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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
What are the Sx of a lateral medulla infarct? DANVAH?
-Dysphagia (PICA - Chew) CN10 -Ataxia -Nystagmus -Vertigo -Anaesthesia (ipsilateral CNV Palsy, contralateral pain + temp lost) -Horners ipsilateral
26
What is Horners syndrome?
A blockage or damage to the sympathetic nerves that lead to your eyes
27
What Sx do you get in Horners?
Ptosis (eyelid droop) miosis (constricted pupils) anhidrosis Endopthalmos (dull retracted eyes) Ipsilateral numbness + tingling in arm
28
What does Benedikt syndrome affect?
The midbrain
29
what Sx do you get in Benedikt syndrome?
webers + gait disturbance (red nucleus)
30
An infarction of the lateral pontine is caused by occlusion of which vessels?
anterior inferior cerebellar arteries (AICA)
31
What Sx do you get in lateral pontine syndrome?
Wallenburg + hearing loss (and no dysphagia)
32
Infarction/occlusion of the basilar artery causes what syndrome? Sx?
Locked in syndrome complete paralysis but can move eyes and aware
33
An infarction of the retinal artery causes? this is?
Amaurosis fugax - temporary vision loss through one eye
34
What is the Dx for stroke? How do you recognise it? What would you rule out?
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)
35
What scale is used for stroke?
NIHSS (NIH stroke scale) grades severity of stroke
36
What is first line and gold standard for ischemic stroke?
1. urgent non contrast CT head (+/- CT angiogram) GS. Diffusion weighted MRI
37
what bloods would be performed to check for ischemic stroke?
FBC, U+E, LFT, Lipid profile, ESR/CRP, Clotting screen, glucose, HbA1C
38
What other investigations would you do for stroke / ischemic stroke?
ECG +/- 72hr tape Carotid doppler USS ECHOcardiogram MRI
39
In an ischemic stroke, what would be seen on CT?
Hypodense region + hyper dense vessel
40
In a haemorrhagic stroke, what would be seen on CT?
hyper dense - iso dense - hypodense
41
Tx for an ischemic stroke? timeline? what medication administered and how?
<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)
42
What is the SE of thrombolysis eg. alteplase?
Bleeding!
43
What are the CI for thrombolysis eg. alteplase?
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
ischemic stroke What can be considered if the clot is in a large artery and when is it indicated?
Thromboectomy (insert mesh through thigh + manually guide to cerebral artery) <6hr ACA confirmed <6-24hr MCA <24hr PCA confirmed
45
What is given if >4.5hr since Sx onset of an ischemic stroke?
300mg stat aspirin repeat head CT to exclude any new haemorrhagic strokes
46
what 2^ care does the patient receive after a stroke?
Consider PEG feeding - aspiration pneumonia risk Rehabilitation: Physio, OT, Speech and language therapist
47
What are the long term medication Px are put on after an ischemic stroke?
Statin - simvastatin Clopidogrel (antiplatelet)
48
Ischemic stroke Statin, what statin is prescribed and dose? How does a statin work? Why is it given?
high dose statin eg. 80mg simvastatin HMG-CoA inhibitor 40% decrease in non HDL cholesterol
49
Ischemic stroke Clopidogrel, How long after a stroke is it given for, dosage? How does it work? what is 2nd line?
Antiplatelet Lifelong - 75mg irreversible P2Y12 binding therefore inhibits PLT aggregation + activation 2nd = aspirin + dipyridamole
50
What is considered at what % stenosis in ischemic stroke?
carotid endartectomy considered at 70% stenosis
51
What 2 scores are used for stroke? community and hospital?
FAST (community) ROSIER (Recognition of stroke in emergency room) >0 = chance of stroke do blood glucose to r/o hypoglycaemia
52
Reversal agents of anticoagulation: Warfarin? Heparin?
Beriplex + vitamin K Protamine
53
Reversal agents of anticoagulation: Apixaban/rivaroxaban/edoxaban? Dabigatran?
Beriplex Idarucizumab
54
what 7 conditions could mimic a stroke?
-Seizures (epilepsy, alcohol, shaking) -space occupying lesion - tumours/abscess -Migraine -Metabolic (eg. hypoglycaemia/natremia) -Functional; -vestibular neuritis -Spinal cord/peripheral nerve/CN lesions
55
What are the layers from skull to brain?
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
What are some red flag Sx of a heamorrhagic brain bleed?
-Headache worse at morning/night -3+ episodes of N+V -Worse on coughing + straining -worse on change position
57
What is and the cause of a subarachnoid haemorrhage?
Ruptured Circle of willis MC = trauma MC non trauma = berry aneurysm other = mycotic aneurysm, AVM
58
where do berry aneurysms usually occur?
usually ACA + anterior communicating artery junction
59
Sx of a subarachnoid haemorrhage?
-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
What is Cushings triad?
Irregular breathing widened PP Hypertension bradycardia N+V Headaches
61
Dx of a subarachnoid haemorrhage? 1st line and GS, What would be seen?
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
Tx of subarachnoid haemorrhage?
lower ICP = Raise bed head 30*, hyperventilate (to induce cerebral vasoconstriction) IV Mannitol Dexamethasone Burr hole
63
What is given for 21 days after a subarachnoid haemorrhage and why?
Nimodipine To decrease artery vasospasm (increased risk for first 3 weeks)
64
What surgery can be done if someone has a berry aneurysm?
Endovascular coiling surgery 2nd = clipping
65
Complications of subarachnoid haemorrhage?
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
What is a subdural haemorrhage?
Ruptured bridging veins (dural sinuses)
67
What are the acute and chronic causes of a subdural haemorrhage?
Acute = deceleration injury Chronic = shaken baby, low impact trauma, alcoholism
68
what is the median lucid interval for a subdural haemorrhage?
17 days
69
Sx onset of an acute subdural haemorrhage?
<3 days of trauma
70
Sx onset of an chronic subdural haemorrhage?
>21 days of trauma (blood pooling, clot formation, osmotic effect - high ICP)
71
Sx of a subdural haemorrhage?
High ICP Sx with headache, low GCS Chronic may show more fatigue
72
Dx, Ix and findings of a subdural haemorrhage?
NCCT head Hyper/iso/hypodense crescent haemotoma NOT suture line confined +/- midline shift
73
Tx of a subdural haemorrhage?
Lower ICP as SAH craniotomy + clot evacuation
74
what % of minor Subdural haemorrhages self resolve?
70% minor SDH self resolve
75
Who is more likely to have a subdural haemorrhage?
Alcoholics, very old, babies
76
Complications of subdural haemorrhage?
cerebral oedema coning
77
what is an extradural haemorrhage?
ruptured middle meningeal artery
78
Cause of extradural haemorrhage? what age is affected?
low impact trauma 20-30y
79
Sx of an extradural haemorrhage?
Initial LOC Lucid interval for hours (venous shunting out of skull to compensate) Rapid Sx deterioration: low GCS, N+V, High ICP
80
What signs would you see of an extradural haemorrhage?
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
Dx of extradural haemorrhage? what would be seen?
NCCT head - hyper dense lens +/- midline shift, confined to suture lines
82
Tx of extradural haemorrhage?
Low ICP craniotomy + evacuation
83
MC cause of head injury? other causes?
RTA! Alcohol + drugs
84
Minor head injury presents with what GCS?
presents with GCS 13-15 of which around 4% deteriorate low GCS, Slurred speech, U/L Hemiparesis, >3 eps N+V, Cushing triad
85
what Sx does a basilar skull fracture cause?
CSF Rhinorrhoea
86
If there is evidence of head laceration, when does the head CT need to be done?
CT head in 1 or less hours
87
If there is no evidence of head laceration, well in self +/- headache, when does the head CT need to be done?
CT head in 8 or less hours
88
High ICP/volume curve shows above 70mmHg, what does this mean? what does the ICP need to be maintained at?
small volume increase = High ICP therefore rapid deterioration Maintain ICP 60-70
89
what should be ruled out in head injury?
vertebral artery dissection
90
Complications of head injuries?
Epilepsy mood disorder personality chance (50%)
91
Syncope what is it?
paroxysmal change in behaviour/cognittion due to insufficient cerebral perfusion
92
Syncope who suffers from it? When it occurs?
Older, CV comorbidity Exertion / posture
93
syncope Pre? Ictal? Post?
pale, clammy, autonomic, chest pain Floppy LOC, eyes closed immediate recovery + no amnesia
94
Epilepsy what is it?
sudden uncontrolled burst of electrical activity in brain causing a seizure
95
Epilepsy who has it? when does it occur?
All ages Alcohol, low sleep, meds
96
Epilepsy Pre? Ictal? Post?
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
what is non epileptic attack disorder (NEAD)?
paroxysmal change in behaviour / cognition due to psychosocial distress
98
Non epileptic attack disorder (NEAD) who gets it? when does it occur?
Younger, psych Hx / stress High stress + panic
99
non epileptic attack disorder (NEAD) Pre? Ictal? post?
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
TIA If its happened within the past week, what happens?
300mg aspirin + specialist assessment within 24hrs
101
TIA >7 days? what imaging is done?
specialist assessment diffusion weighted MRI
102
what is 2^ prevention in TIA? initial and long term?
Initial 21 days; DAPT (clopidogrel) with aspirin Long term 2^ = clopidogrel
103
Brugado type of inheritance? Affects what? causes what 3 ECG changes?
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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