate from the basilar artery on the brainstem to the pons
What are the three clinical features of pontine haemorrhages?
Quadriplegia Limb Paralysis
Bilateral Pinpoint Pupils
Reduced Glasgow Coma Score
What are the four Bamford classifications of strokes?
Total Anterior Circulation Stroke (TACS)
Partial Anterior Circulation Stroke (PACS)
Posterior Circulation Syndrome (POCS)
Lacunar Stroke (LACS)
What are total anterior circulation strokes (TACS)?
They are defined as large cortical strokes affecting the areas of the brain supplied by both the anterior cerebral artery and the middle cerebral artery
What are the three clinical features of total anterior circulation strokes?
It results in the following three clinical features…
- Unilateral Weakness of Face/Limbs
- Homonymous Hemianopia
- Higher Cerebral Dysfunction
What are two higher cerebral dysfunction clinical features?
Dysphasia
Visuospatial Disorder
What are partial anterior circulation strokes (PACS)?
They are defined as small cortical strokes affecting either the upper division or lower division of the middle cerebral artery
What are the three clinical features of partial anterior circulation strokes (PACS)?
It results in two of the following clinical features…
- Unilateral Weakness of Face/Limbs
- Homonymous Hemianopia
- Higher Cerebral Dysfunction
What are posterior circulation syndromes (POCS)?
They are defined as cortical strokes affecting the arteries supplying the posterior circulation – vertebrobasilar arteries
What are the five clinical features of posterior circulation syndromes (PCOS)?
It results in one of the following clinical features…
- Bilateral Motor/Sensory Deficit
- Cranial Nerve Palsy & Contralateral Motor/Sensory Deficit
- Conjugate Eye Movement Disorder
- Cerebellar Dysfunction
- Isolated Homonymous Hemianopia
What are the three cerebellar dysfunction clinical features?
Vertigo
Nystagmus
Ataxia
What are lacunar strokes (LACS)?
They are defined as subcortical strokes affecting perforating arteries around the internal capsule, thalamus and basal ganglia
What are the four clinical features of lacunar strokes (LACS)?
Pure Sensory Stroke
Pure Motor Stroke
Sensori-Motor Stroke
Ataxic Hemiparesis
What four investigations are used to diagnose strokes?
FAST Screening Tool
ROSIER Scoring System
Blood Tests
Non-Contrast CT Scans
How is the FAST screening tool used to diagnose strokes?
It is used to identify strokes within the community
What is the FAST screening tool?
Face Drooping
Arm Weakness
Slurred Speech
Time To Call 999
How is the ROSIER scoring system used to diagnose strokes?
It is used by medical professionals in order to differentiate between acute strokes and stroke mimics
What is the ROSIER scoring system?
Loss of Consciousness = -1 Point
Seizure Episode = -1 Point
Asymmetric Facial Weakness = + 1 Point
Asymmetric Arm Weakness = + 1 Point
Asymmetric Leg Weakness = + 1 Point
Speech Disturbance = +1 Point
Visual Field Defect = +1 Point
What ROSIER score indicates stroke diagnosis?
> 0
When are blood tests used to investigate strokes?
They are used to investigate strokes in those who present under 55 years old and with no obvious cause
How are blood tests used to investigate strokes?
They are used to screen for autoimmune and thrombophilia disorders
What six blood tests are used to investigate strokes?
Antinuclear Antibodies (ANA)
Antiphospholipid Antibodies (APL)
Anticardiolipin Antibodies (ACL)
Lupus Anticoagulant (LA)
Coagulation Factors
ESR Levels
When are non-contrast CT scans used to diagnose strokes?
They are the first line imaging investigation used to diagnose strokes
What is the feature of acute ischaemic strokes on non-contrast CT scans?
There is hypodense (black) material within the grey/white matter of the brain, alongside a hyperdense (white) artery
What is the feature of acute haemorrhagic strokes on non-contrast CT scans?
There is hyperdense (white) material surrounded by low density
What is the pharmacological management option of ischaemic strokes?
Thrombolysis
When is thrombolysis used to manage ischaemic strokes?
When individuals present within 4.5 hours of clinical feature onset, and haemorrhagic stroke has been definitively excluded with CT scans
When is thrombolysis used to manage ischaemic strokes - in > 80 year olds?
When individuals present within 3 hours of clinical feature onset, and haemorrhagic stroke has been definitively excluded with CT scans
What is thrombolysis?
It involves administration of thrombolytic drugs, such as altepase, which are tissue plasminogen activators used to rapidly break down clots and reverse stroke clinical features
What investigation is conducted 24 hours following thrombolysis? Why?
CT Scan
In order to monitor for post thrombolysis complications, such as intracranial/systemic haemorrhage
How do we manage post thrombolysis complications?
We stop aspirin and administer hypertensives
What are the ten absolute contraindications of thrombolysis?
Previous Intracranial Haemorrhage
Stroke In Preceding 3 Months
Seizure At Stroke Onset
Intracranial Neoplasm
Lumbar Puncture In Preceding 7 Days
Oesophageal Varices
Gastrointestinal Haemorrhage In Preceding 3 Weeks
Active Bleeding
Pregnancy
Uncontrolled Hypertension > 200/120mmHg
What are the five relative contraindications of thrombolysis?
Concurrent Anticoagulation
Haemorrhagic Diathesis
Suspected Intracardiac Thrombus
Active Diabetic Haemorrhagic Retinopathy
Major Trauma In Preceding 2 Weeks
What should be conducted when individuals present outwith of the thrombolysis window?
Secondary prophylaxis aspirin
What is the surgical management option of ischaemic strokes?
Thrombectomy
When is thrombectomy used to manage ischaemic strokes - in addition to thrombolysis?
When individuals present within 6 hours of clinical feature onset with a confirmed thrombus involving the proximal anterior circulation – demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
What is thrombectomy ?
It involves surgical removal of a thrombus from a blood vessel
A catheter is inserted into the femoral/radial artery, which is attached to an expandable mesh structure, and guided towards the affected cerebral vessel
The mesh structure is then expanded into the clot and removed from the circulation
In which circumstance, do we extend the target time of thrombectomy up to 24 hours?
When advanced brain imaging indicates substantial salvageable brain tissue is still present, with a limited infact core volume
What are the three secondary prophylaxis pharmacological management options of strokes?
Antiplatelet Drugs
Anticoagulant Drugs
Statin Drugs
When are antiplatelet drugs used to prophylactically manage strokes?
It is the first line management option used in all ischaemic stroke patients
What antiplatelet drug regime is used to prophylactically manage strokes?
It is recommended that aspirin 300mg once daily is administered immediately and continued for a period of 2 weeks
They should then be switched to clopidogrel 75mg once daily lifelong
What antiplatelet drug is recommended when clopidogrel is contraindicated?
Modified release dipyridamole, alongside low dose aspirin
When are anticoagulant drugs used to prophylactically manage strokes?
When ischaemic stroke occurs in individuals with atrial fibrillation
It is recommended that it is commenced lifelong 2 weeks post-stroke, after aspirin treatment, alongside clopidogrel
Name three anticoagulant drugs used to prophylactically manage strokes
Warfarin
Direct Factor Xa Inhibitors
Direct Thrombin Inhibitors
When are statin drugs used to prophylactically manage strokes?
They are used to manage ischaemic stroke patients with cholesterol levels > 3.5mmol/l
It is recommended it is not administered until 48 hours after clinical feature onset, due to the risk of haemorrhagic transformation
What is the surgical prophylactic management option of strokes?
Carotid Artery Endarterectomy
When are carotid artery endarterectomies used to manage strokes?
When individuals have suffered strokes within the carotid territory, in which there is carotid stenosis > 70%
What is carotid artery endarterectomy?
It involves surgical removal of atherosclerotic plaques from the carotid arteries
What nerve is at risk of damage during carotid artery endarterectomy?
Hypoglossal Nerve
What is the Barthel scale?
It is used to measure disability to dependence in activities of daily living in stroke patients
