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Nervous System > Stroke > Flashcards

Stroke Flashcards

1
Q

what is the definition of stroke?

A

the sudden onset of focal or global neurological symptoms caused by ischemia or hemorrhage and lasting more than 24 hours.

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2
Q

what percentage of strokes are ischaemic and haemorrhagic?

A

85% are ischaemic strokes

15% haemorrhagic strokes

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3
Q

what is a TIA?

A

is the term used if the symptoms resolve within 24 hours.

Most TIAs resolve within 1-60 min.

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4
Q

what is a hemorragic stroke?

A

hemorrhage/blood leaks into brain tissue

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5
Q

what is an ischemic stroke?

A

clot stops blood supply to an area of the brain

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6
Q

what are the different causes of an ischaemic stroke?

A

Large artery atherosclerosis (e.g. Carotid) 35%
Cardioembolic (e.g. atrial fibrillation) 25%
Small artery occlusion (Lacune) 25%
Undetermined/Cryptogenic 10-15%
Rare causes <5%
Arterial dissection
Venous sinus thrombosis

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7
Q

what are the different causes of a hemorrhagic stroke?

A

Primary intracerebral hemorrhage 70%
Secondary hemorrhage 30%
Subarachnoid hemorrhage
Arteriovenous malformation

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8
Q

what are modifiable stroke risk factors?

A

oestrogenic pills or even HRT prothrombotic

Drugs of abuse like cocaine can be damaging to cerebral blood vessels

Smoking

heart disease, atherothrombosis, risk of subarachnoid haemorrhage,

Bad diet because of high cholesterol and increased risk of atheroma

centripetal obesity

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9
Q

what are non-modifyable risk factors?

A

Previous stroke
Age
Male
Family history

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10
Q

what is the most important modifyable risk factor?

A

hypertension

The risk of stroke is related to the level of blood pressure

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11
Q

what does chronic hypertension exacerbate?

A

atheroma and increases involvement of smaller distal arteries

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12
Q

which arteries experience the most pressure?

A

Small end arteries coming directly off large arteries experience higher pressure and are at risk of lipohyalinosis

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13
Q

what does lipohyalinosis of small arteries cause?

A

Lacunar ischaemic stroke

Small vessel haemorrahges

Especially in
Brainstem
Basal ganglia
Subcortical areas

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14
Q

what are smokers at increased risk of?

A

2x increased risk of cerebral infarction

3x increased risk for sub-arachnoid hemorrhage

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15
Q

how does diabetes affect the likelyhood of suffering from a stroke?

A

Diabetes mellitus increases the incidence of strokes 3x

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16
Q

how do lipids impact the likelyhood of suffering from a stroke?

A

The relationship between serum lipids and stroke is established.

Risk related to development of atheroma in blood vessel walls.

A high plasma level of low density lipoprotein (LDL) results in excessive amounts of LDL within the arterial wall.

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17
Q

how does atrial fibrillation increase the risk of a stroke?

A

Prevalence doubles with age : 9% at 80-90 years

5x increased risk embolic stroke

More severe strokes

Higher mortality and morbidity, longer hospital stays, and lower rates of discharge to patients’ own homes

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18
Q

what has no benefit in patients with AF in reducing chance of ischaemic stroke?

A

antiplatelets (e.g. Aspirin)

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19
Q

what reduces the risk of ischaemic stroke by 2/3?

A

Anticoagulants (warfarin and DOACS)

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20
Q

what has less of a risk of causing bleeding than warfarin?

A

DOACS (e.g. Edoxaban and Apixaban)

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21
Q

what are other risk factors for suffering from a stroke?

A

Other cardiac causes (recent heart attack, myxoma, PFO).

Oral contraceptives (+ HRT) with a high estrogen content. Progesterone-only OK

Hyper-coagulable states:
- malignancy
- genetic

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22
Q

what is the anterior arterial supply to the brain?

A

2 x Internal carotid arteries
2 x Anterior Cerebral Artery (ACA)
2 x Middle Cerebral Artery (MCA)

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23
Q

what is the posterior arterial supply to the brain?

A

2 Vertebral arteries →1 basilar

3 pairs of cerebellar arteries
2 Posterior cerebral arteries (PCA)

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24
Q

what parts of the brain does the carotid system supply?

A

The carotid system supplies most of the hemispheres and cortical deep white matter

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25
Q

what parts of the brain does the vertebrobasilar system supply?

A

the vertebro-basilar system supplies the brain stem, cerebellum and occipital lobes

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26
Q

which questions should you ask when making diagnosis of a stroke?

A

What is the neurological deficit?
Where is the lesion?
What is the lesion?
Why has the lesion occurred?
What are the potential complications and prognosis?

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27
Q

what are functions of the frontal lobe?

A

High level cognitive functions ie. abstraction, concentration, reasoning

Memory

Control of voluntary eye movement

Motor control of speech (dominant hemisphere)

Motor cortex

Urinary continence

Emotion and personality

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28
Q

what aspect of speech is within the frontal lobe, and what happens if this area is affected?

A

motor control of speech

Broca’s aphasia or expressive aphasia is when people find it very difficult to find and say the right words, although they probably know exactly what they want to say.

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29
Q

what are functions of the parietal lobe?

A

Sensory cortex

Sensation (identify modalities of touch, pressure, position)

Awareness of parts of the body

Spatial orientation and visuospatial information (non dominant hemisphere)

Ability to perform learned motor tasks (dominant)

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30
Q

what are functions of the temporal lobe?

A

Primary auditory receptive area

Comprehension of speech (dominant) – Wernicke’s

Visual, auditory and olfactory perception

Important role in learning, memory and emotional affect

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31
Q

what aspect of speech is within the temporal lobe, and what happens if this area is affected?

A

Wernicke’s aphasia – usually left hemisphere. Deficit in language comprehension. Can speak fluently but has semantic errors and may sound nonsensical/jargon

32
Q

what is the homonculus?

A

The sensory homunculus is a topographic representation of the sensory distribution of the body found in the cerebral cortex. This topograph usually has body parts illustrated along the surface of the postcentral and precentral gyrus of the parietal lobe.

33
Q

what would infarct of the anterior cerebral artery cause weakness of, (supplies part of the precentral gyrus)?

A

leg>arm weakness

34
Q

what would infarct of the middle cerebral artery cause weakness of, (supplies part of the precentral gyrus)?

A

face and arm> leg weakness

35
Q

what will a small stroke in deep white matter/corticospinal tract result in?

A

A small stroke here
(or there)
will result in a major deficit as the fibres are packed close together

36
Q

what function is controlled by the cerebellum?

A

Balance and coordination

37
Q

what makes up the brainstem?

A

Midbrain, pons and medulla

38
Q

which cranial nerves arise from the brainstem?

A

10 of 12 cranial nerves arise in brainstem (ipsilateral signs)

39
Q

what would a stroke in brainstem result in?

A

Contralateral hemiparesis due to crossing of cortical tracts in lower medulla

Some major functions: eye movement, breathing, swallowing, heart beat, consciousness

40
Q

what are functions of occipital lobe?

A

Primary visual cortex

Visual perception

Involuntary smooth eye movement

41
Q

what are clinical presentations of stroke?

A

Motor (clumsy or weak limb)
Sensory (loss of feeling)
Speech: Dysarthria/Dysphasia
Neglect / visuospatial problems
Vision: loss in one eye (amaurosis fugax) or hemianopia
Gaze palsy

Ataxia/ vertigo / incoordination / nystagmus

42
Q

do symptoms of stroke have a rapid onset?

A

yes

43
Q

what do symptoms depend on?

A

which part of the brain is affected

44
Q

how can strokes be classified?

A

according to Oxford Community Stroke Project Classification (OCSP)

45
Q

what are the four different clinical classifications of stroke?

A

Total Anterior Circulation Stroke (TACS)

Partial Anterior Circulation Stroke (PACS)

Lacunar Stroke (LACS)

Posterior Circulation Stroke (POCS)

46
Q

describe OCSP classification of LACS?

A

small vessel

anterior

+/- weakness (>2/3 face arm leg)

+/- numbness (>2/3 face arm leg)

  • hemianopia/dysphagia/neglect
  • cerebellar signs
47
Q

describe OCSP classification of PACS?

A

large / partial vessel

anterior

+/- weakness (>2/3 face arm leg)

+/- numbness (>2/3 face arm leg)

1 of hemianopia/dysphagia/neglect

  • cerebellar signs
48
Q

describe OCSP classification of TACS?

A

large / total vessel

anterior

+/- weakness (>2/3 face arm leg)

+/- numbness (>2/3 face arm leg)

2 of hemianopia/dysphagia/neglect (must have hemianopia)

  • cerebellar signs
49
Q

describe OCSP classification of POCS?

A

either large or small vessel

posterior

+/- weakness (>2/3 face arm leg)

+/- numbness (>2/3 face arm leg)

+/-hemianopia/dysphagia/neglect (must have hemianopia)

+ cerebellar signs

50
Q

what would a patient present with following a stroke affecting right hemisphere?

A

Left hemiplegia, homonymous hemianopia
Neglect syndromes (agnosias)

Visual agnosia
Sensory agnosia
Anosagnosia (denial of hemiplegia)
Prosopagnosia (failure to recognise faces)

51
Q

describe the criteria for a TACS?

A

Main artery to one hemisphere
“Full house” of effects 3 of 3:

Complete hemiparesis/numbness
Loss of vision on one side (hemianopia)
Loss of awareness on one side (inattention) non-dominant
or
Dysphasia dominant

TACS is often due to blocked Carotid or Middle cerebral artery

52
Q

describe criteria for a PACS?

A

Branch of main artery
In-between LACS and TACS

2 of 3 TACS criteria
or
One higher cortical deficit:
Inattention
Or dysphasia
or
Monoparesis

53
Q

describe the criteria for a LACS?

A

Small “perforating” artery

Movement and sensation pathways

Weakness/numbness of:
Face + arm + leg
Or Face + arm
Or Arm + leg

May have dysarthria

Ataxic hemiparesis

No affect on higher function
Will not have dysphasia, inattention or hemianopia

54
Q

describe the criteria for a POCS?

A

Any posterior artery

Combination of symptoms including:
Loss of balance/coordination
Vertigo
Double vision
Dysarthria
Visual loss (hemianopia)

55
Q

describe the criteria for a basilar artery occlusion?

A

Ischaemia in pons

Predominantly motor/oculomotor signs/symptoms

Bilateral but asymmetrical

Alteration in level of consciousness common
– may progress over 12-24hours

May present as reduced responsiveness
?cause requiring critical care

56
Q

what is the mortality and reccurance rate of TACS at 12 months?

A

mortality - 60%
recurrance rate - 6%

57
Q

what is the mortality and reccurance rate of PACS at 12 months?

A

16%
17%

58
Q

what is the mortality and reccurance rate of LACS at 12 months?

A

11%
9%

59
Q

what is the mortality and reccurance rate of POCS at 12 months?

A

19%
20%

60
Q

what conditions can mimic symptoms of a stroke?

A

Seizures

Syncope (hypotension)

Sugar (hypo or hyper)

Sepsis (+previous stroke)

Severe migraine

Space occupying lesions

Si-chological (Functional)

And
Vestibular disorders

Demyelination

Transient global amnesia

Mononeuropathy

61
Q

what are positive symptoms for a stroke?

A

excess CNS neurone electrical discharges
visual (eg, flashing lights, zigzags, shapes, lines, objects)
somatosensory (eg, pain, paraesthesia)
motor (eg, jerking limb movements)

62
Q

what are negative symptoms of a stroke?

A

Loss or reduction of CNS neurone function
Loss of vision
Loss of sensation
Loss of limb power

63
Q

what do >20% of patients with suspected TIA have?

A

migraine aura - most common mimic

64
Q

what is a migraine aura?

A

Migraine aura symptoms include temporary visual or other disturbances that usually strike before other migraine symptoms — such as intense head pain, nausea, and sensitivity to light and sound. Migraine aura usually occurs within an hour before head pain begins and generally lasts less than 60 minutes.

65
Q

what symptoms occur alongside a migraine aura?

A

Visual disturbances
scintillating scotomata
geometric (especially zigzag) patterns
positive symptoms (like a kaleidoscope, running water etc)
Can include sensory, motor or speech disturbance
Headache onset can be >1hour after the end of the aura or no headache

66
Q

who does functional/anxiety disorder most commonly affect?

A

Younger
More common in women
No conventional risk factors

67
Q

what is hoovers sign?

A

Hoover’s sign1 is a manoeuvre aimed to separate organic from non-organic paresis of the leg. The sign relies on the principle of synergistic contraction. Involuntary extension of the “paralysed” leg occurs when flexing the contralateral leg against resistance

68
Q

what are the signs and symptoms of acute vestibular syndrome?

A

Common, onset can be acute

Can be very disabling

‘True vertigo’ vs unsteadiness vs dizziness

Nystagmus – unidirectional, increases in intensity when patient looks in direction of fast phase

Vomiting

Even an expert taking a careful history may remain uncertain

MRI can be helpful

69
Q

what investigations are done for a stroke in all patients?

A

Routine blood tests (FBC, glucose, lipids, ESR…)
CT or MRI head scan (infarct vs. hemorrhage)
ECG + Holter (?AF, LVH)
Carotid doppler ultrasound (?stenosis)

70
Q

what investigations are done for stroke in some patients?

A

Echocardiogram (valves, ASD, VSD, PFO)
Cerebral angiogram/venogram (vasculitis?)
Hyper-coaguable blood screen

71
Q

what should acute ischaemic stroke therapies do?

A

Restore blood supply.

Prevent extension of ischemic damage.

Protect vulnerable brain tissue.

72
Q

what are different stroke treatments offered?

A

aspirin
thrombolysis
thrombectomy

73
Q

what are compoenents of a stroke unit

A

Clinical staff
Stroke nurses
Physiotherapists
Speech and Language therapists
Occupational therapists
Dietician
Psychologist
Orthoptist

74
Q

what is the strict criteria dor use of TPA?

A

< 4.5 hours from symptom onset.

Disabling neurological deficit.

Symptoms present > 60 minutes.

Consent obtained.

75
Q

what is exclusion criteria for IV TPA?

A

Anything that increases the possibility of hemorrhage:
blood on CT scan
recent surgery
recent episodes of bleeding
coagulation problems

BP >185 systolic or >110 diastolic

Glucose <2.8 or > 22mmol/L

76
Q

what is effective treatment in symptomatic internal carotid artery stenosis?

A

Carotid endarterectomy

77
Q

what is secondary preventatives for stroke?

A

Anti-hypertensives >25%
Anti-platelets 25%
Lipid lowering agents 25%
Warfarin for AF 66%
Carotid endarterectomy NNT of 3
(Absolute reduction of 30%)

Nervous System (40 decks)

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