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stroke Flashcards

1
Q

define stroke

A

cerebrovascular event caused by abnormal perfusion of cerebral tissue
- Clinical syndrome characterised by sudden onset of developing focal or neuro disturbance that lasts more than 24hr or leads to death

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2
Q

what is an ischaemic stroke?

A

occlusion of blood vessels –

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3
Q

which type of stroke is most common?

A

ischaemic - 85%
haemorrhagic - 15%

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4
Q

what is infarction?

A
  • Infarction: tissue death due to ischaemia
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5
Q

what types of haemorrhagic strokes are there?

A
  • Intracerebral haemorrhage or subarachnoid haemorrhage
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6
Q

what is the pathophysiology causing an ischaemic stroke?

A

thrombus formation
emboli
thrombosis
dissection
all resulting in occlusion to cerebral vessels

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7
Q

how can a thrombosis lead to ischaemic stroke?

A
  • Result of thrombus (atheromatous plaque) within vessel, embolus (blood clot) arising from distant site or even dissection
  • Thrombosis: blockage of vessel due to atherosclerosis (CVS RF or small vessel disease – vasculitis, sickle cell disease)
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8
Q

how can an emboli lead to a stroke?

A
  • Emboli: propagation of blood clot leading to acute obstruction and ischaemia – AF or carotid artery disease
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9
Q

how can a dissection lead to an ischaemic stroke?

A
  • Dissection: rare cause of cerebral ischaemia from tearing intimal layer of artery  leads to intramural haematoma that comprises cerebral blood flow. May be secondary to trauma
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10
Q

what is the most common cause of a haemorrhagic stroke?

A

hypertension

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11
Q

what are non traumatic causes of a haemorrhagic stroke?

A
  • Other causes of non-traumatic intracerebral haemorrhage include vascular malformations eg AV malformation, AV fistula, brain tumour, vasculitis, bleeding disorder
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12
Q

what RF are there for a stroke?

A
  • Smoking
  • DM
  • Hypertension
  • Hypercholesterolemia
  • Obesity ‘
  • AF
  • Cartodi artery disease
  • Thrombophilia disorders eg antiphopspholipid syndrome
  • Sickle cell disease
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13
Q

what symptoms are seen in a haemorrhagic stroke?

A

more likely to have global features such as headache and altered mental status
- Headache
- Altered mental status
- N+V
- Hypertension
- Seizures
- Focal neuro deficits – dependent on location of bleeding

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14
Q

what signs/ symptoms are seen with a anterior ischaemic stroke?

A

Unilateral weakness/ sensory deficits eg face/ arms/ legs
- Homonymous hemianopia: visual field loss on same side
- Higher cerebral dysfunction: dysphasia, visuospatial dysfunction eg neglect , agnosia

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15
Q

what is agnosia?

A

Agnosia: rare disorder where a patient can not recognise and identify objects, persons or sounds using one or more senses despite otherwise normally functioning senses

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16
Q

what features are seen within a posterior ischaemic stroke?

A

Posterior ischaemic stroke: affects balance, vision, cranial nerves
- Dizziness
- Diplopia
- Dysarthria and dysphagia
- Ataxia
- Visual field defects
- Brainstem syndromes

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17
Q

what assessments are required for a suspected stroke?

A
  • FAST test
  • Assessed using NIHSS score with urgent cross sectional imaging eg CT head with/without CT head angiography
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18
Q

what NIHSS score is linked to good outcomes?

A

<4

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19
Q

what NIHSS score is linked to ischaemic stroke?

A

22-26

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20
Q

what score is linked to haemorrhagic stroke and therefore contra-indicated thrombolysis?

A

> 26

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21
Q

what is the FAST test?

A

new facial weakness, new arm weakness and new speech difficulty

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22
Q

what is the acute management of a stroke?

A
  1. ABCDE
  2. NIHSS assessment
  3. capillary blood glucose measurement ‘
    4> imaging - determine ischaemic or haemorrhagic stroke
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23
Q

why would you do a capillary blood glucose?

A

remove hypoglycaemia/ hyper as differential
similar symptoms

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24
Q

what imaging can be done to differentiate between ischaemic or haemorrhagic?

A

CT angiogram
MRI FAST - assess if still perfusion and if they can have thrombolysis

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25
Q

what is the window for thrombolysis within an ischaemic stroke?

A

<4.5hrs

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26
Q

what is thrombolysis?

A

IV infusion of altepase - clot busting drug

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27
Q

why is thrombolysis contra-indicated within haemorrhagic?

A

would make them bleed more - stops all clotting
would turn into catastrophic event

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28
Q

if someone missed thrombolysis window, what other options are available?

A

mechanical thrombectomy
medicinal

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29
Q

what is mechanical thrombectomy?

A

endovascular removal of clot from large cerebral vessel

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30
Q

when in mechanical thrombectomy indicated?

A

NIHSS score of >5
presenting <6hrs

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31
Q

if a patient can not have thrombolysis or surgery, what options can they have for an ischaemic stroke?

A
  1. aspirin 200mg for 2 weeks and then clopidrogrel for life time (75mg)
  2. life long anticoags eg apixaban
32
Q

what is the management for haemorrhagic stroke?

A

Anticoag reversal  discuss with haemtology
Blood pressure Lowering  aim for <140 systolic if <6hrs
Referral to neurosurgery eg Burr Holes procedure

33
Q

what lifelong management is required post stroke?

A

blood pressure control
blood glucose control
anti-lipid therapy
anticoags
antiplatelets
lifestyle advice

34
Q

why would anticoags be needed post stroke?

A

incase a clot cause
common in those with AF

35
Q

what anti-lipid therpay is needed, when do you start it post stroke?

A

start statin 48hrs post stroke

36
Q

what lifestyle management is needed post stroke?

A

improve diet
more exercise
stop smoking
reduce alcohol

37
Q

what is the DVLA advice following a stroke?

A

do not drive initially
if symptoms resolve 1mth post - do not need to inform
inform if haemorrhagic stroke occurred
inform if drive larger than car

38
Q

what are early complications of a stroke?

A
  • Haemorrhagic transformation of ischaemic stroke
  • Cerebral oedema
  • Seizures
  • Infection eg aspiration pneumonia from dysphagia
  • Venous thromboembolism
  • Death
39
Q

what are late complications of a stroke?

A
  • Mobility and sensory issues
  • Bladder and bowel dysfunction
  • Pain
  • Fatigue
  • Cognitive problems
  • Visual problems
  • Emotional and psychological issues
  • Issues with swallowing, hydration and nutrition
40
Q

what are toxic/ metabolite stroke mimics differentials?

A

hypoglycaemia, drug and alcohol consumption

41
Q

what are neurological differentials of a stroke?

A
  • Neurological: seizure, migraine, Bell’s Palsy
42
Q

what infection differentials are there of a stroke?

A
  • Infection: meningitis/ encephalitis, systemic infection with decompensation of old stroke
43
Q

how would differentiate between seizure and stroke?

A

Seizure: often cause loss of consciousness
- EMG would reveal the surge in electrical activity

44
Q

how would you differentiate between migraine and stroke?

A

Migraine: be sitting in dark room and no stimulation would improve symptoms  would not in stoke
- Migraine – positive sensation  tingly, prickly, seeing spots
- Stroke: absence of sensation  feeling numb or weak, having vision loss

45
Q

how would you differentiate between bell’s palsy and stroke?

A

Bell’s Palsy: watering from eye on affected side, changes in ability to taste, sound sensitivity and ringing in ear
- Stroke: trouble finding words, eyes gazing in one direction, trouble walking and vision changes
- Bells: can not move eyebrows and lower portion of face but limbs are not affected

46
Q

how would you differentiate between stroke and meningitis?

A

Meningitis: systemically unwell – fever, photophobia and neck stiffness

47
Q

how would you differentiate between stroke and encephalitis?

A

Encephalitis: altered consciousness, seizures and focal deficits

48
Q

how would you differentiate between syncope and stroke?

A

Syncope: transient loss of consciousness with spontaneous and unaided come around and no further issues following

49
Q

what would indicate psychogenic/ functional/ conversion therapy?

A
  • Excessive hesitation in locomotion
  • Increasing swayings in rombergs test
  • Uneconomic postures wasting muscle energy
  • Small cautions steps like walking on ice
  • Sudden buckling of the knees emotional distress
  • Seen in young women most frequently
50
Q

what is rombergs test?

A

positive test is inability to maintain an erect posture over 60seconds with eyes closed

51
Q

which patients is venous sinus thrombosis most common in?

A

often in obese young women in hypercoagable states
- Pregnant or taking OCP

52
Q

which type of CT should be used to assess query stroke?

A

non contrast
if it is haemorrhagic - will cause them to bleed out

53
Q

what does dysdiadochokinesia indicate?

A

parkinsons - can not do fast repetitive movements

54
Q

what is the most common cause of haemorrhagic stroke?

A

hypertension

55
Q

if a CT comes back unremarkable following query stroke, what would it indicate?

A

ischaemic stroke- would not see for a couple weeks after
needs altepase

56
Q

how long does a TIA last?

A

less than 24hrs

57
Q

what is a TIA?

A

transient ischaemic attack - temporary neuro dysfunction

58
Q

what is a cresendo TIA?

A

2+ TIAs in a week - higher risk of stroke

59
Q

what symptoms would indicate a posterior ischaemic stroke?

A

ataxia and vertigo

60
Q

what would be seen in total anterior circulation stroke?

A

3/3
- unilateral weakness
- homonymous hemianopia
- higher cerebral dysfunction

61
Q

what would be seen on a partial anterior stroke?

A

2/3
- unilateral weakness - face, arm, leg
- homonymous hemianopia
- higher cerebral dsyfunction

62
Q

what is seen within a lacunar syndrome?

A

1/4
- pure sensory stroke
- pure motor stroke
- sensori- motor
- ataxic hemiparesis

63
Q

what is seen within a posterior circulation?

A

1/5
- cranial nerve palsy +/- contralateral motor or sensory
- bilateral motor+/- sensory
- conjugate eye movement
- cerebellar dysfunction
- isolated homonymous hemianopia

64
Q

what

A
65
Q

would an anterior cerebral artery stroke present as?

A

opposite side weakness (hemiparesis)
sensory loss - mainly lower extremities

66
Q

how would a middle cerebral artery stroke present as?

A

opposite side weakness
sensory loss - mainly upper extremities
contralateral homonymous hemianopia

67
Q

how would a posterior cerebral artery stroke appear as?

A

contralteral homonymous hemianopia with macular sparing
visual agnosia

68
Q

what is visual agnosia?

A

inability to recognise and name known objects

69
Q

where does ‘weber syndrome’ affect within a stroke in the brain?

A

branches of posterior supplying midbrain

70
Q

how does a webber - branches of posterior supplying midbrain stroke present?

A

ipsilater CNIII palsy
contralateral weakness of upper and lower extemity

71
Q

how does a posterior inferior cerebellar stroke present?

A

ipsilateral facial pain and temp loss
contralateral limb/ torso pain and temp loss
ataxia, nystagmus

72
Q

how does an anterior inferior cerebellar stroke present?

A

ipsilateral facial pain and temp loss
contralateral limb/ torso pain and temp loss
ataxia, nystagmus
ipsilateral facial paralysis and deafness

73
Q

how does a basilar artery stroke present?

A

locked in syndrome

74
Q

what is a lacunar stroke?

A

small occlusion in a large artery

75
Q

how does a lacunar stroke present?

A

isolated hemiparesis
hemisensory loss
linked to HTN

76
Q
A

neuro (12 decks)

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