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Year 4 - 6. OPIC > Stroke > Flashcards

Stroke Flashcards

1
Q

List some stroke mimics

A

Previous/old stroke!

T: brain injury
I: meningitis/encephalitis, abscess
N: (SOL) or neurological e.g. functional syndrome, focal seizures, epilepsy, Bell’s palsy, Todd’s paresis (after seizure)
D: e.g. intoxication or sedating drugs
E: e.g. hypoglycaemia, hyponatremia, Wernicke’s encephalopathy

V: e.g. aneurysm, migraine with aura/hemiplegia
I:
C: e.g. cerebral palsy
A:

Other:
- Transient global amnesia
- BPPV
- Vesitubular neuronitis
- Syncope syndrome

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2
Q

List some important risk factors to ask about in a stroke history

A

Non-modifiable:
- Check age
- Previous stroke / TIA
- Family history

Modifiable:
- Smoker
- Alcohol intake
- HTN
- Hypercholesterolaemia

PMH:
- Atrial fibrillation
- Carotid artery stenosis
- HTN
- Diabetes
- Ischaemic heart disease
- Migraine with aura / COCP use

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3
Q

State the 5 most common stroke mimics

A
  • Migraine
  • Syncope (fainting)
  • Seizures
  • Sepsis
  • Functional neurological disorder (FND)
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4
Q

On a practical level, suggest the most important steps to managing a patient with a history of suspected stroke

A

After history and examination:

Urgent CT head (non-contrast)

If ischaemic, then give Aspirin 300mg stat AND Clopidogrel 600mg
Later on, can do diffusion weighted MRI for further information
Ensure bloods have been completed e.g. FBC, clotting screen, U&Es, CRP etc.

If haemorrhagic, contact on call neurosurgeons to discuss interventions

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5
Q

State some changes that may be visible on a CT scan following a stroke

A

Ischaemic stroke:
- Loss of grey / white matter differentiation
- Effacement
- Increased density of affected blood vessel

Haemorrhagic stroke:
- Increased attenuation (tend to be deep in the brain)

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6
Q

List some investigations to do for a patient presenting with a suspected stroke

A

B: baseline obs: (temp, BP, HR), CBG, ECG + basic swallow assessment

L: FBC, U&E, LFTs, calcium and phosphate, TFTs, clotting screen

I: URGENT CT head +/- CT angiogram, chest x-ray if concerned with aspiration

P

Also carotid doppler, cardiac monitoring (24 hr ECG) +/- echocardiogram

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7
Q

List some complications of strokes

A
  • Recurrent stroke
  • Dysphagia / aspiration pneumonia
  • Raised ICP (malignant oedema, hydrocephalus, haemorrhagic transformation)
  • Infections (chest, UTI)
  • Immobility (bed sores, VTE, constipation)
  • Post-stroke pain and fatigue
  • Secondary epilepsy
  • Mood and other cognitive issues
  • Death
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8
Q

Outline some management considerations for stroke patients (stroke bundle)

A
  • Admission to stroke unit
  • Reperfusion therapy
  • Optimising physiology and surveillance, prevention
    and early intervention of complications
  • Nutritional support
  • Secondary prevention (management risk factors etc.)
  • Rehabilitation
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9
Q

List some secondary prevention measures, to help prevent future strokes

A
  • Antithrombotic therapy e.g. antiplatelet / anticoagulation
  • BP control (aim 130/80mmHg)
  • Lipid control
  • Glycaemic control (HbA1c < 7%)
  • Carotid endarterectomy if required

Lifestyle changes:
- Smoking cessation
- Weight loss
- Reduce stress
- Exercise

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10
Q

List some contraindications for thrombolysis in stroke patients (in 4.5 hour window)

A
  • Stroke in the past 3 months
  • Recent head trauma
  • Intracranial haemorrhage
  • GI bleeding
  • Recent surgery, acceptable BP, platelet count, and INR
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11
Q

List some contraindications for thrombectomy in stroke patients (in 24 hour window)

A
  • Hypertension
  • Coagulopathy
  • Stroke in the past 3 months
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12
Q

If thrombolysis or mechanical thrombectomy isn’t perfromed, outline the next treatment steps

A

Oral Aspirin 300mg (OD) for the next 2 weeks

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13
Q

State the 2 main categories of haemorrhagic stroke

A
  1. Intracerebral (within the brain tissue itself or within the ventricles)
  2. Subarachnoid
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14
Q

Outline the difference between dysarthria and dysphasia

A

Dysarthria: a motor problen resulting in poor articulation
Dysphasia: difficulties in the generation or comprehension of speech (expressive or receptive dysphasia)

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15
Q

State the target BP in a patient with haemorrhagic stroke

A

Systolic BP < 140

Can use GTN or Labetalol

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16
Q

State the 2 main types of revascularisation therapy for ischaemic strokes and the time limits for these therapies

A
  1. Thrombolysis drugs e.g. IV Alteplase
    - Must be within 4.5 hours of symptom onset
  2. Thrombectomy (surgical clot removal)
    - Must be within 24 hours of symptom onset
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17
Q

State the name of the scoring system used for strokes presenting to hospital and what it is used for

A

NIH Stroke Scale/Score (NIHSS)

Used to assess the severity of a stroke (0-42) = guides assessment

Composed of 11 parameters e.g. consious level, eye movements, motor arm & leg movements etc.

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18
Q

For the Oxford-Bamford stroke classification TACS, state the features

A

3/3 of the following:
- Unilateral weakness +/- sensory deficit
- Homonous hemianopia
- Higher cortical function loss e.g. visuospatial deficit, dysphasia

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19
Q

For the Oxford-Bamford stroke classification PACS, state the features

A

2/3 of the following:
- Unilateral weakness +/- sensory deficit
- Higher cortical function loss e.g. visuospatial deficit, dysphasia
- Homonous hemianopia

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20
Q

For the Oxford-Bamford stroke classification LACS, state the features

A

Any 1 of the following:
- Purely motor symptoms
- Purely sensory symptoms
- Mixed sensory-motor stroke (same area affected for both)
- Ataxia

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21
Q

For the Oxford-Bamford stroke classification POCS, state the features

A

Any 1 of the following:
- Bilateral sensory / motor deficit
- Cranial nerve palsy with contralateral sensory / motor deficit
- Cerebellar dysfunction e.g. ataxia, nystagmus
- Conjugate eye movement disorder
- Isolate homonomyous hemianopia

22
Q

For a LACS stroke (Oxford-Bamford classification) presenting with purely motor signs - which area of the brain is affected?

A

Posterior limb of the internal capsule (carries descending corticospinal and corticobulbar tracts)

23
Q

For a LACS stroke (Oxford-Bamford classification) presenting with ataxia - which area of the brain is affected?

A

Posterior limb of the internal capsule, basis pontis or corona radiata

24
Q

For a LACS stroke (Oxford-Bamford classification) presenting with purely sensory signs - which area of the brain is affected?

A

Ventral posterolateral (VPL) nucleus of the thalamus

25
Q

For a LACS stroke (Oxford-Bamford classification) presenting with mixed motor & sensory signs - which area of the brain is affected?

A

Posterior limb of the internal capsule AND ventral posterolateral (VPL) nucleus of the thalamus

26
Q

How soon after the onset of stroke symptoms will evidence show on an MRI scan?

A

30 minutes after the onset of symptoms

27
Q

What is the name of the scoring system used after a patient presents with symptoms of a TIA and what is it used for

A

ABCD-2

Estimates the risk of stroke after a suspected TIA, looks at: age, BP, diabetes, duration and clinical features of TIA)

28
Q

What is the purpose of CHA2DS2-VASc score and when is it used

A

Estimates the risk of stroke in patients with AF

Used to determine whether or not treatment is required (anticoagulation or antiplatelet therapy)

29
Q

What is the purpose of HAS-BED score and when is it used

A

Estimates 1-year risk of major bleeding in people taking anticoagulants for AF

Used to ssess risk-benefit of anticoagulation in AF (in stroke prevention)

30
Q

What is the OCSP classification and what is it used for?

A

OCSP classification = Oxfordshire Community Stroke Project Classification

Used as a clinical tool to categorise stroke syndromes into 4 main subtypes:
1. TACS (total anterior circulation infarct)
2. PACS (partial anterior circulation infarct)
3. LACS (lacunar circulation infarcts)
4. POCS (posterior circulation infarct)

31
Q

Describe the 3 main tragectories for patients who have a stroke

A

Early, high functioning plateau (excellent recovery) = from TIA / minor stroke and likely to make an excellent recovery

Delayed / medium functioning plateau (potential for recovery) = from moderate stroke, can reach a plataeu of function with help of rehabilitation

Early, low functioning plateau (poor/no recovery) = from major stroke, unlikely to make any functional recovery

32
Q

How long is the duration of not driving after a TIA

A

1 month (don’t need to inform the DVLA)

(BUT 1 year if bus, coach or lorry licence)

Then reassessment after by the DVLA if any residual symptoms e.g. weakness, visual disturbance

33
Q

List some of the stroke services at UHL

A
  • TIA clinic / stroke outpatient clinic
  • HASU / acute stroke wards
  • RAP team (rapid assessment protocol)
  • Rehabilitation services + early supported discharge team
34
Q

List some brief assessment tools for a patient presenting with stroke

A
  • FAST (face, arms, slurred speech, time)
  • NIHSS (national insitute of health stroke scale)
  • mRS (modified rankin scale)
  • ASPECTS score (Alberta stroke programme early CT score) for MCA strokes
  • ROSIER scale
35
Q

Outline the ASPECTs score and when it is used

A

Alberta stroke programme early CT score = 10 point CT scan score

Used in patients with a MCA stroke = determine the use of revascularisation therapy

36
Q

Outline the TOAST classification and when it is used

A

Classification system denoting 5 major subtypes of ischaemic strokes, based on clinical features and imaging findings

  1. Atherosclerosis in large artery
  2. Cardiac embolism
  3. Occlusion in small-vessel (lacune)
  4. Stroke of other determined aetiology
  5. Stroke of undetermined aetiology

Helps predict likelihood of recurrence and choice of management

37
Q

Outline the mRS (modified rankin scale)

A

Score between 0-6 (0 = no symptoms, 6 = death)

  • Measures the degree of disability or dependence in the ADLs of patients who have suffered a stroke
38
Q

Outline the ROSIER scale

A

Used in acute medical settings e.g. A&E
Helps differentiate between true strokes and stroke mimics

Series of questions to fill in and given score -2 to +5 (less likely to be a stroke if score < 0 or minus)

39
Q

List some antithrombotic therapiest for patients presenting with an ischaemic stroke

A
  • DOACs
  • Warfarin
  • IV or subcut Heparin

For patients with: AF, left ventricular dysfunction, thrombophilias or venous sinus thrombosis

40
Q

At what % obstruction of carotid atherosclerosis should a carotid endartectomy be performed?

A

> 50% obstruction of carotid artery by the plaque

41
Q

If anticoagulation is contraindicated in a a patient with AF and recent stroke, what procedure can be done instead?

A

Left atrial appendage closure (prevent collection of blood and clots forming in the atrial appendage)

42
Q

State what investigations can be used to assess safe swallow in stroke patients

A
  • Bedside swallow assessment = trial of difference substances
  • Video fluoroscopy = x-ray swallow sequence
  • Flexible endoscopic evaluation of swallow (FEES) = direct visualisation with endoscope
43
Q

Very generally, outline the presenting symptoms of a total / partial anterior circulation stroke (TACS/PACS)

A

Either 3/3 or 2/3 of the following:
- Unilateral weakness +/- sensory deficit
- Visual problems: homonymous hemianopia
- Higher brain problem e.g. dysphasia, visuospatial disorder

44
Q

Very generally, outline the presenting symptoms of a lacunar stroke (LACS)

A

Purely motor or sensory deficit

45
Q

Very generally, outline the presenting symptoms of a posterior circulation stroke (PoCS)

A

Can be a varied clinical picture, any of the following:
- vertigo / dizziness
- nystagmus
- ataxia

46
Q
A
47
Q

Which artery is most likely to be occluded in a total anterior circulation stroke (TACS)

A

Middle cerebral artery

MCA supplies most of the anterior circulation - also a contribution from the anterior cerebral arteries

48
Q

List the 2 medical and 2 surgical interventions for haemorrhagic stroke management

A

Medical:
1. BP control
2. Correct any coagulation abnormalities

Surgical:
1. Clot evaucation
2. Venticular drains

49
Q

List some investigations prior to starting someone on anticoagulation following a stroke

A

B - ECG
L - thrombophilia screen
I - echocardiogram
P -

50
Q

State the surgery that can be done if a patient is unable to have anticoauglation for secondary stroke prevention

A

Left atrial appendage closure

51
Q

Is a CT head scan for a stroke patient contrast or non-contrast normally?

A

NON-contrsat

Year 4 - 6. OPIC (6 decks)

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