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Y4 OPIC > Stroke > Flashcards

Stroke Flashcards

1
Q

Ischaemic stroke

A

Blockage in the blood vessel stops blood flow

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2
Q

Ischaemic stroke subtypes

A

Thrombotic stroke - thrombosis from large vessels eg. carotid

Embolic stroke - usually a blood clot but fat, air or clumps of bacteria may act as an embolus

  • AF
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3
Q

Ischaemic stroke risk factors

A

General risk factors for cardiovascular disease

Age

HTN

Smoking

Hyperlipidaemia

Diabetes mellitus

AF

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4
Q

Oxford stroke classification

A

Classifies strokes based on the initial symptoms

Criteria:

1) unilateral hemiparesis and/or hemisensory loss of the face, arm & leg

2) homonymous hemianopia

3) higher cognitive dysfunction e.g. dysphagia

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5
Q

TACI

A

Involves middle and anterior cerebral arteries

1) unilateral hemiparesis and/or hemisensory loss of the face, arm & leg

2) homonymous hemianopia

3) higher cognitive dysfunction e.g. dysphagia

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6
Q

PACI

A

Involves smaller arteries of anterior circulation eg. upper/lower division of middle cerebral artery

2 of the following present:

1) unilateral hemiparesis and/or hemisensory loss of the face, arm & leg

2) homonymous hemianopia

3) higher cognitive dysfunction e.g. dysphagia

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7
Q

LACI

A

Involves perforating arteries around the internal capsule, thalamus & basal ganglia

Presents with 1 of the following:

1) unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.

2) pure sensory stroke

3) ataxic hemiparesis

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8
Q

POCI

A

Involves vertebrobasilar arteries

Presents with 1 of the following:

1) cerebellar or brainstem syndromes

2) loss of consciousness

3) isolated homonymous hemianopia

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9
Q

Other types of stroke

A

Lateral medullary syndrome (PICA) aka Wallenberg’s syndrome

  • ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, CN palsy (eg. Horner’s)
  • contralateral: limb sensory loss

Weber’s syndrome (branches of posterior cerebral artery that supply the midbrain)

  • ipsilateral III palsy
  • contralateral weakness

Lateral pontine syndrome (AICA)

  • symptoms similar to Wallenberg’s
  • ipsilateral: facial paralysis and deafness

Retinal/ophthalmic artery

  • Amaurosis fugax

Basilar artery

  • ‘Locked-in’ syndrome
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10
Q

FAST campaign

A

Face - has face fallen on one side? can they smile?

Arms - can they raise both arms & keep them there?

Speech - is it slurred?

Time - call 999 if see any of these signs

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11
Q

ROSIER score

A

Exclude hypoglycaemia first

LOC or syncope -1

Seizure activity -1

New, acute onset of:

Asymmetric facial weakness +1

Asymmetric arm weakness +1

Speech disturbance +1

Visual field defect +1

Stroke likely > 0

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12
Q

Ischaemic stroke ix

A

Non-contrast CT head scan - differentiate ischaemic vs haemorrhagic

  • areas of low density & white matter of the territory → changes may take time to develop
  • ‘hyperdense artery’ → corresponding with the responsible arterial clot; visible immediately
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13
Q

General management principles for stroke

A

Blood glucose, hydration, oxygen saturation & temperature should be maintained within normal limits

BP not lowered in acute phase

Aspirin 300mg given ASAP if haemorrhagic stroke has been excluded

AF → anticoagulants should not be started until 14 days after ischaemic stroke

Cholesterol > 3.5mmol/L, pt commenced statin (delay for 48 hrs → haemorrhagic transformation)

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14
Q

Thrombolysis for acute ischaemic stroke

A

Administered within 4.5 hours of onset of stroke symptoms

Haemorrhage has been definitively excluded

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15
Q

Contraindications to thrombolysis

A

Absolute - previous intracranial haemorrhage, seizure at onset of stroke, intracranial neoplasm, stroke/traumatic brain injury in preceding 3 months, LP in past 7 days, active bleeding, pregnancy

Relative - concurrent anticoagulation (INR > 1.7), haemorrhagic diathesis, active diabetic haemorrhage retinopathy, major surgery/trauma in preceding 2 weeks

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16
Q

Thrombectomy for acute ischaemic stroke

A

Offer ASAP & within 6 hours of symptom onset, together with IV thrombolysis (if within 4.5 hours), to people who have:

  • acute ischaemic stroke
  • confirmed occlusion of proximal anterior circulation (CTA/MRA)

Offer ASAP to people who were last known to be well between 6 hours & 24 hours previously:

  • confirmed occlusion of proximal anterior circulation (CTA/MRA)
  • potential to salvage brain tissue

Consider with IV thrombolysis (if within 4.5 hours) ASAP for people last known to be well up to 24 hours previously:

  • acute ischaemic stroke & confirmed occlusion of proximal posterior circulation (basilar/PCA)
  • potential to salvage brain tissue
17
Q

Ischaemic stroke secondary prevention

A

Clopidogrel

Aspirin is now recommended only if clopidogrel is contraindicated/not tolerated

Carotid artery endarterectomy:

  • patient has suffered stroke/TIA in carotid territory and are not severely disabled
  • should only be considered if carotid stenosis > 70% according ECST criteria or > 50% according to NASCET criteria
18
Q

Post-stroke fluid mx

A

Ensure patients remain normovolaemic

Oral hydration is preferable in all patients who are able to safely swallow

  • IV hydration otherwise - isotonic saline without dextrose
    • take into account any electrolyte disturbances and/or CVS status
19
Q

Post-stroke glycaemic control

A

Closely monitor and control blood sugar

Maintaining a blood sugar level between 4 & 11mmol/L in people with acute stroke

Diabetic patients - optimise insulin treatment, manage hypoglycaemia appropriately

20
Q

Post-stroke BP mx

A

Use of anti-hypertensive medications should only be used for BP control in patients post ischaemic stroke if HTN emergency

Lowering BP too much → compromise collateral blood flow to affected region

Patients who are candidates for thrombolytic therapy for acute stroke, BP reduced to 185/110mmHg or lower

21
Q

Post-stroke feeding assessment & mx

A

Screen for safe swallow

Any concerns → specialist assessment of swallowing (preferably within 24 hours)

Deemed unsafe for oral intake:

  • NGT feed, within 24 hours of admission
  • Nasal bridle tube/gastrostomy if NGT not tolerated

Nutritional support

22
Q

Post-stroke disability scales

A

Medically stabilised → transfer to a rehab team for ongoing treatment depending on level of disability

Barthel index - used to assess functional status of a patient post stroke & monitor their improvement with ongoing rehab to regain independence after the event

23
Q

Haemorrhagic stroke

A

Blood vessel ‘bursts’ leading to reduction in blood flow

24
Q

Haemorrhagic stroke subtypes

A

Intracerebral haemorrhage - bleeding within the brain

Subarachnoid haemorrhage - bleeding on the surface of the brain

25
Q

Haemorrhagic stroke risk factors

A

Age

Hypertension

AVN malformation

Anticoagulation therapy

26
Q

Symptoms patients who have had haemorrhagic strokes are more likely to experience

A

Decrease in the level of consciousness

Headache

N&V

Seizures

27
Q

Haemorrhagic stroke ix

A

Emergency neuroimaging - CT/MRI

  • areas of hyperdense material (blood) surrounded by low density (oedema)
28
Q

Haemorrhagic stroke mx

A

Neurosurgical referral

Supportive mx - anticoagulants & antithrombotic meds should be stopped, BP lowered acutely

29
Q

TIA

A

Brief period of neurological deficit due to a vascular cause, typically lasting less than an hour

Transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischaemia without acute infarction

30
Q

TIA clinical features

A

Features resolve, typically within 1 hour

Possible features include:

  • unilateral weakness/sensory loss
  • Aphasia or dysarthria
  • ataxia, vertigo or loss of balance
  • visual problems
    • amaurosis fugax (sudden transient loss of vision in one eye)
    • diplopia
    • homonymous hemianopia
31
Q

TIA initial mx

A

Give aspirin 300mg immediately unless:

1) pt has bleeding disorder/taking anticoagulant

2) patient is already taking low-dose aspirin

3) aspirin is contraindicated

32
Q

TIA referral for specialist review

A

If patient has had more than 1 TIA/suspected cardioembolic source/severe carotid stenosis:

  • discuss the need for admission/observation urgently with a stroke specialist

If patient has had a suspected TIA in the last 7 days:

  • arrange urgent assessment within 24 hours by a specialist stroke physician

If patient has had a suspected TIA which occurred more than a week previously:

  • refer for specialist assessment ASAP within 7 days
33
Q

TIA ix

A

Neuroimaging - MRI preferred

Carotid imaging - urgent carotid doppler

34
Q

TIA further mx

A

Secondary prevention

  • antiplatelet therapy to follow on from initial aspirin therapy → clopidogrel first line

Lipid modification

  • high-intensity statin

Carotid artery endarterectomy if indicated

Y4 OPIC (4 decks)

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