Stroke Flashcards
Possible presentations of stroke
Weakness
Speech disturbance
Visual deficit
Visio-spatial dysfunction
Ataxia
Headache
Coma
what weakness is presented in stroke
sudden (over minutes) unilateral weakness with rapid progression in a hemiplegic (paralysis) manner
what other symptoms are present if weakness is present
reflexes are reduced initially, then tone and reflexes are increased
also, facial weakness is often present
what speech manifestation are present in stroke
Dysphasia - indicates dominant frontal or parietal lobe damage
Dysarthria - caused by weakness, or in-coordination of face and pharyngeal muscles
what visual changes could occur in a stroke patient
Monocular blindess - caused by reduced blood flow in the internal carotid or ophthalmic arteries
If transient (amaurosis fugax)
contralateral hemianopia - caused by ischaemic damage occiptal cortex, optic tracts
visuo-spatial dysfunction could occur when there is damage to?
Non-dominant cortex
what symptoms are associated with visuo-spatial dysfunction
contralateral sensory or visual neglect and apraxia (difficulty performing tasks, “movements when asked”)
What is apraxia mistaken for usually
confusion
If stroke causes damage to the cerebellum and its connection this could cause
ataxia
sometimes +- diplopia, and vertigo
Sometimes stroke presents as headaches
sudden severe headache is a cardinal symptom of SAH
it can also occur in intracerebral haemorrhage or cerebral venous disease
what is an unusual symptom in stroke
seizures, but may occur in cerebral venous disease
coma is also uncommon, mostly associated brainstem event
what is a focal neurological deficit?
it is problems involving the nerves, brainstem, or brain
it affects specific parts (left sided, tongue)
speech vision and hearing
How is stroke usually classified
according to affected vascular territory
stroke can be classified by time of deficit
If >24hrs –> stroke
if <24hrs –> TIA
if focal deficit worsens after first presentation it is classified as a “progressing stroke (stroke in evolution)”
if focal deficit is still present but not progressing then it is classified as a “completed stroke”
what are the aims of stroke investigation
confirm vascular nature of lesion
distinguish infarction from haemorrhage
Hemorrhagic vs ischaemic infarct
hemorrhagic infarct there is leakage from the blood vessels affected and shows a “red” brain if looked at grossly
ischaemic infarct is occlusion of the blood vessel without leakage causing no supply to that region in the brain then which causes a pale appearance when looking grossly
Investigation to be undertaken in stroke
CT and MRI in all patients LP (SAH) Duplex USS carotids ECG, Echo --> underlying cause? magnetic resonance angiography (MRA) CT angiography FBC, cholestrol, glucose --> risk factors ESR, clotting, thrombophilia screen --> rule out
most common causes of cardiac embolisom?
AF
prosthetic heart valves
valvular abnormalities
recent MI
Management Aims
minimise volume of brain with irreversible damage
prevent complications
reduce disability with rehabilitation
management
early IV thromobolysis maximise benefits, use recombinant tissue plasminoge activatior (alteplase –> rt-PA). if later maybe fatal
aspirin (300mg) daily should be started immediately unless (rt-PA) is used, withhold for 24hrs
Heparins are useless and not good in acute stroke
warfarin when cario source
risk factors of stroke
HTN, smoking, DM --> same as ACS heart disease (valvular, ischaemic, AF) hypercholestrolaemia alcohol PVD Hx of TIA the pill increased clotting
stroke causes
small vessel occlusion –> thrombosis
cardiac emboli
atherothromboembolism from carotids
CNS bleeds
primary prevention of stroke
this is before a stroke happens
contorl risk factors
encourage exercise
secondary prevention of stroke
this is after first event
clopidogrel monotherapy is suggested to be beneficial (more than aspirin)
Signs of TIA
AF
murmur from valvular disease
carotid bruits - if no bruits does not rule out carotid stenosis (tight stenosis no bruit)
HTN
fundoscopy may show emboli from retinal artery
risk factors of haemorrhagic stroke
Age HTN Arteriovenous malformation Anticoagulation Substance/drug abuse
risk factors of ischaemic stroke
Age HTN DM Hypercholestraemia smoking alcohol major risk factor - AF
Stroke in pathology can be either
Cerebral infarct - 85% of strokes
Intracerebral haemorrhage - 10%
What is the commonest cause of cerebral infarct
thromboembolus from atherosclerotic patches in carotids or aortic arch
How to manage a Px with haemorrhagic stroke unilateral weakness and reduced GCS?
Blood pressure reduction and consider neuro referal
Which arteries are affected in a total anterior circulation infarct
Middle and anterior cerebral arteries
What is ABCD2 criteria
The ABCD2 score:
A — age: 60 years of age or more, 1 point.
B — blood pressure at presentation: 140/90 mm Hg or greater, 1 point.
C — clinical features: unilateral weakness, 2 points; speech disturbance without weakness, 1 point.
D — duration of symptoms: 60 minutes or longer, 2 points; 10–59 minutes, 1 point.
D — presence of diabetes: 1 point.
When is ABCD2 used
If TIA is suspected
What is dysarthria
slow or slurred speech
What is dysphasia
Dysphasia can be receptive or expressive. Receptive dysphasia is difficulty in comprehension, whilst expressive dysphasia is difficulty in putting words together to make meaning.
