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MBBS 3: Internal Medicine > Stroke > Flashcards

Stroke Flashcards

1
Q

Blood supply to the brain?

A
  1. basilar artery
  2. posterior cerebral artery
  3. left and right carotid arteries
  4. middle cerebral artery
    > posterior communicating artery
  5. anterior cerebral artery
    > anterior communicating artery
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2
Q

What is the blood supply to the brain called?

A

Circle of Willis

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3
Q

Circle of Willis is famous for what pathology?

A

berry aneurysms
- main cause of non-traumatic subarachnoid hemorrhage

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4
Q

Middle cerebral artery supplies?

A

anterior two thirds of the brain

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5
Q

Anterior cerebral artery supplies?

A

remaining medial 2/3 of the brain

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6
Q

Posterior cerebral artery supplies?

A

posterior 1/3 of the brain
- occipital lobe

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7
Q

Brainstem and cerebellum are supplied by?

A

vertebral and basilar arteries

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8
Q

Common sites for stroke?

A

MCA>ACA>lacunar>PCA

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9
Q

What is a stroke?

A
  • Sudden neurological deficit
  • Lasting more than 24 hours/causing death
  • With no explanation other than a vascular cause
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10
Q

What is a transient ischaemic attack?

A
  • Sudden neurologic deficit lasting less than 24 hours with full recovery.
  • Danger sign for an eminent stroke in the near future
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11
Q

Risk of stroke after TIA?

A
  1. Stroke in 30% of the patients within 1 year
  2. 15% within three months
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12
Q

Aetiological classification of stroke?

A
  1. ischaemic - 80%
  2. haemorrhagic - 20%
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13
Q

Ischemic stroke?

A

Blockage of the arteries causing ischaemia
1. Thrombosis
- arteriosclerosis, dissection, fibromuscular dysplasia
2. Embolism.
3. Systemic hypoperfusion.

dissection - when blood extrudes into the connective tissue framework of a vessel wall, causing seperation of the natural vessels causing luminal narrowing or occlusion
fibromuscular dysplasia - progressive twisting of the blood vessels throughout the body

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14
Q

Haemorrhagic stroke?

Types?

A

Rupture of the arteries causing haemorrhage.
1. Parenchymal/intracerebral haemorrhage.
2. Subarachnoid haemorrhage.

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15
Q

Clinical classification of stroke?

A
  1. progressing/evolving - Progressive neurological deficits
  2. completed - Persistent neurological deficits not getting worse
  3. TIA - Resolved neurological deficits
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16
Q

Cardiac output required by the brain?

A

Receives 15% of resting cardiac output

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17
Q

Oxygen consumption of the brain?

A

Accounts for 20% of total body oxygen consumption

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18
Q

Consequences of reduced blood flow?

A
  1. If zero leads to death within 4-10mins
  2. <16-18ml/100g tissue/min causes infarction within 1hr
  3. <20ml/100g tissue/min causes ischaemia without infarction
    - Unless prolonged for several hours or days
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19
Q

Pathogenesis of hemorrhagic stroke?

A
  1. hemorrhage
  2. cytotoxic and vasogenic edema
  3. swelling of the brain
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20
Q

Pathogenesis of ischemic stroke?

A
  1. loss of blood supply
  2. infarction/necrosis
  3. cytotoxic and vasogenic edema
  4. swelling of the brain
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21
Q

Why is Stroke now one of the leading causes of neurological admissions and death in urban hospitals throughout Africa?

A

Because of increasing urbanization and life style changes

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22
Q

Epidemiological risk factors?

A
  1. high income countries
  2. > 65 years
23
Q

Risk factors for stroke?

A
  1. age - highest
  2. hypertension
  3. atrial fibrillation
  4. previous TIA/stroke
  5. elicit drugs e.g. marijuana, amphetamines and cocaine
    - very high
  6. ischemic heart disease
  7. lifestyle e.g. diet, high salt, lack of exercise, drinking and smoking
    - moderate
  8. obesity
    - low
24
Q

FAST tool for stroke recognition?

A
  1. Face droops
  2. Arm weakness
  3. Speech difficulty
  4. Time is critical
25
Q

History taking in stroke?

A
  1. Onset and progression of neurological symptoms
    - completed Vs stroke in evolution, other stroke mimics
  2. Exposure to major risk factors.
  3. Previous stroke like symptoms
    - possible TIA
  4. Drug history
    - Diabetic medications, anticoagulation therapy
  5. Any hypercoaguable disorders
    e.g SCD & polycythemia
  6. HIV status
  7. History of trauma
  8. Screen for stroke mimics
    - Substance abuse, seizure, migraine etc
26
Q

Important finding in neuro exam?

A

Stroke territory: Localization

27
Q

How do you assess the extent of neurological deficit?

A

NIHSS - National Institute of Health Stroke Scale

28
Q

General examination for precipitating causes, risk factors & stroke mimics?

A

Neck stiffness: CNS infections/SAH
CVS: Pulse rate and rhythm, Blood pressure, Carotid murmurs and Carotid bruits
Respiratory: Signs of pulmonary edema.
Skin: Xanthelasma
Locomotor: injuries sustained during collapse.

29
Q

ICA localization in stroke?

A
  1. hemiplegia - arm, face and leg
  2. hemisensory deficit
  3. hemianopia
30
Q

ACA localization in stroke?

A

hemiplegia - leg>arm

31
Q

MCA localization in stroke?

A
  1. hemiplegia and numbness - face = arm > leg
  2. aphasia - dominant hemisphere
  3. hemianopia
  4. sensory inattention - non dominant hemisphere
32
Q

PCA localization in stroke?

A

hemianopia

33
Q

Lacunar localization in stroke?

A
  1. hemiplegia - face = arm = leg
  2. hemisensory - face = arm = leg
34
Q

Vertebro-basilar artery localization in stroke?

A
  1. dysphagia + dysarthria
  2. hemiplegia/quadriplegia
  3. cranial nerve pulsies
  4. ataxia
35
Q

Investigations?

A
  1. CT/MRI
  2. Gold standard investigation – anterior and posterior circulation angiography
    - stroke vs stroke mimic
    - ischaemic vs hemorrhagic
  3. LP
    - r/o subarachnoid hemorrhage
  4. cardiac echo
  5. ECG
    - r/o cardiac source of embolism
  6. Duplex USS of carotids
  7. Magnetic Resonance Angiography
    - r/o underlying vascular disease
  8. HIV
  9. VDRL
36
Q

Investigations to rule out risk factors?

A
  1. Full blood count
  2. Cholesterol
  3. Blood glucose
  4. ESR
  5. clotting time
  6. PBF
  7. Protein C
  8. Protein S
  9. Factor V Leiden
  10. Lupus anticoagulant profile
37
Q

Management objectives?

A
  1. Minimize volume of brain irreversibly damaged
  2. Prevent complications
  3. Rehabilitation
  4. Reduce risk of recurrence
38
Q

Management of stroke?

A
  1. Manage seizures as necessary
  2. Urgent CT/MRI
  3. Thrombolysis
  4. Antiplatelet agents
  5. Anticoagulants
  6. Explain what has happened.
  7. Admission to stroke unit
39
Q

Airway management?

A
  1. Patency
  2. swallowing ability
  3. Nil by mouth
  4. NGT
40
Q

Breathing management?

A
  1. Oxygen saturation
  2. respiratory rate
  3. breath sounds
  4. Oxygen therapy where necessary
41
Q

Circulation management?

A
  1. IV access + get blood samples
  2. Pulse rate, blood pressure, heart sounds.
  3. Fluid resuscitation where necessary to maintain euvolemia
  4. Blood pressure control where necessary
    - If Bp > 220/120 mmHg, otherwise delayed up to first 5 days
42
Q

Exceptions for BP control in circulation management of stroke?

A
  1. Intracerebral hemorrhage on CT (<160/90)
  2. Recanalization therapy(<185/110)
  3. Subarachnoid hemorrhage based on CT/LP
43
Q

Disability management?

A
  1. GCS ≤ 8: Intubation.
  2. Focal neurological signs
  3. Never forget to check glucose
44
Q

Observation during and after treatment?

A
  1. Assess neurological condition daily
  2. Check for bedsores and contractures daily
  3. Check for signs of:
    - Aspiration Pneumonia
    - UTIs due to long term catheterization
    - DVT due to immobility
  4. Early physiotherapy preferably from day 1
  5. Assess for ability to eat, talk, walk, dress and toilet prior to discharge.
    - Necessary for post discharge care
45
Q

Acute complications of stroke?

A
  1. aspiration pneumonia
    - main cause of death
    - associated with poor prognosis
  2. pulmonary embolism
  3. pressure sores
  4. urinary tract infections
46
Q

Chronic long term complications of stroke?

A
  1. depression
  2. dementia
  3. late onset seizures
  4. spasticity
  5. contractures
  6. pain
47
Q

Stroke prognosis?

A
  • Outcome for stroke patients is poor.
  • Mortality within the first year is over 30%.
  • Majority of deaths occur within first month after the stroke and continue throughout the first year.
  • The risk of recurrence continues over time.
  • Over half of all stroke survivors die within 5 years.
  • Long term prognosis is worse in Africa because of the lack of secondary and tertiary care.
48
Q

Stroke mimics?

A

Diseases which present like stroke = Stroke mimics
- Incorrect stroke diagnosis

49
Q

Stroke chameleons?

A

Stroke presenting like other diseases = Stroke chameleons
- Missed stroke diagnosis
- Account for up to 30% of acute stroke admissions

50
Q

Importance of proper stroke diagnosis?

A
  1. Delays in treatment
  2. Potentially harmful medication prescriptions
  3. Unnecessary longer hospital stays
  4. Leading to increased costs for the patient/public hospital
51
Q

Minimizing stroke mimics?

A
  1. Be thorough. NO short-cuts OR spot diagnoses
  2. History taking (risk factors + comorbidities)
  3. Physical examination
  4. Plus investigations (including brain imaging)
  5. FABS score
52
Q

FABS score?

A

FABS = proposed scale used in discriminating SM from true strokes.
Consists of six parameters

53
Q

Parameters of FABS score?

A
  1. abscence of facial drooping
  2. negative history of atrial fibrillation
  3. age less < 50 years
  4. Systolic blood pressure <150mmHg
  5. history of seizure
  6. isolated sensory deficits
54
Q

Scoring of FABS?

A

Score ≥ 3 suggestive of SM
- Sensitivity: 90%
- Specificity: 91%

MBBS 3: Internal Medicine (72 decks)

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