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Cardiology > Stroke > Flashcards

Stroke Flashcards

To learn about stroke

1
Q

How is Stroke defined?

A

Clinical syndrome of rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24h, or death with no apparent cause other than that of vascular origin.

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2
Q

What is a TIA?

A

A transient ischaemic attack (TIA) is defined as a stroke and symptoms that resolve within 24h

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3
Q

How does stroke come about?

A
  1. Cerebral infarction (84%)
  2. Secondary to thrombosis (54%)
  3. Embolus (31%)
  4. Primary intracerebral haemorrhage (10%)
  5. Subarachnoid hemorrhage (6%)
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4
Q

How is a non disabling stroke defined?

A

A stroke with symptoms that last for more than 24 hours, but later resolve leaving no permanent damage

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5
Q

What are the approaches to thinking about stroke?

A

Anatomically:
1. With respect to vascular territory
2. With respect to the cerebral structures affect
Pathologically

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6
Q

What are the modifiable risk factors for stroke?

A
  1. Hypertension
  2. Smoking
  3. AF
  4. DM
  5. Diet, XS alcohol
  6. Obesity, little exercise
  7. Raised cholesterol
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7
Q

What are the non modifiable risk factors for stroke?

A
  1. Increasing age
  2. Male gender
  3. Afro-caribbean descent
  4. Hx of stroke in family
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8
Q

What is the aetiology of thrombotic stroke, affecting major arteries?

A
  1. Atherosclerosis
  2. Dissecting aneurysm (especially in the young)
  3. Fibromuscular dysplasia
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9
Q

What is the aetiology of thrombotic stroke affecting the small vessels?

A
  1. Hypertension
  2. Arteriosclerosis
  3. DM
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10
Q

What hypercoagulable states contribute to thrombotic stroke?

A
  1. Congestive heart failure
  2. Polycythaemia
  3. Thrombocythaemia
  4. Malignancy: myeloma, leukaemia
  5. Sickle cell disease
  6. Pregnancy, oral contraceptive
  7. Anti phosholipid syndrome
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11
Q

What is the aetiology of an intercranial haemorrhage?

A

Rupture of Charcot-Bouchard aneurysms is the main cause.

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12
Q

What are other causes of Inter cerebral haemorrhage?

A
  1. Arterial rupture maybe spontaneous
  2. 50% of ICH no history of high BP
  3. Drugs: amphetamine, cocaine
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13
Q

What further causes if ICH?

A
  1. Amyloid angiopathy: third of cases in elderly
  2. Vascular malformations:
  3. Bleeding diastheses: thrombocytopaenia, leukaemia, haemophilia,
  4. Anticoagulant therapy
  5. Head injury
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14
Q

What is the aetiology of a subarachnoid heamorrhage?

A
  1. 80% due to Berry aneurysm
  2. 10-15% due to other aneurysms:
    (i) arteriosclerotic
    (ii) inflammatory
    (iii) traumatic
  3. 5% due to arteriovenous malformations
  4. Bleeding diastheses, tumours
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15
Q

What are the clinical features of a stroke?

A
  1. Sudden onset hemiparesis in person > 60

2. Focal brain may reflect distribution of affected artery

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16
Q

What are the clinical features of a cerebral hemisphere infarct?

A
  1. Contra lateral hemiplegia: limb first becomes flaccid then spasticity
  2. Homonymous hemianopia
  3. Sensory loss
  4. Dysphagia
  5. Upper motor neurone signs
17
Q

Describe an anterior cerebral artery stroke?

A
  1. Occlusion of the anterior cerebral artery by embolus or thrombus.
  2. Effects may depend on site of occlusion
18
Q

What is the anatomy of the anterior cerebral artery?

A
  1. The anterior cerebral artery. is a branch of the internal carotid
  2. Deep branches passes to the internal capsule and basal nuclei
  3. Cortical branches supply the medial surface of the orbital, frontal and parietal lobes
19
Q

What are the clinical features of the anterior communicating artery when the occlusion is proximal?

A

Occlusion proximal to the anterior communicating artery is often well tolerated due to collateral flow

20
Q

What are the clinical features when there is a proximal occlusion when both arteries arise from the same anterior cerebral stem?

A
  1. Paraplegia, usually of both limbs
  2. Sensory loss
  3. Incontinence
  4. Mental symptoms
  5. Grasp, snout and pout reflexes
21
Q

What are the clinical features of an anterior communicating artery infarct when the occlusion is distal?

A
  1. Contralateral hemiplegia/hemisensory loss of lower limbs with upper limbs spared
  2. Occasionally a contralateral grasp reflex
22
Q

Describe a middle artery stroke?

A
  1. The middle cerebral artery maybe occluded by thrombus or embolus
  2. TIA in MCA produce a transient hemiparesis in association with dysphasia
23
Q

What is the anatomy of the middle cerebral artery?

A
  1. The MCA is the largest branch of the internal carotid artery.
  2. Gives off branches to anterior limb of internal capsule and basal nuclei.
  3. Gives branches to temporal, frontal and parietal structures.
  4. A rough approximation of the distribution may be obtained by placing a hand over the side of one’s own head, with fingers spread and pointing forwards
24
Q

What are the clinical features of an occluded middle cerebral artery?

A
  1. Contra lateral hemiplegia: face tongue, upper limb affected leg spared (ish)
  2. Contralateral hemisensory loss/hemianopia
  3. Neuropsychological fx:
    (i) Neglect of Contralateral limbs and dressing
    ability
    (ii) Global dysphasia and Gerstmann’s synd
25
Q

What is Gerstmann’s Syndrome?

A
  1. Finger agnosia
  2. Acalculia
  3. Agraphia
  4. Left/right limb disorientation
26
Q

Describe a posterior cerebral artery stroke?

A

Occlusion of the posterior cerebral artery results :

  1. Visual disturbances
  2. Stoke usually caused by thrombus or embolus
  3. Transient global amnesia may result from a TIA in this area
27
Q

What is Lacunae syndrome?

A
  1. Lacunes are small fluid filled cavities: found in basal ganglia, thalamus, internal capsule, pond and cerebral and cerebellar white matter.
  2. Result of infarction secondary to the occlusion of the small penetrating branches of the major intracracnial arteries.
28
Q

What the clinical features of lacunar syndrome?

A
  1. Patient likely conscious
  2. Infarct causes motor/sensory/ mixed deficit
  3. Sudden onset unilateral cerebellar ataxia
  4. Sudden dyarthria with clumsy hand caused by single lacunar infarcts
29
Q

What is a brainstem infarction?

A
  1. Site of 25% of strokes.

2. Causes complex patterns of destruction depending on site.

30
Q

What are the clinical features of a brainstem infarction?

A
  1. Diplopia occulomotor system
  2. Facial numbness (vth cranial nerve)
  3. Facial weakness (LMN) VIIth cranial
  4. Dysphagia, dysarthria (IXth/X cranial)
  5. Hemiparesis/tetraparesis
  6. Sensory loss medial lemniscus
  7. Nystagmus, vertigo vestibular connections
  8. Dysarthria, ataxia, brain stem and cerebellar vomiting
  9. Horner’s syndrome
  10. Altered consciousness
31
Q

What does NICE say about investigations for stroke?

A

Brain imaging should be done immediately if following apply:

  1. Indications for thrombolysis/anticoag
  2. Known bleeding tendency
  3. Glasgow coma scale of <13
  4. Papiloedema, neck stifness, fever
  5. Severe headache at onset of symptoms
32
Q

What are the differential diagnoses for stroke?

A
  1. Meningitis
  2. Encephalitis (herpes simplex)
  3. Cerebral abscess
  4. Cerebral tumour
  5. Head injury
  6. Acute hypoglycaemia
  7. Chronic subdural hematoma
  8. Extradural hematoma
  9. Hypertensive encephalopathy
  10. MS
  11. Cerebral malaria
  12. Cerebral lupus
33
Q

What is the management of stroke?

A

Patients with a history of stroke or TIA > risk of suffering further stroke.

34
Q

Once intracracnial haemorrhage has been excluded what are the principles of stroke prevention?

A
  1. Antiplatelet therapy: aspirin within 24 hrs

2. Aspirin for 2 weeks then anti platelet therapy commenced

35
Q

Once patients have a stroke then how should they be treated?

A
  1. 1st line: Clopidogrel (long-term)
  2. 2nd line: Mod Rel dipyridamol plus aspirin if Clopidogrel Contra - Ind
  3. 3rd line: long term treatment with MR dipyridamol alone if 1st and 2nd line treatments not tolerated
36
Q

How should patients be treated after TIA?

A
  1. 1st line: MR dipyridamole plus aspirin
  2. MR dipyridamole alone not indicated if first line treatment is not tolerated.
  3. Clopidogrel not indicated for TIA

Cardiology (23 decks)

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