Stroke Flashcards by Lucy Jefford

When do risks of stroke increase?

With age

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Public awareness of stroke has been raised using which campaign?

FAST

(Facial weakness
Arm weakness
Slurred speech
Time to call 999)

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Define stroke.

Sudden onset of focal or global neurological symptoms caused by ischaemia or haemorrhage lasting more than 24hrs

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What % of stroke are ischaemic compared to haemorrhagic?

85% are ischaemic
15% of haemorrhagic

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What is meant by a transient ischemic attack?

Sudden onset of focal or global neurological symptoms caused by ischaemia or haemorrhage lasting less than 24hrs

->stroke basically but less than 24hrs

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What happens in haemorrhagic stroke?

Blood leaks into brain tissue

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What happens in ischaemic stroke?

Clot stops blood supplying an area of the brain

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Give some of the common causes of ischaemic stroke.

Large artery atherosclerosis e.g. carotid artery
Cardioembolic
Small artery occlusion

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What is the most common causes of a cardioembolic ischaemic stroke?

Atrial fibrillation

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What is another name for small artery occlusion?

Lacune strokes

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What may a secondary haemorrhagic stroke follow?

Subarachnoid haemorrhage
Arteriovenous malformation

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What are some of the non-modifiable risk factors for stroke?

Age
Male
Previous stroke
FH

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What are some of the modifiable risk factors for stroke?

Oestrogenic pills (small increase in risks)
HRT (small increase in risk)
Cocaine
Smoking
Poor diet
Diabetes
Hypertension
Atrial fibrillation

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What is the most important modifiable risk factor of stroke?

Hypertension

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What does chronic hypertension due to vessels?

Exacerbates atheroma and increases the involvement of smaller distal arteries

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Small end arteries coming off large arteries experience higher pressure and are more likely to have a lacunar ischaemic stroke or a small vessel haemorrhage.
Which areas of the brain is this more likely to occur?

Brainstem
Basal ganglia
Subcortical areas

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How many times more likely are smokers to get a cerebral infarction?

2x more likely

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How many times more likely are smokers to get an arachnoid haemorrhage?

3 x more likely

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How many times more likely are those with diabetes to develop a stroke?

3 x more likely

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What does hypertension, cigarette smoke and diabetes contribute towards in arteries?

Low density lipoprotein deposition in arterial walls

-> risk between development of atheroma in blood vessel walls and stroke

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What can drinking small amounts of alcohol do to risk of stroke?

Decreases risks

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What can drinking large amounts of alcohol do to risk of stroke?

Increases risk

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Who is more likely to get atrial fibrillation?

Those of older age

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How many times more likely is someone with atrial fibrillation to develop a stroke?

5 x greater risk of embolic stroke

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How does atrial fibrillation link to higher morbidity and mortality of stroke?

Tend to be larger clots leading to more severe strokes ->therefore longer hospital stays

In those with AF, is there any benefit in reducing ischaemic stroke if the patient takes antiplatelets, like aspirin?

In those with AF, is there any benefit in reducing ischaemic stroke if the patient takes anticoagulants, like warfarin?

Yes -> reduces risks by 2/3

Which type of drug have less risk of bleeding than warfarin?

DOACS like edoxaban and apixaban

Which two arteries make up the anterior circulation of the brain?

2x anterior cerebral artery 2x middle cerebral arteries

Which two arteries make up the posterior circulation of the brain?

2 vertebral arteries which join to form 1 basilar artery

In terms of making the diagnosis of stroke, which questions should be asked to work out the type of stroke?

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?

List the functions of the frontal lobe.

High level cognitive function Memory Voluntary eye movement Motor control of speech Motor cortex Urinary continence Emotion and personality

List the functions of the parietal lobe.

Sensory cortex Sensation Awareness of parts of the body Spatial orientation Ability to perform learned motor tasks

List the functions of the temporal lobe.

Primary auditory receptive area Comprehension of speech (Wernicke's) Visual, auditory and olfactory perception Learning Memory Emotion

Where would the motor homunculus be?

Precentral gyrus

Where would the sensory homunculus be?

Postcentral gyrus

Describe the symptoms of a middle cerebral artery stroke.

Upper limb and facial weakness Less so leg weakness

Describe the symptoms of a anterior cerebral artery stroke.

Mainly leg weakness

What is controlled by the cerebellum?

Balance and coordination

How many of the 12 cranial nerves arise from the brainstem?

10/12

What could happen if there is a stroke in the brainstem?

Cranial problems on the ipsilateral side Hemiparesis or arm/leg weakness on contralateral side. -> contralateral hemiparesis and weakness due to the crossing over of cortical tracts in the medulla

What are the functions of the occipital lobe?

Primary visual cortex Visual perception Involuntary smooth eye movement

If you damage one optic nerve, what happens?

Loss of vision/visual changes in one eye, same eye as damaged nerve

Describe the clinical presentation of a stroke.

Sudden onset of symptoms. Motor issues- clumsy or weak limb Sensory- loss of feeling Dysarthria/dysphasia- speech problems Neglect/visuospatial problems Vision loss in one eye or hemianopia Gaze palsy Ataxia/vertigo

Describe the onset of stroke symptoms.

Rapidly, suddenly

What do stroke symptoms depend on?

Area of the brain affected

Is is normal to have abnormal movements, like a jerk or tremor, after a stroke?

Is a severe headache normal after a stroke?

If a patient has positive visual phenomena*, what is it more likely to be than a stroke? *just loads of weird changes to vision as far as I can work out

A migraine

Which classification is used for stroke?

OSCP

What are the four categories of OCSP (Oxford Community Stroke Project Classification)?

TACS PACS LACS POCS

TACS?

Total anterior circulation stroke

PACS?

Partial anterior circulation stroke

LACS?

Lacunar stroke

POCS?

Posterior circulation stroke

Agnosia?

Patient unable to recognize objects, persons or sounds using one or more of their senses.

Anosagnosia?

When patient doesn't think they're paralysed when they are

Propsopagnosia?

Inability to recognise faces

Which area of the brain would likely be affected if a person had neglect symptoms like agnosia?

Parietal lobe

Blockage of which types of artery usually causes TACS?

Carotid or middle meningeal

What are the symptoms of TACS?

Complete hemiparesis/numbness Loss of vision on one side (hemianopia) Loss of awareness on one side

What are some of the symptoms of POCS?

Loss of balance/coordination Vertigo Double vision Dysarthria Visual loss

Basilar artery occlusion can lead to one of the worst strokes. Why is this?

Basilar artery supplies brainstem which help us breathe and remain conscious

What can basilar artery occlusion cause to happen in the pons?

Ischaemia in pons

List things which can mimic strokes (mostly also begin with letter S)

Seizures Syncope (hypertension) Sugar (hypoglycaemic or hyperglycaemic) in diabetes Sepsis and previous stroke Severe migraine Space occupying lesions Vestibular disorders Demyelination Transient global ischaemia Mononeuropathy Psychological

Migraines give positive symptoms whilst strokes give negative symptoms. What is meant by positive symptoms?

Excess CNS neurone electrical discharges

Migraines give positive symptoms whilst strokes give negative symptoms. What is meant by negative symptoms?

Loss or reduction of CNS neurone function

Give some examples of positive symptoms in the following categories: 1. visual 2. somatosensory 3. motor

1. Flashing lights, zigzags. lines, objects 2. Pain, paraesthesia 3. Jerky limb movements

Give some examples of negative symptoms.

Loss of vision Loss of power Loss of sensation

So, if there are positive symptoms, it is likely to be a ???

Migraine

And if there are negative symptoms, it is more likely to be a ???

Stroke

Which investigations are carried out for all/most patients with stroke?

Routine blood tests CT or MRI ECG + Holter Carotid doppler stenosis

Why is CT or MRI done in patients with a stroke?

To determine if it's of haemorrhage or ischaemic cause

Why is an ECG done in someone with a stroke?

Looking for AF and signs of left ventricular hypertrophy

When would you not give a patient thrombolytic drugs?

If they have bleeding in the brain

Which type of imaging is good to show up bleeding in the brain?

What are the three aims of treatment for acute ischaemic stroke?

Restore blood supply Prevent extension of ischaemic damage Protect vulnerable brain tissue

Which three symptoms need to be present for a diagnosis of TACS?

Unilateral weakness of the face, arm and leg Homonymous hemianopia Higher cerebral dysfunction e.g. dysphasia, visuospatial disorder

Which symptoms must a patient have to be diagnosed with a PACS?

Two of the following: -Unilateral weakness of the face, arm and leg -Homonymous hemianopia -Higher cerebral dysfunction e.g. dysphasia, visuospatial disorder

Which symptoms need to be present to diagnose someone with POCS?

One of the following: -Cranial nerve palsy and a contralateral motor/sensory deficit -Bilateral motor/sensory deficit -Conjugate eye movement disorder e.g. horizontal gaze palsy -Isolated homonymous hemianopia

Which symptoms would have to be present in order to diagnose a LACS?

One of the following: -Pure sensory stroke -Pure motor stroke -Semsori-motor stroke -Ataxic hemiparesis

What is the treatment of choice for a large vessel occlusions?

Thrombectomy, removal or the clot in less than six hours ->however, not very realistic as not many patients eligible or will get it done in less than six hours

Even admission to a stroke unit helps with the treatment of stroke. Name some of the members of the stroke unit team.

Clinical staff Stroke nurse Physiotherapists OT Speech and language therapists Dietician Psychologist Orthoptist

Which acute stroke treatment has the biggest effect on the individual pateint?

Thrombolysis and thrombectomy

Which acute stroke patient has the biggest effect on the MOST patients?

Stroke unit admission -> small effect but many more people can benefit from it

Thrombolysis is more effective when?

More effective the quicker it's given from symptom onset

When should thrombolysis be given?

<4.5hrs ->better to give as soon as possible but must wait an hour to confirm the symptoms are due to stroke

When should thrombolysis not be given?

Blood seen on CT Recent surgery Recent episodes of bleeding Coagulation problems

At which BP levels would it be unsuitable to give thrombolysis?

Systolic > 185 Diastolic > 110

At which glucose levels would it be unsuitable to give thrombolysis?

Less than 2.8 mmol/L More than 22mmol/L

What is a warning sign of a stroke?

A transient ischaemic attack ->10% of strokes reoccur within first 2 weeks after TIA

What is an effective treatment if there in symptomatic internal carotid artery stenosis?

Carotid endarterectomy

Which drugs can help in the secondary prevention of strokes?

Anti-hypertensives Anti-platelets Lipid lowering agents

Which drug should be given in those with AF who have had a stroke to reduce their risks of developing another?

Warfarin