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Neurology > Stroke > Flashcards

Stroke Flashcards

1
Q

Epidemiology

A
  1. increases with age
  2. 40% dependent at 6/12
  3. Causes: Cerebral infarction 80%, Intracerebral haemorrhages 15%, SAH 5%
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2
Q
  1. Atheroma risk f

2. Haemorrhagic risk f.

A
  1. Age, Hypert, diabetes, Smoking, Fhx, Cholesterol, Alcohol. *AF risk f for cardioembolism.
  2. age, hypert., AV malformation, anticoag.
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3
Q

Thrombotic strokes:

  1. Abn in vessel wall
  2. Abn tendency of blood to thrombose
  3. Stasis of blood flow
A
  1. Atheroma. Rarely: inflam arterial disease ie temporal arteritis, SLE, Rh. arthritis
  2. Polycythaemia, Thrombocythaemia, sickle cell disease, coagulation disorders(def. in protein C & S, antiphospholipid syndrome)
  3. Severe atheroma, arterial dissection.
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4
Q

Intracerebral haemorrhage

A
  • usually due to hypert
  • microaneurysms
  • occasionally ruptured saccular aneurysm
  • AV malformations
  • Drugs ie anticoagulants & thrombolytics
  • basal ganglia(50%), lobar white matter(20%), pons(10%), cerebellum(10%)
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5
Q

Other types of stroke:

A
  1. Hypotensive/watershed strokes:
    - cardiac arrest
  2. Intracranial venous thrombosis:
    - surgery, infection, inflammation, tumour
    - may present w raised ICP
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6
Q

CLINICAL FEATURES
(according to Oxford Stroke Classification/Bamford Classification)

  1. Total anterior circulation stroke
    - complete MCA infarct, internal carotid disease, massive ICB haemorrhage
    - cardiac embolism
  2. Partial anterior circulation stroke
    - infarct of MCA branch
    - cardiac embolism
  3. Posterior circulation stroke.
    - basilar/vertebral/post cerebral arteries
    - cardiac embolism/thrombosis in situ
  4. Lacunar syndrome
    - small branches of ant and post circulation vessels
    - thrombosis in situ
A
  1. Hemiparesis, homonymous hemianopia, complete aphasia(dominant), self-neglect(non-dominant), hemisensory loss, transient dysarthria/incontinence/impaired swallowing.
  2. Isolated motor loss/higher cerebral dysfunction/mixture of both
    a) inferior: hemianopia, Wernicke’s aphasia(dominant). Constructional apraxia(non-dominant)
    b) superior: hemiparesis, Broca’s aphasia(dominant). neglect(non-dominant)
  3. Cortical blindness; homonymous hemianopia; cerebellar signs; nystagmus, dysarthria, diplopia, ‘locked in state’, crossed cranial nerves and long tract sensory/motor deficit(brain stem lesions)
    • Pure motor hemiparesis(internal capsule)
      - ataxic hemiparesis(post. internal capsule/midbrain/pons)
      - dysarthria/clumsy hand syndrome
      - pure sensory stroke(thalamus)
      - sensorimotor stroke
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7
Q

Other Sx and Signs:

  1. Headaches
  2. Horner’s syndrome
  3. Raised BP
  4. Angina/intermittent claudication/ diabetic or hypertensive retionopathy or peripheral neuropathy
A
  1. a) in ischaemic stroke: 10% preceding the stroke, 20% at stroke onset.
    b) in intracerebral haemorrhage: 50% at onset, more severe.
  2. additional clue when assoc with ipsilat. anterior circ. event
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8
Q

DDx:

A
  1. Space-ocuppying lesions(more insidious onset):
    - tumour
    - bleeding
    - abcess(more rapid progression, presents as septic)

2, Chronic subdural haematoma
- slower onset, focal deficits, raised ICP.

  1. MS esp in younger pts.
  2. Head injury
  3. Hypoglycaemia
    - can have focal deficits
  4. Todd’s paralysis post seizure
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9
Q

INVESTIGATIONS

  1. Is it stroke? type of stroke?
  2. Cause of stroke?
A
  1. a) CT
    - early CT normal => likely ischaemic

b) MRI(DWI)
- distinguish old from new infarcts.

2.

a) Risk f for atheroma
- *BP
- Blood tests: *glucose, *cholesterol, *TFT, LFT(alcohol)

b) Sources of embolism
- *ECG
- echo
- blood cultures
- 24h tape
- carotid Doppler
- angiography/MR angiography

c) Thrombotic tendencies
- Blood tests: *FBC, thrombophilia screen(includes lupus anticoagulant), sickle cell screen

d) Inflam. vascular disease
- Blood tests: *ESR, ANA, anticardiolipin
- syphilis serology
- temporal artery biopsy

*U&E’s to monitor fluid balance

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10
Q 
MANAGEMENT:
1. General medical support
2. Minimise stroke risk
3. Prevent complications
4. Optimize recovery
5, Prev stroke recurrence
A
  1. -resuscitation
    - monitor glucose, hydration, sats, temperature.
    - NBM, nasogastric tube, assess swallowing
    - keep slightly underhydrated
    - monitor BP, antihypertensive if diastolic >120/hypert. encephalopathy
    - tx hypoxia, hypo/hyperglycemia
  2. -After excl. haemorrhagic stroke. Aspirin 300 mg(PO/PR)(reduces 30d mortality) with antiplatelet
    - Thrombolysis w IV alteplase within 4.5h of onset. CT to exclude haemorrhage/significant cerebral dmg.

Absolute CI: Prev intracranial haemorrhage, Seizure at onset, intracranial neoplasm, suspected SAH, stroke/TBI in preceding 3/12, LP/aterial puncture in prev 7d, GI haemorrhage in preceding 3/53, active bleeding, pregnancy, oesophageal varices, uncontrolled hypert(>200/120)

Relative CI: Conccurent anticoag(INR.1.7), haemorrhagic diathesis, active diabetic haemorrhagic retinopathy, suspected intracardiac thrombus, major surg/trauma in preceding 2/52.

  • statin if cholesterol >3.5 mmol/L, usually delay tx until 48h.
  1. a) Decompressive hemicraniectomy
    - to prev fatal brain herniation w raised ICP after large anterior circ infarct.

b) Posterior fossa decompression
- control ICP to prev brain stem compression & hydrocephalus in large cerebellar strokes

c) drain intracranial haematoma

d) Active nursing care
- 2-hourly turns to prev bed sores
- feeding w NG tube/percutaneous gastrostomy(if long term)
- positiong & physio to prev pneumonia
- graded pressure stocking for DVT prophylaxis
- laxatives/suppositories/enemas for bowel control
- psychological and social support after stroke
- May req Seizure prophylaxis(5% pts hv seizure within 1y)
- pain modulating drugs ie amitriptyline&carbamazepine => thalamic pain.

  • avoid LMWH and urinary catheterization
    4. MDT involvement
  • Anticoagulants after haemorrhage excl and after 14d from onset of ischaemic stroke.
    5. Measures for secondary prevention as soon as Dx. confirmed.
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11
Q

Prognosis:

A
  • Intracranial haemorrhage: 50% mortality, 50% survivors dependent at 6/12.
  • Total anterior circulation: about 50% mortality, 90% dependent at 6/12.
  • Partial ant./lacurnar/post: 10-15% mortality, 20-40% survivors dependent at 6/12.
  • IHD most common cause of death
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12
Q

Definition

A

WHO: rapidly developing clinical signs of focal disturbance of cerebral fn., lasting>24h or leading to death w no apparent cause other than that of vascular origin.

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13
Q

Ischaemic vs Haemorrhagic

  1. Proportion
  2. Subtypes
A
  1. 85% vs 15%
  2. Thrombotic/embolic vs intracerebral/subarachnoid

*hamorrhagic strokes more likely to have decreased consciousness(up to 50%), headache, N+V, seizures(up to 25%)

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14
Q

Oxford Stroke Classification/Bamford Classificaiton:

Criteria:

  1. Unilateral hemiparesis and/or hemisensory loss of face/arms/leg
  2. Homonymous hemianopia
  3. Higher cognitive dysfunction eg dysphasia
  4. TACI(15%)
  5. PACI
  6. LACI(25%)
  7. POCI(25%)
A
  1. All 3 criteria
  2. 2 criteria
  3. 1 of:
    - unilat. weakness(and/or sensory deficit) of face and arm, arm and leg or all three
    - pure sensory stroke
    - ataxic hemiparesis
  4. 1 of:
    - cerebellar/brainstem syndromes
    - LOC
    - isolated homonymous heminaopia
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15
Q

Mx. of haemorrhagic stroke

A

Reverse anticoagulation, stop antithrombotic meds, supportive tx. May reduce BP.

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16
Q

FAST

-PPV 78%

A

F -face uneven
A -Unable to lift arm
S -Speech difficulty
T -time to call 911

17
Q

ROSIER score
-exclude hypoglycaemia first

Stroke likely if score>0

A
  • LOC/syncope(-1 pt)
  • Seizure(-1 pt)

New, acute onset of:

  • asymmetrical facial weakness(+1 pt)
  • asymmetrical arm weakness(+1 pt)
  • asymmetrical leg weakness(+1 pt)
  • speech disturbance(+1 pt)
  • visual field defect(+1 pt)

Neurology (14 decks)

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