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Cardiovascular 2018 > Stroke > Flashcards

Stroke Flashcards

1
Q

Define stroke

A

Acute onset of focal neurological symptoms and signs Due to disruption of blood supply

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2
Q

What are the two types of stroke?

A

Haemorrhagic

Ischaemic

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3
Q

Describe haemorrhagic stroke?

A

-raised blood pressure

-weakened blood vessel wall due to
>structural abnormalities like aneurysm, arteriovenous malformation (AVM)
>inflammation of vessel wall (vasculitis)

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4
Q

Describe ischaemic stroke?

A

> thrombotic- clot blocking artery at the site of the occlusion
embolic- clot blocking artery has travelled to artery it occludes from somewhere more proximally in the arteries of the heart
hypo-perfusion- due to reduced flow of blood due to stenosed artery rather than the occlusion of the artery

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5
Q

What are the non-modifiable risk factors of stroke?

A
  • age
  • family history of any vascular disease
  • gender (males)
  • race (south Asians are higher risk)
  • previous stroke
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6
Q

What are the potentially modifiable risk factors of stroke?

A
  • hypertension
  • hyperlipidaemia
  • smoking
  • prior history of TIA
  • AF
  • Diabetes
  • CHF
  • Alcohol excess
  • obesity
  • physical inactivity
  • poor sociaoeconomic status
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7
Q

What are some rarer causes of stroke?

A
  • homocysteinemia
  • vasculitis, antiphospholipid antibody syndrome
  • protein S, C, Antithrombin III deficiency
  • paradoxical embolism
  • Genetic
  • Cardioembolic
  • Cervical artery dissection
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8
Q

What is paradoxical embolism?

A

(venous clot to arterial side) through patent foramen ovale/pulmonary AV shunts (these are openings large enough between arterial and venous circulations)

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9
Q

Name some genetic factors?

A

Factor V Leiden mutation, common prothrombin mutation, MELAS, CADASIL, Fabry’s disease

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10
Q

What are some cardioembolic causes of stroke?

A

mural thrombi, infective endocarditis, myxoma

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11
Q

What are the behavioural adaptations for stroke prevention?

A

Diet
Exercise
Weight control
Smoking cessation

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12
Q

What is the window of opportunity after stroke?

A

up to 3-4 hours after symptoms started you could prevent the extent of the damage by opening up blocked artery

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13
Q

What is the treatment for stroke?

A

thrombolysis or thrombectomy

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14
Q

How do you prevent further stroke?

A

Discover origin, deal with it

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15
Q

What are some stroke mimics?

A

-hypoglycaemia
-seizure- postictal state
-migraine
-hyperglycaemia, hyponatremia
-space occupying lesions like brain tumours
>if they all of a sudden bleed into tumour
-functional hemiparesis

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16
Q

How do you determine which kind of stroke it is?

A

o brain scan

  • CT/MRI
  • angiogram
  • DWI: sequence of MRI scan which is useful to look for ischaemic stroke
  • SWI: sequence of MRI scan which is useful to look for old bleeds
17
Q

If the patient is having an ischaemic stroke what is the protocol?

A
  • find cause of embolism
  • blood tests: glucose, lipids, thrombophilia (in young patients)
  • assess for hypertension
  • any other sign of blood vessel disease? coronary artery disease? PVD? maybe stroke is directly embolic from heart
18
Q

What is atheroembolism?

A

embolism from a thrombus forming on a atherosclerotic plaque- platelet rich clots

19
Q

Where does an atheroembolism infarct?

A

same side as affected carotid artery

20
Q

What should be done if atheroembolism is suspected?

A

carotid scanning, CT/MR angiography of aortic arch

21
Q

What is a cardioembolism?

A

embolism from a clot formed in the heart (usually left atrium)

22
Q

What kind of clot is formed in cardioembolism?

A

clotting factor rich clots

23
Q

Where does cardioembolism infarct?

A

More than one arterial artery

24
Q

What investigations should be done if cardioembolism is suspected?

A

> ECG- ? AF? old ischaemic changes (mural thrombus)? LVH (suggests uncontrolled hypertension-commonest cause of AF)

> Echocardiogram (transthoracic, transoesophageal, bubble contrast study to look for interatrial connection)

> 24 hour- 5 day ECG monitor tests (Paroxysmal AF)

25
Q

What kind of patients have haemorrhagic strokes and where in the brain?

A

Hypertensive- usually deep in the brain, older patients

26
Q

If a haemorrhagic patient is young and not hypertensive and superficial haemorrhage what should be done?

A

investigate for underlying aneurysm, AVM

27
Q

What should be suspected if there are multiple haemorrhages?

A

vasculitis

Moya Moya disease

cerebral amyloid angiopathy

28
Q

What can be done to reverse disability in ischaemic stroke?

A

> Thrombolysis- upto 4.5 hrs from onset of symptoms
Thrombectomy- upto 6 hrs from symptom onset, usually after having started thrombolysis

Both are time dependent treatments as brain tissue dies rapidly with any delay

29
Q

What is the medical management of an atheroembolic or embolic stroke?

A

> Antiplatelets(Aspirin 75 mg + Dipyridamole MR 200 mg twice daily/Clopidogrel 75mg daily)

> Statins to treat high lipids

> Diabetes management

> Hypertension management

> Lifestyle advice

30
Q

What is the medical management of a stroke due to AF?

A

anticoagulate as soon as possible
>Warfarin (Vitamin K antagonist)

> Direct acting oral anticoagulants (act by inhibiting clotting factors directly like factor X and thrombin)

> Rivaroxaban, Dabigatran, Apixaban, Edoxaban

31
Q

What is more important in stroke than in CHD?

A

Control of hypertension

32
Q

What is the PROGRESS trial?

A

Perindopril + Indapamide reduced recurrence of stroke even when commenced on normotensive patients

33
Q

What is the surgical management of stroke?

A

> Haematoma evacuation

> Relief of raised intracranial pressure

> Obstructive hydrocephalus

> Large total MCA infarctions

> Carotid endarterectomy

> > 70% stenosis in same sided internal carotid artery(as affected side of brain)

34
Q

What is a TIA?

A

Temporary neurological symptoms due to occlusion of artery stopping flow of blood; temporary because arteries are capable of dissolving small clots

35
Q

Why is TIA an emergency?

A

because risk of stroke after TIA
>Up to 11-15% in first month
>24% to 29% in five years

36
Q

How long do symptoms of a TIA have to last to see changes on MRI?

A

Over 1hr

Cardiovascular 2018 (39 decks)

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