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Junior Clinical Posting > Stroke > Flashcards

Stroke Flashcards

1
Q

Define stroke

A

Rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin

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2
Q

TRANSIENT ISCHAEMIC ATTACK

A

Transient ischemic attacks are episodes of temporary and focal dysfunction of vascular origin, which are variable in duration, commonly lasting from 2 to 15 minutes, but occasionally lasting as long as a day (24 hours). They leave no persistent neurological deficit.

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3
Q

What is an Ischaemic stroke?

A

An episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction

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4
Q

What is a Stroke caused by ICH (Intracerebral hemorrhage)?

A

Rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma

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5
Q

What is a Stroke caused by subarachnoid hemorrhage?

A

Rapidly developing signs of neurological dysfunction and/or headache because of bleeding into the subarachnoid space (the space between the arachnoid membrane and the pia mater of the brain or spinal cord), which is not caused by trauma.

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6
Q

What is a Stroke caused by cerebral venous thrombosis?

A

Infarction or hemorrhage in the brain, spinal cord, or retina because of thrombosis of a cerebral venous structure.

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7
Q

What is a Stroke not otherwise specified?

A

An episode of acute neurological dysfunction presumed to be caused by ischemia or hemorrhage, persisting ≥24 hours or until death, but without sufficient evidence to be classified as one of the above.

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8
Q

Classification of Stroke

A
  1. Ischemic stroke (80%)
    i) Thrombotic (50%): These are caused by a blood clot (thromus) that develops in the brain’s blood vessels (usually seen in older persons, especially those with high cholesterol and atherosclerosis, or diabetes.

They can be further divided into:
1. Large vessel thrombosis 2. Small vessel thrombosis

ii) Embolic (30%): These are caused by a blood clot or plaque debris that develops elsewhere in the body and then travels to one of the blood vessels in the brain through the bloodstream

  1. Haemorrhagic Stroke (20%): Hemorrhagic strokes occur when an artery supplying the brain ruptures and bleeds. It can be divided into:

i) Intracerebral haemorrhage (15%): Bleeding is from the arteries within the brain.

ii) Subarachnoid haemorrhage (5%): Bleeding is in the subarachnoid space

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9
Q

Clinical classification of stroke

A

1- Completed stroke: Complete focal neurological deficit at onset and lasting > 24hrs.

2- Progressive stroke/Stroke in evolution: symptoms worsening gradually or in stepwise fashion over hrs or days with symptoms lasting >24 hrs

3- Transient ischemic attack (TIA): symptoms lasting < 24hrs

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10
Q

Difference between haemorrhagic and ischaemic stroke

A

In a hemorrhagic stroke, blood leaks into brain tissue
In an ischaemic stroke, the clot stops blood supply to an area of the brain

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11
Q

What are 5 Non-modifiable risk factors of stroke?

A

Age
Race
Male gender
Previous stroke
Family hx

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12
Q

What are modifiable risk factors of stroke?

A

Hypertension
Diabetes mellitus
Alcohol
Cigarette smoking
Dyslipidemia
Physical inactivity
Cardiac risk factors
Hemoglobinopathies
Vasculitis – HIV, syphilis,
Connective tissue diseases

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13
Q

Causes of Hemorrhagic Stroke (7 A’s of hemorrhagic stroke)

A
  1. Chronic hypertension (rupture of Charcot-Bouchard aneurysms, Saccular aneurysms)
  2. AV malformations
  3. Amyloid angiopathy,
  4. Anticoagulant therapy (Warfarin, Heparin)
  5. Antiplatelets
  6. Angioma (Cavernous hemangioma)
  7. Amphetamines and other Drugs-cocaine, sympathomimetics
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14
Q

What are the areas of infarction in the brain?

A

Core area: infarct with irreversible damage (dead area) <10% cerebral bloos flow

Penumbra: tissue at risk, sustains reversible damage (dying area) < 20% cerebral blood flow

Oligemia: viable tissue, no infarct or risk

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15
Q

PATHOPHYSIOLOGY ISCHAEMIC STROKE

A
  1. Lack of oxygen supply to ischaemic neurones
  2. ATP depletion
  3. Membrane ions system stops functioning
  4. Depolarisation of neurones
  5. Influx of calcium
  6. Release of neurotransmitters, including glutamate, activation of N-methyl-D-aspartate and other excitatory receptors at the membrane of neurones
  7. Further depolarisation of cells
  8. Further calcium influx
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16
Q

Pathophysiology of Hemorrhagic Stroke

A

Explosive entry of blood into the brain parenchyma structurally disrupts neuronal activity by:

  1. Compression of neurons and vessels leading to additional ischemic damage
  2. Cerebral oedema
  3. Splitting neuronal planes
  4. Vasospasm from Direct neurotoxicity of blood

The above 4 mechanisms leading to severely elevated Intracranial pressure leading to brain herniation and death

17
Q

What are the Clinical Features of Ischemic stroke & Intracerebral hemorrhage?

(a) General features
(b) MCA distribution
(c) PCA distribution
(d) Internal Capsule

A

(a) General features – LOC (loss of consciousness), vomiting, seizures, HA (headache)

(b) MCA distribution – contralateral weakness (face & arm > leg);+ aphasia (difficulty communicating/speaking) (R), + sensory neglect (L)

(c) PCA distribution – Homonymous hemianopia (loss of vision in the same half of both eyes) + other motor deficits

(d) Internal capsule – sensorimotor loss (face=arm=leg), marked dysarthria (slurred speech), no cortical deficits eg aphasia)

17
Q

What are Lacunar Syndromes = Small vessel syndromes?

A

Indicate occlusion of perforating arteries in the subcortex, brainstem, or cerebellum,

often associated with chronic hypertension and diabetes mellitus.

may be clinically silent, (only seen on imaging), or result in stroke syndromes involving densely packed white matter tracts with specific localization patterns.

18
Q

The most commonly described small vessel syndromes include:

A
  1. pure motor
  2. pure sensory
  3. sensorimotor
  4. ataxic hemiparesis, and l
  5. dysarthria-clumsy hand syndrome.

A less common, but striking, small vessel syndrome manifests as hemiballism from infarction in the subthalamic nucleus.

18
Q

INVESTIGATIONS for lacunae syndromes

A

Imaging – non-enhanced CT Brain
Blood workup – FBC, ESR, Glucose, lipid profile, E & U, Cr, (± HIV, VDRL, Clotting profile, autoantibodies for individual cases), lipid profile
ECG, ECHO
± Carotid Doppler (ischaemic stroke)
CXR,

18
Q

Principles of Acute Ischaemic Stroke Care

A

(1) achieve timely recanalization of the occluded artery and reperfusion of the ischemic tissue
(2) optimize collateral flow
(3) avoid secondary brain injury.

19
Q

Management of stroke; General measures

A
  1. Stabilise; ABCs
  2. If applicable care of the unconscious patient (HDU/ICU, careful nursing, attention to airway and vital signs, regular turning & skin care, oral hygiene via suctioning, irrigation of the eyes ± taping, sphincter care, feed – IV, NG, PEG)
  3. Monitor blood pressure
  4. Assess swallowing (gag reflex ± swallow test); NPO for the 1st 24 hours post stroke
    ISOTONIC IVFs ONLY
  5. Early physiotherapy
  6. Insulin for elevated blood glucose (Known DM or not)
19
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19
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20
Q

MANAGEMENT; Indications for antihypertensive use in acute ischemic stroke

A

BP > 220/120mmHg on more than 2 occasions or MAP > 140 (EXCLUDE pain, raised ICP,)
Associated hypertensive emergencies
Acute pulmonary edema
Acute kidney dysfunction
Hypertensive encephalopathy
Aortic dissection
DO NOT CRASH/RAPIDLY LOWER THE BP

21
Q

Which arteries supply the:

  1. Lateral potions of the Frontal, Parietal and Temporal lobes
  2. Medial portion of the Frontal and Parietal lobes
  3. Cerebellum and Brain Stem
  4. Occipital lobe
A
  1. Lateral potions of the Frontal, Parietal and Temporal lobes: Middle Cerebral Arteries
  2. Medial portion of the Frontal and Parietal lobes: Anterior Cerebral Arteries
  3. Cerebellum and Brain Stem: branches of the Vertebral and Basilar artery
  4. Occipital lobe: Posterior Cerebral Artery

Junior Clinical Posting (31 decks)

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