Stroke Flashcards
what are some possible causes of haemorrhagic stroke
hypertension tumour bleeding disorder vascular malformation amyloid angiopathy
what is a TIA
symptoms last less than 24 hours
interruption to the blood supply causing loss of neurological function
what are some possible mechanisms for ischaemic strokes
cardioembolism
large vessel atherothrombosis
small vessel disease
hypoperfusion
what is a watershed stroke
ischaemia in the border between the territories of two major arteries in the brain
what is the blood supply of the anterior brain
middle cerebral artery
anterior cerebral artery
striate arteries
what does diplopia mean
double vision
what does ataxia mean
loss of full control of body movements
what is the medical name for blindness in one half of the field of vision
hemianopia
what are the steps for an emergency room assesment of a stroke
airway, breathing, circulation
clarify the history
check medical history
check the signs
exclude stroke mimics
level one investigations
what is the OCSP Classification of strokes
- total anterior circulation syndrome
2 partial anterior circulation syndrome
3 lacunar syndrome
4 posterior circulation syndrome
what can you examine
•BP and pulse measurement in 2 arms
•Conscious level (GCS; document breakdown)
•Cardiac and carotid bruits
•BM/blood glucose value
•Neck stiffness/meningism (Kernig’s/Brudzinski signs)
•Abnormal or involuntary movements
•Any seizure-like activity
•Skin rash/infarcts e.g. vasculitic, papular rash
•Specific neurological
-eye movements (gaze preference,fixed deviation)
-speech, visual fields, inattention, motor & sensory
-gait assessment
what are the features of LACS (lacunar syndrome)
pure motor or pur sensory, sensorimotor, ataxic hemiparesis
what are the features of POCS (posterior circulation syndrome)
brainstem, cerebellar and/ or homonymous hemianopia
what are the features of TACS
triad of hemiparesis (or hemisensory loss), dysphasia, homonymous hemianopia
what are the features of PACS (partial anterior circulation syndrome)
2 of the features of TACS or isolated dysphasia or parietal lobe signs
(inattention, agnosia, apraxia, agraphaesthesia, alexia)
what is agraphaesthesia
loss of orientation of skin sensations, pt is unable to understand letters traced across the skin
what is alexia
loss of ability to read
what is the ABCD2 stroke risk calculator
7 points score to predict early stroke risk post TIA
•Age [60 or above;=1]
•Blood pressure [systolic > 140 and/or diastolic =/> 90; =1]
•Clinical features [unilateral weakness = 2; speech disturbance w/o weakness = 1; other = 0]
•Duration of Symptoms in mins [=/> 60 =2; 10-59 =1;
what mnemonic is used to remember stroke mimics
five S seizures sepsis syncope SOL (space occupying lesion) somatisation
what is somatisation
the manifestation of psychological distress by the presentation of bodily symptoms.
what are red flags
no history no risk factors no imaging abnormality young age seizures unusual headache
what things should you not overlook during a history taking for a stroke
evolution of symptoms
maximum deficit
drugs: newly prescribed, oral contraceptives, recreational
what 3 factors should you attempt to discover on clinical assessment
localisation of lesion
likely vascular or non vascular aetiology
mechanism of vascular event
how can you breifly assess risk of reccurent stroke
recurrent events in the past
long duration of TIA
concomitant vascular risk factors
high risk of cardioembolism e.g. AF
what investigations can you do after a stroke
ECG (24hr), echo cholesterol, autoimmune and thrombophilia screen carotid doppler CT/MRI brain cerebral angiography
what are the indications for urgent head imaging
depressed level of consciousness
unexplained progressive or fluctuating symptoms
papilloedema
neck stiffness, fever
history of trauma
indication for thrombolysis or anticoagulant
history of anticoagluant or bleeding tendency
what is papilloedema
optic disc swelling caused by raised intracranial pressure
what does SDH stand for
subdural haematoma
what might you find on a head CT
bleed tumour SOL subdural haematoma early ischaemia
what is diffusion weighted imaging
mixture of T2 weighted and diffusion weighting
what is apparent diffusion coeficient
pure diffusion of water on MRI
describe how DWI/ADC changes after a stroke
initially high signal DWI, low ADC
1-2 weeks DWI stays high and ADC returns to normal
2 weeks DWI decreases and ADC becomes high
when are antihypertensives indicated after ischaemic stroke
when MABP is above 130 mmhg
What blood pressure should you aim for following haemorrhagic stroke
less than 140 mmHg
what drug should you give for persistantly elevated BP
IV labetolol
avoid abrupt falls in BP
how do you treat raised intercranial pressure
mechanical hyperventilation
mannitol
decompressive hemicraniectomy
what are the advantages of MRI over CT
sensitive
diagnostic
aids management
prognostic
how do you treat acute strokes
300mg/d in ischaemic stroke
thrombolysis if haemorrhagic stroke excluded
endovascular treatment/mechanical thrombectomy
surgery if hydrocephalus
anticoagulation in AF, once bleed is excluded
how is a SAH managed
•CT brain/ lumbar puncture if CT normal looking for bilirubin & xanthochromia. Cerebral angiogram •Management: -airway: intubate if severe hypoxaemia -fluid: 3L of 0.9% NaCl per 24 hrs -BP: keep MAP
what antithrombotics can be used in secondary prevention
Clopidogrel or Aspirin + Dipyridamole. In atrial fibrillation: Warfarin or NOAC (dabigatran, rixaroxaban, apixaban)
how do you manage blood pressure as part of secondary prevention
Target BP
how do you manage cholesterol post stroke
If total cholesterol > 4.0 mmol/l (or LDL-C > 2.5mmol/l [100 mg/dl], treat with statin e.g. Simvastatin (but caution in ICH or history of cerebral haemorrhage)
describe longer term management for stroke pts
- 6 mths after stroke, over 50% survivors need some help with their ADL; 15% communication impairment and 53% motor weakness
- Psychosocial and support needs reviewed on regular basis
- Potential issues: Communication, mobility, driving, depression, pressure sores, sepsis, nutrition, post-stroke seizure, shoulder pain, cognitive impairment & behavioural problem
what is the modified rankin scale
0- no symptoms
1- no significant disability despite symptoms
2- slight disability, but able to independantly live
3- moderate disability but able to walk unaided
4- moderately severe disability, unable to walk/ attend bodily functions without help
5- severe disability requiring constant nursing care and attention
6- dead
describe stroke outcomes
- Mortality: 2ndcommonest cause of death wordwide. 20-30% in the first month; ischaemic stroke mortality up to 40%, haemorrhagic stroke mortality up to 70%
- Disability in survivors: 1/3 near independent, 1/3 severely disabled and 1/3 independent with support. Commonestcause of adult disability
- High risk developing stroke after TIA: up to 20% within first month with highest risk within first 72 hrs
