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Nervous System > Stroke > Flashcards

Stroke Flashcards

1
Q

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?

A

blood pressure reduction + consider neurosurgical referral

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2
Q

what is a stroke

A

AKA a cerebrovascular accident

sudden interruption in blood supply to the brain

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3
Q

what are the two main types of strokes

A

ischaemic (85%)
-strokes >24hrs
-TIAs <24hrs
haemorrhagic (15%)

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4
Q

what is the main problem with ischaemic stroke

A

‘blockage’ in blood vessels stops blood flow to brain

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5
Q

what is the main problem with haemorrhagic stroke

A

blood vessel ‘bursts’ leading to reduction in blood flow

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6
Q

what are the subtypes of ischaemic strokes

A 
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
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7
Q

what are the subtypes of haemorrhagic strokes

A

1 intracerebral haemorrhage
-bleeding in brain
2 subarachnoid haemorrhage
-bleeding on surface of brain

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8
Q

risk factors of ischaemic stroke

A 
risk factors of CVS disease
-age
-male
-HTN
-smoking
-hyperlipidaemia
-DM
risk factors of cardioembolism
-AF
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9
Q

risk factors of haemorrhagic stroke

A
  • age
  • HTN
  • arteriovenous malformation
  • anticoagulation therapy
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10
Q

definition of stroke

A

clinical syndrome consisting of rapidly developing signs of focal disturbance of cerebral function lasting >24hrs

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11
Q

what would quariplegia indicate

A

brainstem infarction

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12
Q

what are lacunar infarcts

A

small infarcts around the basal ganglia, internal capsule, thalamus + pons

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13
Q

what do lacunar infarcts result in

A

pure motor
pure sensory
mixed motor+sensory
ataxia

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14
Q

def of ataxia

A

loss of full control of bodily movements

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15
Q

what classification system is used for strokes

A

Bamford/Oxford Stroke Classification

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16
Q

what criteria is assessed in the oxford stroke classification

A

1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg
2 homonymous hemianopia
3 high cognitive dysfunction (e.g. dysphasia)

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17
Q

using the oxford stroke classification what are the different stroke types

A

1 TACI
2 PACI
3 Lacunar infarcts
4 POCI

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18
Q

which arteries does a TACI involve

A

middle and anterior cerebral arteries

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19
Q

what features are present in a TACI

A

1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg
2 homonymous hemianopia
3 high cognitive dysfunction (e.g. dysphasia)

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20
Q

what arteries does a PACI involve

A

smaller arteries off middle and anterior cerebral arteries

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21
Q

what features are present in a PACI

A

any 2 of:
1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg
2 homonymous hemianopia
3 high cognitive dysfunction (e.g. dysphasia)

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22
Q

what arteries does a lacunar infarct involve

A

perforating arteries around internal capsule, thalamus, basal ganglia

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23
Q

what features are present in a lacunar infarct

A

any 1 of:
1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg OR all three
2 pure sensory stroke
3. ataxic hemiparesis

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24
Q

what arteries does a POCI involve

A

vertebrobasilar arteries

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25
Q

what features are present in a POCI

A

any 1 of:
1 cerebellar or brainstem syndromes
2 LOC
3 isolated homonymous hemianopia

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26
Q

what features are more suggestive of haemorrhagic stroke than ischaemic stroke

A

1 decreased consciousness
2 headache (much more common in haemorrhagic)
3 N+V
4 seizures

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27
Q

what is the first line management for stroke

A

CT/MRI to determine if ischaemic or haemorrhagic

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28
Q

what are the criteria for ischaemic stroke patients to be thrombolysed

A

1 patients present within 4.5hrs of onset of stroke symptoms

2 patient has not had previous intracranial haemorrhage, uncontrolled HTN, pregnant

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29
Q

what is the management for ischaemic stroke patients

A

aspirin 300mg + antiplatelets

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30
Q

what is the treatment of TIAs based on

A

ABCD2 prognostic score

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31
Q

what is the ABCD2 prognostic score

A

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)
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32
Q

what would a ABCD2 score >4 indicate

A

increased risk of stroke

aspirin (300mg/daily)

33
Q

what is the general management for haemorrhagic stroke

A

supportive (reduce BP)

anticoagulants (warfarin) + antiplatelets (clopidogrel) stopped

34
Q

decrease in GCS, headache and N+V are often seen in what sort of stroke

A

haemorrhagic stroke

35
Q

a patient who presents with ataxia and is found to have widespread cerebellar signs is most likely to have what sort of infarct

A

posterior circulation infarct

36
Q

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

A

thrombolysis

37
Q

what is the site of the lesion with:
contralateral hemiparesis + sensory loss
lower extremity>upper

A

anterior cerebral artery

38
Q

what is the site of the lesion with:
contralateral hemiparesis + sensory loss
upper extremity>lower

A

middle cerebral artery

39
Q

what is the site of the lesion with:
contralateral homonymous hemianopia with macular sparing
visual agnosia

A

posterior cerebral artery

40
Q

what is visual agnosia

A

a person can see but not recognise or interpret visual information

41
Q

disorder in which lobes causes visual agnosia

A

parietal lobes

42
Q

nystagmus is associated with which nerve

A

VIII

43
Q

what is a stroke

A

ischaemic infarction or bleeding (haemorrhage) into the brain

44
Q

what are the causes of stroke

A 
infarction (80%)
-vessel occlusion due to thrombosis or emboli
-hypotension
haemorrhage
-HTN
-charcot-bouchard aneurysm rupture
-anticoagulation
45
Q

what are causes of stroke in younger patients

A

sudden BP drop (e.g. sepsis)

carotid artery dissection (spontaneous or trauma)

46
Q

what is the definition of stroke

A

rapid onset neurological deficit by cerebrovascular insult causing focal or global impairment of the CNS function lasting >24h

47
Q

what can cause thrombosis

A

in the elderly, atherosclerosis is the common cause

48
Q

what can cause emboli

A

atheromatous plaques from carotids

emboli from heart in AF

49
Q

risk factors

A

HTN
smoking + alcohol
DM
AF

50
Q

epi

A

common

elderly

51
Q

history

A

sudden onset (seconds)
weakness/paralysis, reduced/loss of sensation in the limbs
visual disturbances

52
Q

what pointers suggest haemorrhagic stroke

A

this is unreliable, however:

  • meningism
  • headache
  • coma
53
Q

what pointers suggest ischaemic stroke

A

carotid bruit
AF
past TIA
IHD

54
Q

what are the different locations of ischaemic strokes

A

cerebral (most common)
brainstem
lacunar

55
Q

what is characteristic of cerebral infarct

A

contralateral (opposite side) sensory loss and paralysis
initially flacid paralysis which later becomes spastic
dysphasia (cannot generate speech)
homonymous hemianopia

56
Q

what is characteristic of brainstem infarcts

A

quadriplegia (paralysis of all four limbs)

locked in syndrome

57
Q

what is characteristic of lacunar infarcts

A

in basal ganglia, internal capsule, thalamus, pons

1 ataxic hemiparesis
2 pure motor
3 pure sensory
4 sensorimotor
5 dysarthria/clumsy
58
Q

in which area does a lacunar infarct cause cognitive deficit or reduced consciousness

A

thalamus

all other areas have no effect on consciousness or cognition

59
Q

how can cerebral infarcts be subdivided

A 
by vessel
1 anterior circulation
2 posterior circulation
3 single lacunar infarct
4 multiple lacunar infacts
60
Q

what areas do the anterior circulation supply and what distinguishes these areas on examination

A 
anterior cerebreal
-lower limb weakness (motor cortex)
-confusion (frontal lobe)
middle cerebral
-facial weakness
-dysphasia
61
Q

what examination findings would you expect with a lacunar infarct to the internal capsule or pons, thalamus, basal ganglia

A 
internal capsule or pons
-pure sensory, pure motor or sensorimotor deficit
thalamus
-LOC
basal ganglia
-parkinsonism
62
Q

what arteries can be affected in a posterior circulation infarct

A

posterior cerebral
anterior/posterior inferior cerebellar artery
basilar artery

63
Q

feature of posterior cerebral infarct

A

hemianopia

64
Q

features of anterior + posterior inferior cerebellar artery infarct

A 
vertigo
ipsilateral ataxia (loss of control of body movements)
65
Q

what distinguishes anterior and posterior inferior cerebellar artery infarcts

A

anterior - ipsilateral deafness + facial weakness

posterior - ipsilateral horner’s syndrome + facial sensory loss

66
Q

features of multiple lacunar infarcts

A

vascular dementia
urinary incontinence
shuffling small-stepped gait

67
Q

what are features of an (intracerebral) haemorrhage

A

headache meningism
N+V
seizures

68
Q

investigations

A 
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
69
Q

what is the management for a hyperacute stroke

A

if hyperacute (<4.5h) and a haemorrhagic stroke has been excluded - thrombolyse

70
Q

what is used to thrombolyse a patient

A

IV recombinant tissue plasminogen activator

alteplase

71
Q

what is the management for an ischaemic acute stroke

A

> 4.5hrs
haemorrhage has been excluded on CT head

antiplatelet therapy
-aspirin + clopidogrel

72
Q

what is the management for an intracerebral haemorrhage

A

control HTN + seizures

IV mannitol + hyperventilation can reduce intracranial pressure

73
Q

what is the primary prevention for stroke (before any stroke)

A

control HTN, hyperlipidaemia, DM, cardiac disease
exercise
smoking cessation
lifelong anticoagulation in AF or if rheumatic or prosthetic heart valves on left hand side

74
Q

what is the secondary prevention for stroke (after stroke)

A

control risk factors
aspirin/clopidogrel
start warfarin 2wks post stroke (with antiplatelet therapy inbetween) if AF

75
Q

what surgical management can be given with stroke or TIA

A

carotid endartectomy (unblocking of carotid artery) reduces risk of further cerebrovascular events

76
Q

what prothrombotic conditions can increase risk of an ischaemic infarction (stroke)

A

thrombophilia

77
Q

what bleeding disorder can increase risk of haemorrhagic stroke

A

thrombocytopenia

78
Q

complications

A

cerebral oedema causing increased ICP and compression

immobility with paralysis

79
Q

prognosis

A

haemorrhagic stroke has poorer prognosis than ischaemic

less than half make a full recovery

Nervous System (27 decks)

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