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3A Neurology > Stroke > Flashcards

Stroke Flashcards

1
Q

Define stroke

A

Stroke is defined as an acute neurological deficit lasting more than 24 hours with infarction

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2
Q

ISCHAEMIC vs HAEMORRHAGIC STROKE %

A

ischaemic - 80
haemorrhagic 20

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3
Q

What is ischaemic stroke caused by

A
  • Reduction in cerebral blood flow due to arterial occlusion/ blockage or stenosis. Typically divided into lacunar , thrombotic and embolic
  • Sites such as carotid, verebral and basilar arteries - mostly carotid
  • Infarcted area dies causing permanent deficit
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4
Q

Aetiology of ischaemic stroke

A
  • Atherothromboembolism
  • Cardioembolism - AF, post MI, IE
  • Vasculitis
  • Fat emboli
  • Hyperviscosity syndrome - blood becomes too thick
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5
Q

What is an embolic stroke usually caused by

A
  • usually a blood clot but fat ,air or clumps of bacteria
  • atrial fibrilation
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6
Q

What are thrombotic strokes usually caused by

A
  • thrombosis from large vessels
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7
Q

Primary investigations for stroke

A
  • 1st line- non contrast CT head - to allow exclusion of haemorrhage
  • Diffusion weighted MRI- gs to confirm after CT
  • ECG- asses for AF or MI
  • Bloods; hba1c, lipids, clotting screen, FBC (RBC), ESR (vasculitis), cholesterol
  • CTA
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8
Q

What are haemorrhagic strokes caused by

A
  • ruptured bv
  • berry aneurysm rupture
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9
Q

What can haemorrhgaic strokes further be divided into

A
  • intracerebral - bleeding within brain parenchyma
  • subarachnoid- bleeding between pia mater and arachnoid mater
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10
Q

Stroke in ACA

A

ACA- weakness of feet and legs with maybe sensory loss, incontinence, drowsiness, Truncal ataxia

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11
Q

Stroke in MCA

A

MCA (contralateral) - speech comprehension and understanding, hands and arms weakness, dysphasia, aphasia, Homonymous hemianopia,

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12
Q

Stroke in PCA

A
  • PCA - visual problems,
  • Propagnosia - inability to recognise faces,
  • Visual agnosia - cannot interpret visual ino
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13
Q

What happens if vertebrobasilar artery is infarcted

A
  • Quadriplegia - symptom of paralysis that affects all a person’s limbs and body from the neck down
  • Dysarthria
  • Vertigo
  • N/V
  • Drowsiness
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14
Q

Stroke in either hemisphere would exhibit ?

A

Hemiparesis
Hemisensory loss
Visual field defect

CONTRALATERAL

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15
Q

Lacunar infarct

A

Deep branches of MCA that feed the basal ganglia , damaged vessels form cysts due to hyaline arteriosclerosis

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16
Q

FEAUTURES of stroke in dominant hemisphere

A
  • usually left
  • Language dysfunction
  • Expressive dysphasia
  • Receptive dysphasia
  • Dyslexia
  • Dysgraphia
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17
Q

non dominant hemisphere stroke features

A
  • Anosognosia
  • Neglect of paralysed limb
  • Denial of weakness
  • Visuospatial dysfunction
  • Geographical agnosia
  • Dressing apraxia
  • Constructional apraxia
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18
Q

Key diagnostic factors for stroke ?

A
  • unilateral weakness or paralysis in the face, arm or leg
  • dysphasia
  • ataxia
  • visual disturbance
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19
Q

posterior circulation symptoms

A
  • Unsteadiness
  • Visual disturbance
  • Slurred speech
  • Headache
  • Vomiting
  • Others e.g. memory loss, confusion
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20
Q

Risk factors

A
  • older age
  • family history of stroke
  • history of ischaemic stroke or TIA
  • hypertension
  • Smoking
  • Male
  • diabetes
  • Vasculitis
  • Hyperlipidaemia
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21
Q

What do haemorrhagic strokes tend to show ..

A

increased intracranial pressure

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22
Q

What is ROSIER

A

Recognition of Stroke in the Emergency Room

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23
Q

DD for stroke

A
  • Hypoglycaemia
  • Hyponatraemia
  • Hypercalcaemia
  • Uraemia
  • Hepatic encephalopathy
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24
Q

increase in intracranial pressure is likely to cause ..?

A

midline shift

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25
Q

Management of ischaemic stroke

A
  • immediate aspirin 300mg until 2 weeks after symptoms
  • thrombolysis with IV alteplase ( tissue plasminogen ) to restablish blood flow - 4.5 hours within symptom onset
  • contraindcations of Thrombolysis
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26
Q

prevention of ischaemic stroke

A
  • clopidogrel daily life long
  • aspirin 75mg daily
  • manage RF
27
Q

What would you need before doing a thrombectomy

A

Confirmation of stroke requires CTA or MR angiogram prior to thrombectomy

28
Q

thrombectomy for Proximal anterior circulation stroke?

A

offer thrombectomy within 6 hours with IV thrombolysis (if within 4.5 hours), or within 6 to 24 hours without IV thrombolysis if there is potential to salvage brain tissue

29
Q

Haemorrhagic stroke management ?

A
  • neurosurgery referral
  • intense monitoring of ICP
30
Q

Epidemiology of stroke

A
  • third leading cause of mortality in the US
  • stroke rates higher in asian and black
31
Q

Cause of a TIA

A
  • thrombosis
  • emboli- eg from AF
  • small vessel occlusion
32
Q

What is a transient ischemic attack

A
  • sudden onset focal neurological deficit that is temporary , lasts less than 24hrs WITHOUT INFARCTION
  • Acute loss of cerebral ocular function with sudden symptoms lasting less than 24 hours
33
Q

How long does a TIA typically last

A

5-15 mins

34
Q

What is the pathophysiology of a TIA

A
  • type of cerebral ischaemia
  • lack of oxygen and nutrients to the brain resulting in cerebral dysfunction
35
Q

RF for TIA

A

Same as IHD
- smoking
- dm
- obesity
- HTN
- AF

36
Q

TIA symptoms in carotid territory symptoms - more common here

A
  • Amaurosis fugax
  • Aphasia
  • Hemiparesis
  • Hemisensory loss
  • Hemainopic visual loss
37
Q

Symptoms of a TIA if in ACA

A

Weak numb contraletral leg

38
Q

Symptoms of a TIA if in MCA

A
  • Weak numb contralateral side of body
  • face drooping with forehead spared
  • dysphasia
39
Q

General clinic presentation of a TIA

A
  • sudden loss of function lasting for minutes
  • complete recovery
  • focal neurological deficit
  • no sign of infarction
40
Q

What percentage of TIA affect the anterior or posterior circulation

A

anterior -90%
posterior - 10%

41
Q

What is amaurosis fugax and how can it be caused

Otherwise known as transient visual disturbance

A
  • sudden transient loss of vision in one eye
  • occlusion/ reduced blood flow to retina through opthalmic, retinal ciliary artery
  • signals that a stroke is impending
42
Q

What is todds paralysis

A

transient weakness of arm, hand , leg after a seizure

43
Q

Investigations for TIA

A
  • 1st line - Diffusion weighted CT/MRI
  • Carotid imaging with doppler sound then MR/CT angiogrpahy if stenosis found
  • Bloods - Glucose, ESR, INR, U&E
  • ECG- AF
  • Echo
44
Q

How to diagnose TIA

A
  • based mostly on description
  • FAST - FACE ARM SPEECH TIME
45
Q

When are patients at a high risk of an early stroke

A
  • AF
  • more than one TIA in a week
  • TIA whilst on anticoagulant
46
Q

What visual problems may occur in a TIA

A
  • sudden transient loss of vision in one eye (amaurosis fugax)
  • diplopia
  • homonymous hemianopia
47
Q

Immediate management of TIA

A

aspirin 300mg

48
Q

for what reasons would you not give aspirin right away after a TIA

A
  1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
  2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
  3. Aspirin is contraindicated: discuss management urgently with the specialist team
49
Q

What imaging is used in TIA and why

A

NAME?

50
Q

What would a carotid bruit indicate

A

Carotid artery stenosis

51
Q

Secondary prevention of stroke ?

A
  • Clopidogrel 75mg once daily
  • Atorvastatin 80mg should be started but not immediately
  • Carotid endarterectomy or stenting in patients with carotid artery disease
  • Treat modifiable risk factors such as hypertension and diabetes
52
Q

if clopidogrel is contraindicated in TIA what would you offer instead

A
  • MRI to determine the area of ischaemia , or to detect haemorrhage
53
Q

what stroke has the poorest prognosis

A

anterior circulation stroke

54
Q

what are the car or motorcycle rules for those who have had a stroke

A
  • Patients must not drive for 1 month after a TIA or stroke
  • Driving may resume after 1 month if there has been satisfactory clinical recovery
  • Patients may not need to inform the DVLA if there is no residual neurological deficit beyond 1 month
  • Multiple TIAs over a short period requires no driving for 3 months and the DVLA must be notified
55
Q

Heavy goods vehicle license rules?

A
  • Patients must not drive for 1 year after a TIA or stroke and the DVLA must be notified
  • Relicensing may be considered after 1 year if there is no significant residual neurological impairment and no other significant risk factors
56
Q

rules of thumb for stroke criteria

A
  • ABRUpt DEFICIT
  • NEGATIVE quality
  • the maximal deficit at the start
57
Q

rules of thumb for non stroke

A
  • gradual onset
  • predominantly non-focal
  • positive
  • increases w time
58
Q

dd for stroke

A
  • epileptic seizure - positive history
  • space occupying lesion- gradual, headache, confusion
  • infection- gradual, fever
59
Q

less common dd for stroke

A
  • metabolic (hyponatraemia, hypoglycaemia)
  • multiple sclerosis- young sub acute progression
  • functional neurological disorder
  • migraine- history of previous attacks
60
Q

common sites of atheroma

A
  • LARGE AND MEDIUM VESSELS
  • carotid artery
  • confluence of arteries
61
Q

small vessel ischaemic stroke involves ?

A
  • Small deep perforator arteries blocked
  • Caused by high blood pressure, diabetes, smoking, age
  • In situ microatheroma or lipohyalinosis
  • At postmortem small holes + “cobweb” mesh
  • Hence term “lacunes”
62
Q

Dissection stroke of carotid or vertebral artery

A

Causes 25% ischaemic strokes in <45 yo

Risk factors

  • trauma or cervical manipulation
  • vigorous physical activity (eg weightlifting)
  • vasculopathy (fibromuscular dysplasia, Marfan’s)
  • sympathomimetic drug abuse
  • Often painful
63
Q

rare causes of stroke

A

vasculitis
venous thrombosis

64
Q

Other Investigations over first few days after a stroke

A
  • Blood tests can include vasculitis screen
  • ECG +- 72 hour tape
  • CT head
  • MRI brain with diffusion weighted imaging
  • Carotid Doppler
  • ECHO
  • CT or MR angiogram

3A Neurology (24 decks)

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