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Stroke Flashcards

Understand how acute ischaemic stroke, intracranial haemorrhage and small vessel cerebrovascular disease present. Understand what is meant by hemispatial neglect. Understand the concept of aphasia, its neuroanatomical basis and its clinical impact. Basic knowledge of the investigations of vascular diseases of the brain. Basic knowledge of the medical treatment of cerebrovascular disease.

1
Q

What are the two main types of stroke?

A

Ischaemic (infarction) and haemorrhagic

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2
Q

What are the risk factors for stroke?

In order of relative risk

A
  • Hypertension
  • Cardiac disease (LVH and AF)
  • TIA
  • Diabetes mellitus
  • Obesity
  • Physical inactivity
  • Hypercholesterolaemia
  • Alcohol
  • Smoking
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3
Q

TACI

A

Total anterior circulation infarct

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4
Q

True or False

Ischaemic strokes are more common than haemorrhagic stroke.

A

True (around 80% are ischaemic)

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5
Q

What are the three main causes of ischaemic stroke

A

Thrombus
Embolus
Atherosclerosis (plaque)

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6
Q

TIA

A

Transient ischaemic attack

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7
Q

What is the definition of a stroke?

A

A sudden onset of focal neurological deficit which is ongoing and has persisted for longer than 24 hours

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8
Q

What are the clinical features of a stroke?

A

Confusion
Headache
Unilateral weakness
Sensory loss
Ataxia
Dysphasia
Dysarthria
Visual disturbance
Gaze paresis
Photophobia
Dizziness, vertigo or loss of balance
Nausea and/ or vomiting

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9
Q

What is a TIA?

A

Sudden onset of focal neurological deficit which has completely resolved within 24 hours of onset

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10
Q

What are the clinical features of a TIA?

A

Unilateral weakness or sensory loss
Dysphasia
Ataxia, vertigo or loss of balance
Syncope
Sudden transient loss of vision in one eye, diploplia or homonymous hemianopia
Cranial nerve deficits

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11
Q

What are the two types of cerebral haemorrhage?

A

Subarachnoid and intracerebral

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12
Q

Which brain areas do ‘deep haemorrhages’ occur?

A

Basal ganglia, thalamus, pons and cerebellum

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13
Q

Which treatments may be indicated in ischaemic stroke?

A

Thrombolysis or thrombectomy

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14
Q

True or False

Thrombolysis is contraindicated in haemorrhagic stroke.

A

True

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15
Q

What are the clinical features of a haemorrhagic stroke in the basal ganglia and internal capsule?

Contralateral features

A

Dense contralateral hemiplegia

Deviation of the head and eyes contralateral to the lesion

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16
Q

Which type of infarcts are localised to subcortical and brainstem areas?

A

Lacunar infarcts (or small artery occlusions)

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17
Q

What are the three main causes of cerebral infarction?

A
  1. Large artery atherosclerosis
  2. Cardioembolism
  3. Small artery occlusion (or lacunar infarct)
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18
Q

What are the two main classifications of ischaemic stroke based on?

A

Aetiology and location

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19
Q

What are the two main stroke classification systems?

A
  1. Oxfordshire Community Stroke Project (OCSP) (location)
  2. TOAST (aetiology)
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20
Q

What are the four OCSP classifications?

A
  1. TACI (Total Anterior Circulation Infarcts)
  2. PACI (Partial Anterior Circulation Infarcts)
  3. LACI (Lacunar Infarcts)
  4. POCI (Posterior Circulation Infarcts)
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21
Q

What are the TOAST classifications of stroke?

A
  1. Large artery atherosclerosis
  2. Cardioembolism
  3. Small artery disease
  4. Other determined aetiologies
  5. Undetermined aetiology
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22
Q

Define TACI

A

A large anterior circulation infarct which involves cortical and subcortical structures

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23
Q

What are the clinical features of TACI?

A

Contralateral hemiparesis or sensory deficit plus hemianopia and a disorder or higher cortical function.

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24
Q

A TACI in the left hemisphere is associated with which disorders of higher cortical functioning?

A
  • Dysphasia
  • Agnosic syndrome
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25
A TACI in the right hemisphere is associated with which disorders of higher cortical functioning?
* disturbance of body image * visuospatial neglect
26
PACI
Partial anterior circulation infarct
27
Define PACI
Predominately cortical
28
What are the clinical features of PACI
Localised cerebral deficit e.g. aphasia, visuospatial neglect, motor or sensory deficits, hemianopia
29
PCI
Posterior circulation infarct
30
What are the clinical features of PCI? | Ipsilateral and contralateral features
Ipsilateral cranial nerve deficit and contralateral motor or sensory deficit or cerebellar signs
31
What are the clinical features of lacunar infarcts?
Pure motor hemiparesis or hemisensory deficit
32
Differential diagnoses for TIA
Migraine aura Structural brain lesion Postictal deficit Epilepsy Hypoglycaemia Simple faint MS Transient global amnesia Cerebral infection Panic attack
33
Within what time frame should a CT be performed to determine if a patient is suitable for thrombolysis?
3 hours
34
What type of MRI can detect haemorrhagic stroke
MRI T2* with gradient echo sequences
35
Which thrombolytic agent is most commonly used?
tPA (tissue-type plasminogen activator) | Number needed to treat to cause significant improvement is 1 in 3 ## Footnote Given intravenously e.g., IV Alteplase
36
What are common post stroke sequelae?
Cognitive impairment and dementia Personality change Caregiver burden Depression Anxiety Emotionalism Psychoses
37
What are the classic focal cortical syndromes?
Dysphasia, apraxia and body image disturbances
38
Define post stroke dementia
Global cognitive impairment following a stroke
39
What are some risk factors for post stroke dementia?
Lower educational level Pre stroke cognitive decline (e.g., MCI) Severity of stroke Left hemisphere stroke
40
What does **FAST** stand for
**F**ace, **A**rms, **S**peech and **T**ime
41
# True or False FAST symptoms have good sensitivity and specificity.
True
42
What are the risk factors for cerebral small vessel disease?
Hypertension, diabetes, smoking
43
Which three areas are affected by cerebral small vessel disease?
1. Lenticulostriate perforating branches 2. Basilar and posterior artery perforators 3. Periventricular white matter
44
Where are lacunar infarcts localised?
Subcortical structures and the brain stem
45
Large-artery atherosclerosis may result from which two types of occlusion?
Cerebral thrombosis or local emboli
46
How does large-artery atherosclerosis lead to stroke? | Cerebral thrombosis
Lipid accumulation under the membrane of the vessel. The plaque thickens and the lumen narrows. This increases the risk of a thrombus forming.
47
Which vessels are most at risk of thrombus formation?
* Aorta * Carotid arteries * Middle cerebral arteries * Vertebrobasilar arteries
48
How does large-artery atherosclerosis lead to stroke? | Local emboli
A local thrombus may form within the stenoic vessel or thromboemboli from proximal arteries.
49
TACI is often the result of which type of cerebral infarction?
Large-artery atherosclerosis
50
Lacunar infarcts are caused by cerebral small vessel disease in which arteries?
The small penetrating arteries which supply the basal ganglia, thalamus, internal capsule or pons.
51
Lacunar artefacts may be caused by which two causes?
Cerebral small vessel disease and/ or white matter changes.
52
What is leucoaraiosis?
The presence of multiple lesions in the deep hemispheric and periventricular white matter on neuroimaging.
53
What are the risk factors for cardiac emboli?
* atrial fibrillation * mitral stenosis * subacute bacterial endocarditis * a recent miocardial infarction
54
What does cerebral small vessel disease increase the risk of?
Dementia Depression Stroke
55
What are the five types of lacunar infarcts?
1. Pure motor 2. Pure sensory 3. Motor sensory 4. Ataxic hemiparesis 5. Clumsy hand-dysarthria syndrome
56
What methods can be used to visualise vessels?
1. Carotid dopplers 2. CT angiogram 3. MR angiogram 4. Formal angiogram - digital subtraction abgiography (DSA)
57
# National Institutes of Health Stroke Scale (NIHSS)
58
What are the indicators for decompressive hemicraniectomy?
* MCA infarct * mRS <2 * NIHSS > 15 * Decreased LOC scoring 1 or more on NIHSS 1a * An infarct of at least 50% of the MCA territory on CT* | Neurosurgery referral w/i 24 hours and tx w/i 48 hours of symptom onset ## Footnote with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume greater than 145 cubic centimetres on diffusion weighted MRI.
59
# True or False The prognosis for infarction is better than haemorrhage?
True
60
Which speech disturbances are seen after stroke?
* Dysarthria/ dyspraxia * Receptive dysphasia * Expressive dysphasia * Conductive dysphasia * Cognitive communication difficulties | Caused by damage to the left hemisphere
61
# Define and localise Dysarthria
A problem with the elocution of speech due to motor-speech dysfunction ## Footnote Lacunar infarct - primary motor cortex, premotor cortex, corona radiata, internal capsule, and brainstem areas like the pons and medulla
62
# Define and localise Receptive dysphasia
A problem with understanding and expressing speech | Wernicke's or fluent aphasia - left posterior temporal lobe ## Footnote Language is fluent but does not make sense
63
# Define and localise Expressive dysphasia
A problem with the production of fluent speech (particularly long sentences or phrases) | Ability to speak in short sentences ## Footnote Broca's aphasia - posterior inferior frontal lobe (inferior frontal gyrus)
64
# Define and localise Conductive dysphasia
A problem with the repitition of speech ## Footnote Grey matter damage to the arcuate fasciculus connecting Broca's (frontal - Brodmann 44 and 45) and Wernicke's (temporal- Brodmann 22) areas
65
# Define and localise Cognitive-communication disorder
A global cognitive language problem | Damage to the right hemisphere
66
Learning objectives
*Understand how the following vascular diseases present* - acute ischaemic stroke - intracranial haemorrhage - small vessel cerebrovascular disease *Gain a* - basic knowledge of the investigations of vascular diseases of the brain - basic knowledge of medical treatment of cerebrovascular diseases

Neuropsychiatric disorders (30 decks)

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