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Phase 3a Neurology > Stroke > Flashcards

Stroke Flashcards

1
Q

Definition of a TIA?

A

<24 hours transient focal neurology with tissue ischemia
marker of IHD + proceeds stroke (10-15% in 10 min”)

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2
Q

what can you use for TIA and what test would you do if Px has had a TIA (ie. resolved acutely)?

A

can use ABCD2 (not NICE recommended)

do MRI

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3
Q

Definition of a stroke?

A

> 24hr focal neurological deficit with tissue infarct

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4
Q

Causes of stroke and %

A

ischemic 85%
haemorrhagic 15%

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5
Q

what are the causes of ischemic stroke?

A

embolism (carotid atherogenesis, ASD, AF, IE)
Thrombosis
Systemic hypo perfusion

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6
Q

what are the causes of haemorrhagic stroke?

A

Extra/subdural/subarachnoid/intrancranial haemorrhage
trauma
alcoholism
anticoags
berry aneurysm

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7
Q

RF for stroke?

A

HTN = Biggest
CVD
T2DM
Obese
high cholesterol
Males
High age
smoking
AF
PKD
Anticoags

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8
Q

How long can’t you drive for after a TIA or if you drive a hgv?

A

1 month after TIA

6-12 months after TIA if HGV

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9
Q

What classification divides people with stroke into different categories based on symptoms?

A

Bamford/Oxford classification

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10
Q

What are the Bamford/Oxford classifications for stroke?

A

Anterior circulation infarct
(total and partial)
Posterior circulation infarct (POCS)
Lacunar infarct

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11
Q

What Sx do you get in a Total anterior Circulation infarct?

A

3/3 (3h)
-Higher cortical dysfunction
-Homonymous Hemianopia
-Unilateral weakness (unilateral hemiplegia or hemisensory loss)

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12
Q

what are examples of higher cortical dysfunction?

A

aphasia
hemispatal neglect (less awareness of stimuli)
agnosia
apraxia

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13
Q

What Sx do you get in a Partial anterior Circulation infarct?

A

2/3
-Higher cortical dysfunction
-Homonymous Hemianopia
-Unilateral weakness (unilateral hemiplegia or hemisensory loss)

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14
Q

What Sx do you get in a Posterior Circulation syndrome infarct?
what area is affected?

A

Occipital lobe, cerebellum + brainstem
1 of:
-isolated vision changes (homonymous hemianopia)
-Cerebellar Sx (DANISH)
-ipsilateral CN palsy

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15
Q

What Sx do you get in a lacunar infarct?
what area is affected?

A

Subcortical areas of basal ganglia + deep brain
-Pure motor or sensory Sx
-Ataxia hemiparesis (unilateral weakness and ipsilateral cerebellar like ataxia)

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16
Q

What does DANISH stand for in cerebellar syndrome?

A

Dysdiadochokinesis (rapid muscle movements)
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia

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17
Q

What Sx are present in an anterior cerebral artery infarct?

A

LL>UL
Urinary/fecal incontinence +/- personally changes

Contralateral weakness/sensory loss, dysarthria (hard to speak as speech muscles weak)

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18
Q

What Sx are present in a Middle cerebral artery infarct?

A

UL>LL
Ipsilateral gaze deviation
face drop + forehead spared
Broca/wernicke (of dominant hemisphere)

Contralateral weakness/sensory loss, dysarthria (hard to speak as speech muscles weak)

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19
Q

What Sx are present in a posterior cerebral artery infarct?

A

Isolated vision changed - occipital only
eg. painful CN3 palsy, homonymous hemianopia + macular sparing

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20
Q

An infarction in the midbrain is caused by occlusion of which vessels?

A

occlusion of the paramedian branches of posterior cerebral arteries (PCA)

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21
Q

What is the acronym for the Sx of a midbrain infarct?

A

WEBER’S
WEB in my eye

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22
Q

What is WEBERS?
What does it stand for?

A

Contralateral Weakness

Ipsilateral oculomotor palsy (EYE) - Down and out eye, ptosis, dilated pupils

May have contralateral Parkinsonism if substantial nigra affected

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23
Q

An infarction of the lateral medulla is caused by occlusion of which vessels?

A

of the posterior inferior cerebellar artery - PICA

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24
Q

What is the acronym for the Sx of a lateral medulla infarct?

A

WALLENBURG
DANVAH

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25
Q

What are the Sx of a lateral medulla infarct?
DANVAH?

A

-Dysphagia (PICA - Chew) CN10
-Ataxia
-Nystagmus
-Vertigo
-Anaesthesia (ipsilateral CNV Palsy, contralateral pain + temp lost)
-Horners ipsilateral

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26
Q

What is Horners syndrome?

A

A blockage or damage to the sympathetic nerves that lead to your eyes

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27
Q

What Sx do you get in Horners?

A

Ptosis (eyelid droop)
miosis (constricted pupils)
anhidrosis
Endopthalmos (dull retracted eyes)
Ipsilateral numbness + tingling in arm

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28
Q

What does Benedikt syndrome affect?

A

The midbrain

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29
Q

what Sx do you get in Benedikt syndrome?

A

webers + gait disturbance (red nucleus)

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30
Q

An infarction of the lateral pontine is caused by occlusion of which vessels?

A

anterior inferior cerebellar arteries (AICA)

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31
Q

What Sx do you get in lateral pontine syndrome?

A

Wallenburg + hearing loss (and no dysphagia)

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32
Q

Infarction/occlusion of the basilar artery causes what syndrome?
Sx?

A

Locked in syndrome
complete paralysis but can move eyes and aware

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33
Q

An infarction of the retinal artery causes?
this is?

A

Amaurosis fugax - temporary vision loss through one eye

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34
Q

What is the Dx for stroke?
How do you recognise it?
What would you rule out?

A

Recognise (think fast)

ABCDE assessment
bloods (r/o other causes), BM (r/o hypo/hyper glycaemia), BP

Brief Hx and Exam (onset, time, RF, CI to thrombolysis)

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35
Q

What scale is used for stroke?

A

NIHSS
(NIH stroke scale)
grades severity of stroke

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36
Q

What is first line and gold standard for ischemic stroke?

A
  1. urgent non contrast CT head (+/- CT angiogram)

GS. Diffusion weighted MRI

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37
Q

what bloods would be performed to check for ischemic stroke?

A

FBC, U+E, LFT, Lipid profile, ESR/CRP, Clotting screen, glucose, HbA1C

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38
Q

What other investigations would you do for stroke / ischemic stroke?

A

ECG +/- 72hr tape
Carotid doppler USS
ECHOcardiogram
MRI

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39
Q

In an ischemic stroke, what would be seen on CT?

A

Hypodense region + hyper dense vessel

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40
Q

In a haemorrhagic stroke, what would be seen on CT?

A

hyper dense - iso dense - hypodense

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41
Q

Tx for an ischemic stroke?
timeline?
what medication administered and how?

A

<4.5 hrs from Sx onset or
<9hrs onset if salvageable brain tissue on imaging:
- IV Alteplase/Tenecteplase
(tissue plasminogen - break down clot)
eg. alteplase 0.9mg/kg (thrombolysis)

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42
Q

What is the SE of thrombolysis eg. alteplase?

A

Bleeding!

43
Q

What are the CI for thrombolysis eg. alteplase?

A

ABCDEFG
-Anticoagulation (in most cases)
-BP >185/110 (Can be lowered)
-CNS trauma/procedure recently
-Diathesis (active bleeding, bleeding disorders, PLT<100, INR>1.7)
-Endocarditis in last 2 weeks
-Former Hx intracranial haemorrhage
-Glucose (<3 or >20), GI bleed

44
Q

ischemic stroke
What can be considered if the clot is in a large artery and when is it indicated?

A

Thromboectomy (insert mesh through thigh + manually guide to cerebral artery)
<6hr ACA confirmed
<6-24hr MCA
<24hr PCA confirmed

45
Q

What is given if >4.5hr since Sx onset of an ischemic stroke?

A

300mg stat aspirin
repeat head CT to exclude any new haemorrhagic strokes

46
Q

what 2^ care does the patient receive after a stroke?

A

Consider PEG feeding - aspiration pneumonia risk
Rehabilitation:
Physio, OT, Speech and language therapist

47
Q

What are the long term medication Px are put on after an ischemic stroke?

A

Statin - simvastatin
Clopidogrel (antiplatelet)

48
Q

Ischemic stroke
Statin, what statin is prescribed and dose?
How does a statin work?
Why is it given?

A

high dose statin eg. 80mg simvastatin
HMG-CoA inhibitor
40% decrease in non HDL cholesterol

49
Q

Ischemic stroke
Clopidogrel, How long after a stroke is it given for, dosage?
How does it work?
what is 2nd line?

A

Antiplatelet
Lifelong - 75mg
irreversible P2Y12 binding therefore inhibits PLT aggregation + activation
2nd = aspirin + dipyridamole

50
Q

What is considered at what % stenosis in ischemic stroke?

A

carotid endartectomy considered at 70% stenosis

51
Q

What 2 scores are used for stroke?
community and hospital?

A

FAST (community)

ROSIER (Recognition of stroke in emergency room)
>0 = chance of stroke
do blood glucose to r/o hypoglycaemia

52
Q

Reversal agents of anticoagulation:
Warfarin?
Heparin?

A

Beriplex + vitamin K

Protamine

53
Q

Reversal agents of anticoagulation:
Apixaban/rivaroxaban/edoxaban?
Dabigatran?

A

Beriplex

Idarucizumab

54
Q

what 7 conditions could mimic a stroke?

A

-Seizures (epilepsy, alcohol, shaking)
-space occupying lesion - tumours/abscess
-Migraine
-Metabolic (eg. hypoglycaemia/natremia)
-Functional;
-vestibular neuritis
-Spinal cord/peripheral nerve/CN lesions

55
Q

What are the layers from skull to brain?

A

skull
Middle meningeal artery
Endosteal layer (dura mater)
Dural venous sinuses
Meningeal layer (dura mater)
Blood vessels
Arachnoid mater
Circle of willis
Pia mater
Brain

56
Q

What are some red flag Sx of a heamorrhagic brain bleed?

A

-Headache worse at morning/night
-3+ episodes of N+V
-Worse on coughing + straining
-worse on change position

57
Q

What is and the cause of a subarachnoid haemorrhage?

A

Ruptured Circle of willis

MC = trauma
MC non trauma = berry aneurysm
other = mycotic aneurysm, AVM

58
Q

where do berry aneurysms usually occur?

A

usually ACA + anterior communicating artery junction

59
Q

Sx of a subarachnoid haemorrhage?

A

-Occipital 10/10 INSTANT thunderclap headache
(+/- weeks prior, sentinel headache) - red flag headache Sx
-Meningism (Kernig + Brudziński)
-High ICP Sx eg. CN3 Palsy, CN6 palsy, Cushing triad

60
Q

What is Cushings triad?

A

Irregular breathing
widened PP
Hypertension
bradycardia

N+V
Headaches

61
Q

Dx of a subarachnoid haemorrhage?
1st line and GS, What would be seen?

A

Bloods (esp U+E, hypOnatremia)

1 = NCCT head - star shaped haematoma
(If CT indefinite)
GS = LP >12hrs later = most sensitive for xanthochromia (>12hr) + high RBC

CT angiogram = locate source of bleed

62
Q

Tx of subarachnoid haemorrhage?

A

lower ICP = Raise bed head 30*,
hyperventilate (to induce cerebral vasoconstriction)
IV Mannitol
Dexamethasone
Burr hole

63
Q

What is given for 21 days after a subarachnoid haemorrhage and why?

A

Nimodipine
To decrease artery vasospasm (increased risk for first 3 weeks)

64
Q

What surgery can be done if someone has a berry aneurysm?

A

Endovascular coiling surgery
2nd = clipping

65
Q

Complications of subarachnoid haemorrhage?

A

Vasospasm (Tx = nimodipine - also hyperventilate and hypervol)

Rebleeding

SIADH (fluid restrict these Px - will lose Na+ + retain H20 = Increased urine conc due to inappropriate vasopressin)

Hyponatremia salt loss

Hydrocephalus

66
Q

What is a subdural haemorrhage?

A

Ruptured bridging veins (dural sinuses)

67
Q

What are the acute and chronic causes of a subdural haemorrhage?

A

Acute = deceleration injury

Chronic = shaken baby, low impact trauma, alcoholism

68
Q

what is the median lucid interval for a subdural haemorrhage?

A

17 days

69
Q

Sx onset of an acute subdural haemorrhage?

A

<3 days of trauma

70
Q

Sx onset of an chronic subdural haemorrhage?

A

> 21 days of trauma
(blood pooling, clot formation, osmotic effect - high ICP)

71
Q

Sx of a subdural haemorrhage?

A

High ICP Sx with headache, low GCS

Chronic may show more fatigue

72
Q

Dx, Ix and findings of a subdural haemorrhage?

A

NCCT head
Hyper/iso/hypodense crescent haemotoma
NOT suture line confined +/- midline shift

73
Q

Tx of a subdural haemorrhage?

A

Lower ICP as SAH
craniotomy + clot evacuation

74
Q

what % of minor Subdural haemorrhages self resolve?

A

70% minor SDH self resolve

75
Q

Who is more likely to have a subdural haemorrhage?

A

Alcoholics, very old, babies

76
Q

Complications of subdural haemorrhage?

A

cerebral oedema
coning

77
Q

what is an extradural haemorrhage?

A

ruptured middle meningeal artery

78
Q

Cause of extradural haemorrhage?
what age is affected?

A

low impact trauma
20-30y

79
Q

Sx of an extradural haemorrhage?

A

Initial LOC
Lucid interval for hours (venous shunting out of skull to compensate)
Rapid Sx deterioration:
low GCS, N+V, High ICP

80
Q

What signs would you see of an extradural haemorrhage?

A

Evidence of head trauma (battle sign - bruising over mastoid)
Raccoon eyes
haemotympanum - blood in middle ear
CSF otorrhoea - spinal fluid drains from ear
these are signs of basilar skull fracture (fracture skull bones at base, 1 or more bones involved)

81
Q

Dx of extradural haemorrhage?
what would be seen?

A

NCCT head - hyper dense lens +/- midline shift, confined to suture lines

82
Q

Tx of extradural haemorrhage?

A

Low ICP
craniotomy + evacuation

83
Q

MC cause of head injury?
other causes?

A

RTA!
Alcohol + drugs

84
Q

Minor head injury presents with what GCS?

A

presents with GCS 13-15 of which around 4% deteriorate
low GCS, Slurred speech, U/L Hemiparesis, >3 eps N+V, Cushing triad

85
Q

what Sx does a basilar skull fracture cause?

A

CSF Rhinorrhoea

86
Q

If there is evidence of head laceration, when does the head CT need to be done?

A

CT head in 1 or less hours

87
Q

If there is no evidence of head laceration, well in self +/- headache, when does the head CT need to be done?

A

CT head in 8 or less hours

88
Q

High ICP/volume curve shows above 70mmHg, what does this mean?
what does the ICP need to be maintained at?

A

small volume increase = High ICP therefore rapid deterioration
Maintain ICP 60-70

89
Q

what should be ruled out in head injury?

A

vertebral artery dissection

90
Q

Complications of head injuries?

A

Epilepsy
mood disorder
personality chance (50%)

91
Q

Syncope
what is it?

A

paroxysmal change in behaviour/cognittion due to insufficient cerebral perfusion

92
Q

Syncope
who suffers from it?
When it occurs?

A

Older, CV comorbidity

Exertion / posture

93
Q

syncope
Pre?
Ictal?
Post?

A

pale, clammy, autonomic, chest pain

Floppy LOC, eyes closed

immediate recovery + no amnesia

94
Q

Epilepsy
what is it?

A

sudden uncontrolled burst of electrical activity in brain causing a seizure

95
Q

Epilepsy
who has it?
when does it occur?

A

All ages

Alcohol, low sleep, meds

96
Q

Epilepsy
Pre?
Ictal?
Post?

A

Aura, deja vu, automatisms

Tonic clonic (rigid, fall to floor, symmetrical limb jerking, eyes open, tongue bitten <5 mins)

Post ictal drowsiness for around 30 mins, Todd paralysis, confusion

97
Q

what is non epileptic attack disorder (NEAD)?

A

paroxysmal change in behaviour / cognition due to psychosocial distress

98
Q

Non epileptic attack disorder (NEAD)
who gets it?
when does it occur?

A

Younger, psych Hx / stress

High stress + panic

99
Q

non epileptic attack disorder (NEAD)
Pre?
Ictal?
post?

A

Panicked + unaware, abrupt

Violent, asymmetrical limb jerking, waxing and waning Sx, eyes + mouth (no tongue bit), pelvic thrusting, >5 mins (often >30 mins)

Rapid increased emotional response, no amnesia

100
Q

TIA
If its happened within the past week, what happens?

A

300mg aspirin + specialist assessment within 24hrs

101
Q

TIA
>7 days?
what imaging is done?

A

specialist assessment
diffusion weighted MRI

102
Q

what is 2^ prevention in TIA?
initial and long term?

A

Initial 21 days; DAPT (clopidogrel) with aspirin

Long term 2^ = clopidogrel

103
Q

Brugado
type of inheritance?
Affects what?
causes what 3 ECG changes?

A

Auto dom SCN5A mutation
Affects CV Na+ channel
1. Pseudo RBBB
2. V1+2 ST elevation
3. Saddle back ST-T elevation

Phase 3a Neurology (3 decks)

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