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MS3 - Neurology > Stroke > Flashcards

Stroke Flashcards

1
Q

Definition of stroke?

A

Rapid onset, focal neurological deficit due to a vascular lesion lasting >24h

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2
Q

Pathogenesis of stroke

A
  • Infarction due ischaemia (80%)

- intracerebral haemorrhage (20%).

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3
Q

Causes of ischaemic strokes?

A

I. Atheroma
- Large (e.g. MCA)
- Small vessel perforators (lacunar)
II. Embolism
- Cardiac (30% of strokes):AF, endocarditis, MI
- Atherothromboembolism: e.g. from carotids

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4
Q

Causes of haemorrhagic stroke?

A
  • ↑BP
  • Trauma
  • Aneurysm rupture
  • Anticoagulation
  • Thrombolysis
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5
Q

Watershed stroke

A

sudden ↓ in BP (e.g. in sepsis)

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6
Q

Risk factors for stroke?

A
  1. IHD RFs: ↑BP, Smoking, DM, ↑ lipids
  2. Cardiac: AF, valve disease
  3. Peripheral vascular disease
  4. ↑ PCV/Hct
  5. OCP
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7
Q

Which ethnicity is more prone to strokes?

A

↑ in Blacks and Asians

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8
Q

Overview of Oxford (/Bamford) classification of stroke?

A
  • Based on clinical localisation of infarct
  • S=syndrome: prior to imaging
  • I=infarct: after imaging when atheroembolic infarct
    confirmed
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9
Q

4 oxford classifications of stroke?

A

TACS- Total Anterior Circulation Stroke
PACS- Partial Anterior Circulation Stroke
POCS- Posterior Circulation Stroke
LACS- Lacunar Stroke

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10
Q

TACS stroke: mortality?

A

Highest mortality (60% @ 1yr) + poor independence

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11
Q

Site of TACS stroke?

A

Large infarct in carotid / MCA, ACA territory

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12
Q

Signs of TACS stroke?

A

All 3 of:

  1. Hemiparesis (contralateral) and/or sensory deficit (≥2 of face, arm and leg)
  2. Homonymous hemianopia (contralateral)
  3. Higher cortical dysfunction
    - Dominant (L usually): dysphasia
    - Non-dominant: hemispatial neglect
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13
Q

PACS stroke site?

A

Carotid / MCA and ACA territory

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14
Q

PACS stroke signs?

A

2/3 of TACS criteria, usually:

  1. Hemiparesis (contralateral) and/or sensory deficit (≥2 of face, arm and leg)
  2. Higher cortical dysfunction
    - Dominant: dysphasia
    - Non-dom: neglect, constructional apraxia
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15
Q

constructional apraxia

A

an inability or difficulty to build, assemble, or draw objects.

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16
Q

Site of POCS stroke?

A

Infarct in vertebrobasilar territory

17
Q

Signs of POCS stroke?

A

Any of

  1. Cerebellar syndrome (DANISH P)
  2. Brainstem syndrome
  3. Contralateral homonymous hemianopia
18
Q

Site of LACS stroke?

A
  • basal ganglia
  • internal capsule
  • thalamus
  • pons
19
Q

Absence of which signs makes the diagnosis LACS stroke more likely?

A

Absence of

  • Higher cortical dysfunction
  • Homonymous hemianopia
  • Drowsiness
  • Brainstem signs
20
Q

Potential syndromes of LACS?

A
  1. Pure motor: posterior limb of internal capsule (Commonest)
  2. Pure sensory: posterior thalamus (VPL)
  3. Mixed sensorimotor: internal capsule
  4. Dysarthria (slurred speech) / clumsy hand
  5. Ataxic hemiparesis: ant. limb of internal capsule
    - Weakness + dysmetria
21
Q

Dysmetria

A
  • a lack of coordination of movement

- eg dysdiadochokinesis

22
Q

Signs of brainstem infarct?

A

Complex signs depending on relationship of infarct to CN nuclei, long tracts and brainstem connections
eg
- facial weakness with CN7 infarct
- Nystagmus and vertigo with CN8, - Horner’s syndrome with sympathetic fibres infarct

23
Q

Site of lateral medullary syndrome ( Wallenberg Syndrome)

A

PICA or vertebral artery territory

24
Q

Features of lateral medullary syndrome ( Wallenberg Syndrome)

A

DANVAH

  • Dysphagia
  • Ataxia (ipsilateral)
  • Nystagmus (ipsilateral)
  • Vertigo
  • Anaesthesia (Ipsilateral facial numbness, Contralateral pain loss)
  • Horner’s syndrome (ipsilateral)
25
Q

Locked-in Syndrome features?

A

Pt. is aware and cognitively intact but completely paralysed except for the eye muscles.

26
Q

Locked-in Syndrome causes?

A
  • Ventral pons infarction: basilar artery
  • Central potine myelinolysis: rapid correction of
    hyponatraemia
27
Q

Overview of Acute management of stroke?

A
  1. Resus (NBM)
  2. Monitor
  3. Imaging
  4. Medical
  5. Surgery
28
Q

Monitoring of acute stroke?

A
  1. Glucose: 4-11mM: sliding scale if DM
  2. BP: <185/110 for thrombolysis
    (Rx of HTN can → ↓ cerebral perfusion)
29
Q

Imaging of acute stroke?

A

Urgent CT/MRI
I. Diffusion-weighted MRI is most sensitive for acute infarct
II. CT will exclude primary haemorrhage

30
Q

Medical management of acute stroke?

A

I. Thrombolysis
II. Aspirin 300mg PO/PR once haemorrhagic stroke excluded ± PPI
(If CI, give Clopidogrel instead)

31
Q

Thrombolysis for stroke?

A
  • Consider if 18-80yrs and <4.5hrs since onset of symptoms
  • Alteplase (rh-tPA)
  • → ↓ death and dependency
  • CT 24h post-thrombolysis to look for haemorrhage
32
Q

Surgical management for stroke?

A
  • May coil bleeding aneurysms

- Decompressive hemicraniectomy for some forms of MCA infarction.

33
Q

Primary prevention of stroke (before)?

A
  • Control RFs: (HTN, ↑ lipids, DM, smoking, cardiac disease)
  • Consider life-long anticoagulation in AF (use CHADS2) - Carotid endarterectomy if symptomatic with 70% stenosis
  • Exercise
34
Q

Secondary prevention of stroke (after)?

A

I. Start a statin after 48h
II. Aspirin / clopi 300mg for 2wks after stroke then either
a. Clopidogrel 75mg OD (preferred option)
b. Aspirin 75mg OD + dipyridamole MR 200mg BD
III. Warfarin instead of aspirin/clopi if Cardioembolic stroke or chronic AF
b. Start from 2wks post-stroke (INR 2-3)
IV. Carotid endarterectomy if good recovery + ipsilat stenosis ≥70%

35
Q

Rehabilitation for stroke?

A

MENDS
I. MDT: SALT (Speech and Lang Therapist) , dietician, OT, PT
II. Eating
a. Screen swallowing: refer to specialist
b. Screen for malnutrition
III. Neurorehab: physio and speech therapy
IV. DVT Prophylaxis
V. Sores: must be avoided @ all costs

36
Q

PACS stroke mortality?

A
  • 20% mortality at 1 year

- 33% independent at 1 yr

MS3 - Neurology (9 decks)

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