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int med 2024 > Stroke > Flashcards

Stroke Flashcards

1
Q

meningeal signs: rapid onset of headache with nuchal rigidity, headache and photophobia

A

subarachnoid haemorrhage or meningitis

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2
Q

initial evaluation

A

primary survey
identify risk factors for stroke, including presence of carotid bruits
determine time of onset and last known normal

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3
Q

investigations

A

serum glucose, vitals
ECG
FBC, INR, APTT, UECs, trops
?urine drug screen and BAL
lab studies should not delay imaging for patients with acute stroke

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4
Q

imaging

A

Non-contrast head CT to rule out haemorrhage before administering thrombolytic therapy
diffusion-weighted MRI
or CTA

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5
Q

if imaging is negative but suspicion for sub arachnoid haemorrhage remains high

A

Lumbar puncture - CSF may show xanthochromia
the presence of bilirubin in the CSF secondary to the breakdown of RBCs resulting in yellow discolouration
may be falsely negative in the first 12 hours of symptoms onset as xanthochromia is a late sign

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6
Q

findings of ischaemic stroke on non contrast CT

A

hyperdense MCA sign (suggesting presence of a thrombus)
effaceemnt of sulci
loss of cortico-medulllary differentiation
oedema

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7
Q

findings on CT for intracranial haemorrhage

A

hyperdense lesion within cerebral parenchyma

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8
Q

findings on non contrast head CT for subarachnoid haemorrhage

A

extensive area of hyperdense signals around the circle of willis

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9
Q

treatment options for ishcaemic stroke

A
  • tPA (tissue plasminogen activator) if within 4.5 hours on onset of symptoms
  • endovascular thrombectomy within 6 hours
  • aspirin within 48 hours
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10
Q

tissue plasminogen activator

A

a serine protease found on endothelial cells of blood vessels
catalyses the conversion of plasminogen to plasmin, which is the main enzyme responsible for clot breakdown
recombinant tissue plasminogen activators (eg. alteplase, reteplase, tenecteplase) are used as thrombolytics in patients with acute coronary syndrome, pulmonary embolism, or ischaemic stroke

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11
Q

intravenous thrombolysis process

A

IV alteplase
if within 4.5 hours of onset of symptoms and as soon as possible
lower BP to below 185/110

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12
Q

endovascular thrombectomy

A

when the stroke is due to the occlusion of a large vessel
within 6 hours of symptom onset

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13
Q

what kinds of patients usually get endovascular thrombectomy

A

eligible patients are usually a subset of those for whom alteplase is indicated, and they can have both surgery and alteplase
endovascular thrombectomy may also be appropriate for those for whom alteplase is contraindicated (eg. patients taking anticoagulants) or those presenting too late for alteplase (between 4.5 hours and 6 hours)
endovascular thrombectomy may also be used for some patients who present up to 24 hours if there is occluded large vessel and salvageable brain tissue

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14
Q

general measures in acute ischemic stroke

A

assess swallow ability before giving oral drugs, if the patient has difficulty swallowing then make them nil by mouth and refer to speech pathology
avoid blood pressure lowering drugs except for patients with malignant hypertension or to lower blood pressure for alteplase
give supplimental oxygen if hypoxic
VTE prophylaxis

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15
Q

treatment for intracerebral haemorrhage

A

reversal of coagulopathy eg. cease anticoagulant
urgently lower BP to reduce hematoma expansion to <140
surgical intervention to evacuate the hematoma may be considered

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16
Q

symptoms of subarachnoid haemorrhage

A

75% present with acute severe headache, the rest present with LOC
mortality is high
many patients die before reaching the hospital

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17
Q

sentinel bleed

A

minor subarachnoid bleed occurring before the main rupture
sudden headache several weeks before the acute event

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18
Q

treatment of subarachnoid haemorrhage

A

patients are managed with a neurosurgeon
most subarachnoid haemorrhages are due to ruptured intracranial aneurysm

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19
Q

inconclusive non contrast CT with thunderclap headache

A

lumber puncture for sub arachnoid haemorrhage

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20
Q

if a non contrast CT shows no haemorrhage

A

ischaemic stroke
is the patient elligible for tPA
is it <4.5 hours from symptom onset -> IV tPA
then consider antiplatelet therapy and supportive management
and initiate secondary prevention

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21
Q

if non contrast CT shows haemorrhage

A

intracranial haemorrhage
neurovascular imaging: CTA, carotid duplex sonography
consider neurosurgery
treat hypertension
stop anticoagulation
supportive management

22
Q

MCA stroke

A

contralateral weakness and sensory loss more marked in upper limbs and lower half of face than lower limbs
gaze deviated toward the side of infarction (ipsilateral)
aphasia if in dominant hemisphere
contralateral homonymous hemianopia without macular sparing
hemineglect if in nondominat hemisphere

23
Q

broca aphasia

A

language comprehension intact
non-fluent, grammatically incorrect speech
supplied by superior division of the MCA

24
Q

wernicke aphasia

A

affected patients speak fluently but produce nonsensical phrases
supplied by inferior division of the MCA

25
Q

damage to optic radiations in MCA stroke

A

contralateral homonymous hemianopia without macular sparing
(or contralateral superior or inferior quatrantanopsia)

26
Q

Anterior cerebral artery stroke

A

contraletral weakness and sensory loss in the lower limbs more marked than in upper limbs
abulia (disinterest/slowed mental state)
urinary incontinence
dysarthria
transcortical motor aphasia
frontal release signs
limb apraxia

27
Q

abulia

A

a milder from of akinetic mutism that is characterised by disinterest and slowed mental state
when asked to perform centrain motor or verbal tasks, patients display a delay in the motor and/or verbal response, or fail to continue the assigned task after intiially complying
usually results from damage to frontal lobe or its connections

28
Q

posterior cerebral artery stroke

A

contralateral homonymous hemianopia with macular sparing due to occipital lobe involvement
contralateral sensory loss due to lateral thalamic involvement - light touch, pinprick, and positional sense may be reduced
memory deficits
vertigo, nausea

29
Q

PCA territory stroke in the dominant hemisphere

A

(usually left hemisphere)
alexia without agraphia (can’t read)
anomic aphasia (word finding for nouns and verbs)
agnosia: impairment of recognition of sensory stimulus (most commonly visual)

30
Q

PCA territory stroke in the non dominant hemisphere

A

usually right hemisphere
prosopagnosia

31
Q

features of thalamic injury

A

because the thalamus contains various nuclei with distinct functions, symptoms depend on the exact location of the lesion
decreased arousal
variable sensory loss
aphasia
visual feild losses
apathy, agitation, personality changes

32
Q

prosopagnosia

A

inability to recognise familiar faces, but still able to name parts of the face or identify known individuals by clothes or voices

33
Q

stroke mimics

A

tumour
subdural hematoma
migraine
hypoglycaemia
postictal paralysis
cerebral abscess

34
Q

an episode is considered to be a TIA if

A

symptoms resolve completely in 24 hours and there is no brain infarction

35
Q

intravenous thrombolysis

A

intravenous alteplase (recombinant tissue plasminogen factor) is effective when given within 4.5 hours of onset of symptoms of ischaemic stroke
earlier treatment has better outcomes

36
Q

immediate treatment options for acute ischaemia stroke

A

Iv thrombolysis (alteplase)
endovascular thrombectomy
antiplatelet therapy
neurosurgery

37
Q

endovascular thrombectomy

A

when stroke is due to occlusion of a large vessel, endovascular thrombectomy is highly effective when performed within 6 hours of symptom onset
physical retrieval or apsiration of the occluding thrombus via th femroal artery using a stent retriever and/or aspiration catheter

38
Q

when is endovascular thrombectomy used

A

used in some patients in combination with alteplase
when alteplase is contraindicated (eg. the patient is taking an anticoagulant) or when patients present too late for alteplase

39
Q

who is eligible for endovascular thrombectomy

A

within 24 hours of symptom onset
has an occluded large vessel and salvageable brain tissue, as detected by CT or MRI perfusion

40
Q

antiplatelet therapy for acute ischaemic stroke

A

aspirin has modest benefit when given within 48 hours of acute ischaemic stroke and is routinely used
do not give aspirin util brain imaging has excluded intracranial haemorrhage
if the patient has recieved alteplase, withhold aspirin for 24 hours and do not start unntil follow up imaging has excluded haemorhage

41
Q

main adverse effects of alteplase

A

bleeding, including symptomatic intracranial haemorrhage

42
Q

do not give aspirin until

A

imaging excludes intracranial haemorhage

43
Q

neurosurgery for acute ischameic stroke

A

due to the effects of cerebral oedema, extensive hemispheric infarct s fatal in over 80%
in a few highly selected patients, hemicraniotomy saves lives and reduces disability

44
Q

dysphagia management during acute ischaemic stroke

A

assess patient’s aability to swallow before giving oral ddrugs
maintain as nil by mouth and refer to speech pathology
dysphagia often improves rapidly

45
Q

blood pressure during acute ischaemic stroke

A

do not lower blood prssure uring first 48 hours of stroke unless the patient has malignant hypertension, hypertensive encephalopathy, or patients neeing bloow pressure lowering to recieve alteplase

46
Q

oxygen and fever

A

give oxygen if the patient is hypoxic, lower fever with panadol

47
Q

hyperglycaemia

A

hyperglycaemia is associated with a worse outcomes after stroke, so avoid IV fluids contaning glucose
20% of patients with acute stroke have unrecognised diabetes
monitor blood glucose and maintain euglycaemia

48
Q

mobilisation

A

early mobilisation, adequate hydration and antiplatelet therapy can help prevent DVT
if a patient is immobilised, give enoxeparin

49
Q

how to decide whether to give tPa

A

no evidence of stroke mimic or intracranial haemorrhage
acute symptoms
consult neurology first
unclear symptoms onset >4.5 hours from last known baselines state: MRI findings will determine whether thrombolysis is indicated

50
Q

absolute contraindications for tPa

A

recent ischaemic stroke or severe head trauma (<3 months ago)
revent intracranial or intraspinal surgery
history of intracranial heamorrhage
GI malignancy or recent GI bleed
acute haemorrhage
acute bleeding diathesis
severe uncontrolled hypertension >185/110

51
Q
A

int med 2024 (47 decks)

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