Stroke Flashcards
A 65-year-old man presents 1 hour after developing right-sided weakness and a reduced GCS. Neuroimaging shows an intracerebral haemorrhage.
What is the best treatment?
blood pressure reduction + consider neurosurgical referral
what is a stroke
AKA a cerebrovascular accident
sudden interruption in blood supply to the brain
what are the two main types of strokes
ischaemic (85%)
-strokes >24hrs
-TIAs <24hrs
haemorrhagic (15%)
what is the main problem with ischaemic stroke
‘blockage’ in blood vessels stops blood flow to brain
what is the main problem with haemorrhagic stroke
blood vessel ‘bursts’ leading to reduction in blood flow
what are the subtypes of ischaemic strokes
1 thrombotic strokes -thrombosis of large vessels (carotids) 2 embolic strokes -blood clot, air embolus -AF causes emboli to form in the heart which can move to the brain and cause blockage to blood supply
what are the subtypes of haemorrhagic strokes
1 intracerebral haemorrhage
-bleeding in brain
2 subarachnoid haemorrhage
-bleeding on surface of brain
risk factors of ischaemic stroke
risk factors of CVS disease -age -male -HTN -smoking -hyperlipidaemia -DM risk factors of cardioembolism -AF
risk factors of haemorrhagic stroke
- age
- HTN
- arteriovenous malformation
- anticoagulation therapy
definition of stroke
clinical syndrome consisting of rapidly developing signs of focal disturbance of cerebral function lasting >24hrs
what would quariplegia indicate
brainstem infarction
what are lacunar infarcts
small infarcts around the basal ganglia, internal capsule, thalamus + pons
what do lacunar infarcts result in
pure motor
pure sensory
mixed motor+sensory
ataxia
def of ataxia
loss of full control of bodily movements
what classification system is used for strokes
Bamford/Oxford Stroke Classification
what criteria is assessed in the oxford stroke classification
1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg
2 homonymous hemianopia
3 high cognitive dysfunction (e.g. dysphasia)
using the oxford stroke classification what are the different stroke types
1 TACI
2 PACI
3 Lacunar infarcts
4 POCI
which arteries does a TACI involve
middle and anterior cerebral arteries
what features are present in a TACI
1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg
2 homonymous hemianopia
3 high cognitive dysfunction (e.g. dysphasia)
what arteries does a PACI involve
smaller arteries off middle and anterior cerebral arteries
what features are present in a PACI
any 2 of:
1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg
2 homonymous hemianopia
3 high cognitive dysfunction (e.g. dysphasia)
what arteries does a lacunar infarct involve
perforating arteries around internal capsule, thalamus, basal ganglia
what features are present in a lacunar infarct
any 1 of:
1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg OR all three
2 pure sensory stroke
3. ataxic hemiparesis
what arteries does a POCI involve
vertebrobasilar arteries
what features are present in a POCI
any 1 of:
1 cerebellar or brainstem syndromes
2 LOC
3 isolated homonymous hemianopia
what features are more suggestive of haemorrhagic stroke than ischaemic stroke
1 decreased consciousness
2 headache (much more common in haemorrhagic)
3 N+V
4 seizures
what is the first line management for stroke
CT/MRI to determine if ischaemic or haemorrhagic
what are the criteria for ischaemic stroke patients to be thrombolysed
1 patients present within 4.5hrs of onset of stroke symptoms
2 patient has not had previous intracranial haemorrhage, uncontrolled HTN, pregnant
what is the management for ischaemic stroke patients
aspirin 300mg + antiplatelets
what is the treatment of TIAs based on
ABCD2 prognostic score
what is the ABCD2 prognostic score
determines risk of future CVA
Age >60yrs (1) BP >140/90 (1) Clinical features -unilateral weakness (2) -speech disturbance with no weakness (1) Duration of symptoms ->60mins (2) -10-59mins (1) Diabetes (1)
what would a ABCD2 score >4 indicate
increased risk of stroke
aspirin (300mg/daily)
what is the general management for haemorrhagic stroke
supportive (reduce BP)
anticoagulants (warfarin) + antiplatelets (clopidogrel) stopped
decrease in GCS, headache and N+V are often seen in what sort of stroke
haemorrhagic stroke
a patient who presents with ataxia and is found to have widespread cerebellar signs is most likely to have what sort of infarct
posterior circulation infarct
what is the best treatment for a 60y/o male who presents 2hrs after developing right arm weakness and loss of consciousness. neuroimaging excludes a haemorrhage
thrombolysis
what is the site of the lesion with:
contralateral hemiparesis + sensory loss
lower extremity>upper
anterior cerebral artery
what is the site of the lesion with:
contralateral hemiparesis + sensory loss
upper extremity>lower
middle cerebral artery
what is the site of the lesion with:
contralateral homonymous hemianopia with macular sparing
visual agnosia
posterior cerebral artery
what is visual agnosia
a person can see but not recognise or interpret visual information
disorder in which lobes causes visual agnosia
parietal lobes
nystagmus is associated with which nerve
VIII
what is a stroke
ischaemic infarction or bleeding (haemorrhage) into the brain
what are the causes of stroke
infarction (80%) -vessel occlusion due to thrombosis or emboli -hypotension haemorrhage -HTN -charcot-bouchard aneurysm rupture -anticoagulation
what are causes of stroke in younger patients
sudden BP drop (e.g. sepsis)
carotid artery dissection (spontaneous or trauma)
what is the definition of stroke
rapid onset neurological deficit by cerebrovascular insult causing focal or global impairment of the CNS function lasting >24h
what can cause thrombosis
in the elderly, atherosclerosis is the common cause
what can cause emboli
atheromatous plaques from carotids
emboli from heart in AF
risk factors
HTN
smoking + alcohol
DM
AF
epi
common
elderly
history
sudden onset (seconds)
weakness/paralysis, reduced/loss of sensation in the limbs
visual disturbances
what pointers suggest haemorrhagic stroke
this is unreliable, however:
- meningism
- headache
- coma
what pointers suggest ischaemic stroke
carotid bruit
AF
past TIA
IHD
what are the different locations of ischaemic strokes
cerebral (most common)
brainstem
lacunar
what is characteristic of cerebral infarct
contralateral (opposite side) sensory loss and paralysis
initially flacid paralysis which later becomes spastic
dysphasia (cannot generate speech)
homonymous hemianopia
what is characteristic of brainstem infarcts
quadriplegia (paralysis of all four limbs)
locked in syndrome
what is characteristic of lacunar infarcts
in basal ganglia, internal capsule, thalamus, pons
1 ataxic hemiparesis 2 pure motor 3 pure sensory 4 sensorimotor 5 dysarthria/clumsy
in which area does a lacunar infarct cause cognitive deficit or reduced consciousness
thalamus
all other areas have no effect on consciousness or cognition
how can cerebral infarcts be subdivided
by vessel 1 anterior circulation 2 posterior circulation 3 single lacunar infarct 4 multiple lacunar infacts
what areas do the anterior circulation supply and what distinguishes these areas on examination
anterior cerebreal -lower limb weakness (motor cortex) -confusion (frontal lobe) middle cerebral -facial weakness -dysphasia
what examination findings would you expect with a lacunar infarct to the internal capsule or pons, thalamus, basal ganglia
internal capsule or pons -pure sensory, pure motor or sensorimotor deficit thalamus -LOC basal ganglia -parkinsonism
what arteries can be affected in a posterior circulation infarct
posterior cerebral
anterior/posterior inferior cerebellar artery
basilar artery
feature of posterior cerebral infarct
hemianopia
features of anterior + posterior inferior cerebellar artery infarct
vertigo ipsilateral ataxia (loss of control of body movements)
what distinguishes anterior and posterior inferior cerebellar artery infarcts
anterior - ipsilateral deafness + facial weakness
posterior - ipsilateral horner’s syndrome + facial sensory loss
features of multiple lacunar infarcts
vascular dementia
urinary incontinence
shuffling small-stepped gait
what are features of an (intracerebral) haemorrhage
headache meningism
N+V
seizures
investigations
1 ABC 2 pulse, BP, ECG -AF embolus aortic dissection 3 bloods -DEFG 4 urgent CT head or MRI -CT head identifies or excludes haemorrhage -MRI used to differentiate between old and new strokes
what is the management for a hyperacute stroke
if hyperacute (<4.5h) and a haemorrhagic stroke has been excluded - thrombolyse
what is used to thrombolyse a patient
IV recombinant tissue plasminogen activator
alteplase
what is the management for an ischaemic acute stroke
> 4.5hrs
haemorrhage has been excluded on CT head
antiplatelet therapy
-aspirin + clopidogrel
what is the management for an intracerebral haemorrhage
control HTN + seizures
IV mannitol + hyperventilation can reduce intracranial pressure
what is the primary prevention for stroke (before any stroke)
control HTN, hyperlipidaemia, DM, cardiac disease
exercise
smoking cessation
lifelong anticoagulation in AF or if rheumatic or prosthetic heart valves on left hand side
what is the secondary prevention for stroke (after stroke)
control risk factors
aspirin/clopidogrel
start warfarin 2wks post stroke (with antiplatelet therapy inbetween) if AF
what surgical management can be given with stroke or TIA
carotid endartectomy (unblocking of carotid artery) reduces risk of further cerebrovascular events
what prothrombotic conditions can increase risk of an ischaemic infarction (stroke)
thrombophilia
what bleeding disorder can increase risk of haemorrhagic stroke
thrombocytopenia
complications
cerebral oedema causing increased ICP and compression
immobility with paralysis
prognosis
haemorrhagic stroke has poorer prognosis than ischaemic
less than half make a full recovery
