Stroke Flashcards
List the BP goals for the management of stroke.
- Haemorrhagic stroke: 140-180mmHg
- Ischaemic stroke that meets lysis criteria: <180/105
- Ischaemic stroke that does NOT meet lysis criteria: no mgt unless 220/120
What is the medication and dose for stroke lysis?
Alteplase 0.9mg/kg (max 90mg)
- 10% of total dose as a bolus over 1min
- 90% as infusion over 60mins
List 6 causes of ICH.
- Hypertensive hemorrhagic strokes ->Often basal ganglia, thalamus, pons, cerebellum
- Haemorrhagic conversion of ischaemic stroke
- SAH/aneurysms/AVM
- Bleeding diathesis - anticoagulants, thrombolytics, thrombocytopenia, DIC, haemophilia
- Trauma - SDH, EDH, parenchymal bleed
- Cerebral venous thrombosis
List ten types of ischaemic stroke.
- Arterial thromboembolism
- Carotid or vertebral artery atheroma
- Intracranial atheroma
- Small vessel disease - lacunar infarcts
- Cardioembolism
- AF
- Aortic/mitral valve disease
- Mural thrombus
- Atrial myxoma
- Vascular disorders
- Arterial dissection
- Gas embolism - CAGE
- Arteritis
- Vasospasm
- Post-SAH
- Pre-eclampsia
What % of embolic CVAs originate in the heart?
20%
What % of CVAs are ischaemic?
80-85%
What are the indications for thrombolysis.
- Age 18-80yrs
- Significant ischaemic stroke - NIHSS >=3
- Time from symptom onset <4.5hrs
Which triala\s validated the use of alteplase for ischaemic stroke? What were the findings, limitations/exclusions?
SITS-MOST was an observational study that showed improved outcomes with the use of alteplase.
Observational study.
It excluded the following patients:
- >80yrs
- Severe strokes NIHSS > 25
- HTN >185/110
- Time of onset >3hrs
NINDS
- 12% additional patients had positive neuro outcome at 3/12 over placebo
- 6% additional symptomatic ICH (half were fatal) but no mortality difference at 3/12
- Majority showed no difference (80%)
Why is hypertension considered a contraindication to thrombolysis in stroke patients?
Hypertension correlates with risk of haemorrhagic transformation.
List 12 stroke mimics.
- Seizures/post-ictal paralysis (Todd’s)
- Complex migraine
- SAH
- EDH/SDH
- Hypoglycaemia
- Hypertensive encephalopathy
- Labrynthitis
- Drug toxicity (Li, carbamazepine, phenytoin) -> ataxia, vertigo, abnormal reflexes
- Bell’s palsy - peripheral 7th CN palsy
- Meniere’s - vertigo + tinnitus + hearing loss
- Demyelinating disease
- Conversion disorder
- Syncope
- Meningitis/encephalitis
- Brain abscess/neoplasm
- Hyponatraemia
- Hypertensive encephalopathy
- Hyperosmotic coma - elevated BSL, known DM
19.
How is stroke severity measured?
The National Institute of Health Stroke Score (NIHSS)
List the common findings in Anterior Cerebral Artery stroke.
Rare (<3%):
- Contralateral motor and sensory deficit in LL
- Hands and face spared
- Mutism and/or aphasia
- Confusion and/or neglect
- Incontinence
List the common findings in Middle Cerebral Artery stroke.
Most common.
Symptoms dependent on hemisphere dominance. (R)-handed and ~80% (L)-handed patients -> (L) hemisphere is dominant.
- Contralateral hemiparesis
- Contralateral facial droop
- Contralateral sensory loss
- Face and UL > LL
- Homonymous hemianopia
- Skewed gaze to side of lesion
If dominant hemisphere affected:
- Aphasia - expressive, receptive or both
If non-dominant hemisphere affected:
- Neglect
- Inattention
- Dysarthria w/out aphasia
- Apraxia
List the common findings in a Posterior Cerebral Artery stroke.
- Vertigo
- Ataxia
- Nystagmus
- ALOC
- Minimal motor symptoms but may be present
- Visual field loss
List the common findings in a Basilar Artery stroke.
Rare -> poor prognosis and high mortality
- Unilateral limb weakness
- Dizzyness
- Dysarthria
- CN VII signs
- N+V
- Locked in syndrome
List the common findings in a Cerebellar stroke.
- Non-specific symptoms
- Dizzyness +/- vertigo
- N+V
- Gait instability
- Headache
- CN abnormalities
Require MRI to image
May require decompression
Can rapidly deteriorate due to small space -> herniation
List the common findings in a VertebroBasilar stroke.
- Dizzyness/vertigo
- N+V
- Headache
- Unilateral limb weakness
- Unilateral CN V symptoms
- Nystagmus
- Gait ataxia
- Horner’s syndrome (miosis, ptosi and anhidrosis)
LIst 4 RFs for carotid or vertebral artery dissection.
- Recent neck trauma (possibly weeks previously)
- Hx of migraine
- Connective tissue disease
- HTN
- Large vessel diseases
What are the features of carotid dissection?
What is the differential dx?
- Headache - frontoparietal - may be “thunderclap” or gradual onset
- Partial Horner’s syndrome (miosis, ptosis, anhydrosis)
- CN palsies
- Can progress to cerebral ischaemia or retinal infaction
Can be confused with:
- migraine
- SAH
- Temporal arteritis
What are the features of vertebral artery dissection?
- History of recent trauma or neck manipulation
- Occipital headache and/or neck pain
- Vertigo/dizzyness
- N+V
- Ataxia
- Diplopia
- Facial paraesthesia
- Limb wekaness
- Hearing loss
- Dysarthria
Outline the ED mgt of stroke patients irrespective of their elligibility for lysis.
- Maintain normoxia
- Maintain normoglycaemia
- Maintain normothermia
- Correct dehydration
- BP mgt:
- If for tPA -> BP < 185/110
- If not for tPA -> BP < 220/120
- Aim for 15% decrease
- Labetalol 10-20mg IV over 1-2mins, can repeat x1 then infusion 2-8mg/min
- Anti-platelet therapy only if patient not elligible for tPA
