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A. MLA Map Acute and Emergency > Stroke > Flashcards

Stroke Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

A stroke is when there is disruption in blood flow to the brain. How common is this?

1 - 2.3 / 100,000
2 - 23 / 100,000
3 - 230 / 100,000
4 - 2300 / 100,000

A

3 - 230 / 100,000

Roughly 150,000 per year

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2
Q

What age do strokes typically peak at?

1 - >40
2 - >50
3 - >60
4 - >70

A

4 - >70

Equally as common in men and women

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3
Q

The cause of strokes can be subdivided into the following ischaemic or hemorrhagic strokes. Which of these is the most common?

A

Ischaemic
- accounts for 87% of strokes

Can be either:
- thrombus = blood clot forms in brain or blood vessels supplying the brain
- embolism = blood clot from somewhere in body becomes lodged in brain

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4
Q

The cause of strokes can be subdivided into the following ischaemic or hemorrhagic strokes. Hemorrhagic strokes can be be subdivided into:

  • Intracerebral haemorrhage
  • Subarachnoid haemorrhage

Which of these is most common?

A
  • Intracerebral haemorrhage
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5
Q

If cerebral ischaemia occurs during an ischaemic stroke, this can lead to reduced blood flow, oxygen and glucose and impaired cellular homeostasis. Which of the following does this NOT typically lead to?

1 - excitotoxicity
2 - oxidative stress
3 - increased intracranial pressure
4 - inflammation
5 - apoptosis and irreversible neuronal damage

A

3 - increased intracranial pressure

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6
Q

If cerebral haemorrhage occurs during a haemorrhagic stroke, this can lead to all of the following, EXCEPT which one?

1 - rupture of a blood vessel
2 - excitotoxicity
3 - blood accumulate in the brain tissue or subarachnoid space
4 - increased intracranial pressure
5 - compression of brain tissue, inflammatory response and neuronal injury

A

2 - excitotoxicity

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7
Q

Which of the following can occur in both an ischaemic and haemorrhagic stroke?

1 - cerebral oedema and intracranial pressure
2 - excitotoxicity
3 - oxidative stress
4 - rupture of blood vessels

A

1 - cerebral oedema and intracranial pressure

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8
Q

Strokes are classified using the Oxford Stroke Classification. Which of the following criteria is NOT typically assessed in this classification?

  1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  2. homonymous hemianopia
  3. higher cognitive dysfunction (dysphasia)
    4 - autonomic function (bladder)
A

4 - autonomic function (bladder)

Unilateral hemiparesis = loss of whole side of the body. Some sensory may be maintained

Homonymous essentially means same side of optical tract affected
- hom = same
- onyma = name

Hemianopia = half of not seeing

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9
Q

Strokes are classified using the Oxford Stroke Classification. The 3 following criteria are typically assessed:

  • unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  • homonymous hemianopia
  • higher cognitive dysfunction (dysphasia)

How many of the above criteria are affected in total anterior circulation infarcts?

1 - 1
2 - >1
3 - >2
4 - all 3

A

4 - all 3

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10
Q

Strokes are classified using the Oxford Stroke Classification. The 3 following criteria are typically assessed:

  • unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  • homonymous hemianopia
  • higher cognitive dysfunction (dysphasia)

In total anterior circulation infarcts all 3 are affected. Which blood vessels are typically affected?

1 - middle and anterior cerebral arteries
2 - middle cerebral arteries
3 - anterior cerebral arteries
4 - posterior cerebral arteries

A

1 - middle and anterior cerebral arteries

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11
Q

Strokes are classified using the Oxford Stroke Classification. The 3 following criteria are typically assessed:

  • unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  • homonymous hemianopia
  • higher cognitive dysfunction (dysphasia)

How many of the above criteria are affected in partial anterior circulation infarcts?

1 - 1
2 - >1
3 - 2
4 - all 3

A

3 - 2

Can involve smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery

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12
Q

Strokes are classified using the Oxford Stroke Classification. Posterior circulation infarcts are classified differently to anterior and Lacunar infarcts. How many of the following must be present to diagnose a posterior circulation infarcts?

  • cerebellar or brainstem syndromes
  • loss of consciousness
  • isolated homonymous hemianopia

1 - 1
2 - 2
3 - all 3

A

1 - 1

At least 1 is needed

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13
Q

Strokes are classified using the Oxford Stroke Classification. Lacunar infarcts are classified differently to anterior and posterior infarcts. How many of the following must be present to diagnose a Lacunar infarcts?

  • unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
  • pure sensory stroke
  • ataxic hemiparesis

1 - 1
2 - 2
3 - all 3

A

1 - 1

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14
Q

In Lacunar infarcts which of the following parts of the brain are typically affected?

1 - basal ganglia
2 - internal capsule
3 - thalamus
4 - pons
5 - all of the above

A

5 - all of the above

Typically deep structures causing:
- pure motor
- pure sensory
- mixed motor and sensory signs or ataxia

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15
Q

All of the following ipsilateral symptoms are which type of a stroke?

  • ataxia
  • nystagmus
  • dysphagia
  • facial numbness
  • cranial nerve
  • contralateral limb sensory loss

1 - Wallenberg’s syndrome
2 - Lacunar infarct
3 - Weber’s syndrome
4 - Partial anterior circulation infarct

A

1 - Wallenberg’s syndrome

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16
Q

All of the following symptoms are which type of a stroke?

  • ipsilateral III palsy
  • contralateral weakness

1 - Wallenberg’s syndrome
2 - Lacunar infarct
3 - Weber’s syndrome
4 - Partial anterior circulation infarct

A

3 - Weber’s syndrome

17
Q

How long do the symptoms have to be present for to be classified as a stroke?

1 - >6h
2 - >12h
3 - >24h
4 - >48h

A

3 - >24h

18
Q

How long do the symptoms have to be present for to be classified as a transient stroke?

1 - <6h
2 - <12h
3 - <24h
4 - <48h

A

3 - <24h

19
Q

All of the following could present in a cerebral hemisphere infarct, but which is unlikely?

1 - contralateral hemiplegia: initially flaccid then spastic
2 - ipsilateral pure motor loss
3 - contralateral sensory loss
4 - homonymous hemianopia
4 - dysphasia

A

2 - ipsilateral pure motor loss

20
Q

Which of the following could present with:

  • severe symptoms
  • quadriplegia
  • lock-in-syndrome

1 - cerebral hemisphere infarct
2 - lacunar infarcts
3 - brainstem infarction
4 - posterior circulation infarcts

A

3 - brainstem infarction

Lock-in-syndrome:
- quadriplegia, bulbar palsy, and whole-body sensory loss due to damage in the brain stem, most commonly the anterior pons.

21
Q

Are patients with an ischaemic or hemorrhagic stroke more likely to have the following?

  • reduced consciousness
  • increased headaches
  • nausea and vomiting
  • seizures
A
  • hemorrhagic stroke

Not diagnostic, but useful

22
Q

Although diagnosing a stroke can be straightforward or difficult, which screening tool has a 78% predictive value?

1 - CHA2DS2-VASc Score
2 - CURB-65
3 - Wells DVT
4 - FAST

A

4 - FAST

F = Face
A = Arms
S = Speech
T = Time

23
Q

Although diagnosing a stroke can be straightforward or difficult, which screening tool can be used. by medics to identify likelihood of a stroke?

1 - CHA2DS2-VASc Score
2 - ROSIER
3 - Wells DVT
4 - FAST

A

2 - ROSIER
MUST EXCLUDE hypoglycaemia

24
Q

What is the 1st line imaging used in a suspected stroke?

1 - non-contrast CT head scan
2 - arterial imaging with angiography (CTA or MRA)
3Venous imaging if CVST suspected (CTV or MRV)
4 - MRI +/- special sequences/ contrast especially if SOL suspected

A

3 - non-contrast CT head scan

Key for distinguishing between ischaemic stroke or haemorrhagic stroke

All other scans can be performed, but would be later on

25
Q

Do ischaemic strokes always appear on imaging straight away?

A
  • No

Can take time to develop

26
Q

Do haemorrhagic strokes always appear on imaging straight away?

A
  • Yes

Hyperdense material (blood) surrounded by low density (oedema)

27
Q

In a patient with suspected stroke, which of the following must be maintained within normal limits?

1 - blood glucose
2 - hydration
3 - oxygen saturation
4 - temperature
5 - all of the above

A

5 - all of the above

Can all be checked during the ABCDE approach

28
Q

If a patient has a suspected stroke and has high blood pressure, should we aim to reduce the blood pressure in the acute phase?

A
  • no

Increases risk of complications such as Hypertensive encephalopathy

29
Q

In a suspected stroke, 300mg such be given as soon as possible. But what must be ruled out 1st?

1 - hypertension
2 - AKI
3 - haemorrhagic stroke
4 - papillodema

A

3 - haemorrhagic stroke

Haemorrhagic stroke must also be ruled out before anticoagulants and thrombolysis given for atrial fibrillation

Typically given for 2 weeks

30
Q

In an ischaemic stroke, anticoagulants may be withheld for how many days from the ischaemic stroke?

1 - 48h
2 - 7 days
3 - 14 days
4 - 28 days

A

3 - 14 days

31
Q

If a patients cholesterol is >3.5mmol/L, they should be started on atorvastatin, at what dose?

1 - 5mg
2 - 10mg
3 - 20mg
4 - 80mg

A

4 - 80mg

Typically given at 48h post stroke

32
Q

Tissue plasminogen activator (tPa) are released from endothelial cells to activate plasmin, which can then initiate fibrinolysis (break down of blood clots). In acute ischaemic stoke presentation, how soon do tPa’s need to be given to reduce disability?

1 - <1 hour from stroke
2 - <2 hours from stroke
3 - <3 hours from stroke
4 - <4.5 hours from stroke

A

4 - <4.5 hours from stroke
Drug of choice is Alteplase, BUT will soon be tenecteplase

MUST rule out haemorrhagic stroke 1st with imaging

33
Q

Mechanical thrombectomy is the removal of blood clots from the artery through a catheter, and can be offered within 24 hours of the symptom onset and alongside IV thrombolysis. However, which 2 arteries must be confirmed to be blocked prior to its use?

1 - proximal anterior circulation
2 - proximal carotid circulation
3 - proximal posterior circulation
4 - proximal medial circulation

A

1 - proximal anterior circulation

3 - proximal posterior circulation

34
Q

Which of the following would lead to a carotid artery endarterectomy?

1 - carotid occlusion of >70%
2 - lacunar infarcts
3 - proximal anterior circulation
4 - atrial fibrillation

A

1 - carotid occlusion of >70%

35
Q

Which of the following is 1st line secondary prevention in a patient following a stroke?

1 - clopidogrel
2 - aspirin and dipyridamole
3 - abciximab
4 - ticagrelor

A

1 - clopidogrel

If unable to take this then 2nd choice is aspirin and dipyridamole

36
Q

Which of the following is NOT typically part of the secondary prevention following a stroke?

1 - Clopidogrel
2 - Atorvastatin
3 - Folic acid
4 - Blood pressure optimised
5 - Diabetes control optimised
6 - Lifestyle change

A

3 - Folic acid

Blood pressure medication is only given if a patient has been thrombolysed as this can increase bleeding risk

37
Q

In the image below, is the top or bottom image and ischaemic stroke?

A
  • top = ischaemic stroke
    White/grey line
  • bottom = hemorrhagic stroke
    White lump is blood

A. MLA Map Acute and Emergency (42 decks)

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