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INTERNAL MED 3+ conditions > Stroke > Flashcards

Stroke Flashcards

1
Q

Define stroke

A

Acute neurological condition in which arterial blood supply to brain tissue is impaired due to a focal vascular cause - >24 hours

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2
Q

What % of strokes are classified ischaemic strokes?

A

85%

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3
Q

Define ischaemic stroke

A

Cerebral infarction due to insufficient cerebral blood flow (hypoperfusion) - leads to ischaemia and neuronal injury

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4
Q

What % of strokes are classified haemorrhagic strokes?

A

15%

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5
Q

3 subtypes of haemorrhagic strokes

A
  • Intracerebral (parenchyma)
  • Intraventricular (ventricles) - can be primary or secondary
  • subarachnoid (subarachnoid space)
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6
Q

What % of strokes are subarachnoid haemorrhages

A

5%

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7
Q

Stroke epidemiology

A
  • 3-5th leading cause of death, and the leading cause of morbidity
  • M > F
  • 2/3 patients 65 years or older
  • Overall incidence of stroke mortality and morbidity has decreased over the past few decades
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8
Q

5 broad causes of ischaemic stroke

A
  • Cardioembolic (25%)
  • Lacunar infarction (small vessel disease) (15%)
  • Intracranial atherosclerosis (10%)
  • Extracranial atherosclerosis (10%)
  • Other (40%)
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9
Q

Describe large artery atherosclerosis

A
  • Usually secondary to hypertension

- Includes carotid artery stenosis

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10
Q

Describe cardioembolism

A
  • Causes include AF, myocardial infarction, infection and atheroemboli
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11
Q

Describe small vessel occlusion

A
  • Includes lipohyalindric thickening of small vessels

- Hypertension and diabetes are the main causes

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12
Q

What is a Watersed stroke?

A

Systemic hypoperfusion causing stroke

  • Border-zone infarct
  • Increased HR, decreased BP, palor, diaphoresis
  • Bilateral symptoms - visual loss, proximal limb weakness
  • Diffuse neurological deterioration
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13
Q

What is the strongest single predisposing factor for both ischaemic and haemorrhagic stroke

A

Arterial hypertension

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14
Q

Stroke risk factors

A
  • Increased age
  • Male
  • African-American/Native American/Hispanics
  • Family history (CVD or cerebrovascular disease)
  • Arterial hypertension
  • Atherosclerosis
  • Hypercholestrolaemia
  • DM
  • Obesity
  • Stress
  • Alcohol
  • Tobacco
  • Illicit drugs
  • CVD
  • OCP/hormones
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15
Q

Main risk factors for intracerebral haemorrhage

A
  • Hypertension
  • Cerebral amyloid angiopathy
  • Ruptured AV malformation
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16
Q

Risk factors for subarachnoid haemorrhage

A
  • Ruptured aneurysm (circle of Willis) (80% berry)
  • Ruptured AV malformation
  • Traumatic brain injury
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17
Q

Clinical features of stroke

A

*** Symptoms depend on location of stroke

  • Sudden onset
  • Impaired consciousness
  • Nausea and vomiting
  • Headache
  • Seizures
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18
Q

Which type of stroke has more distinct/unique clinical features

A

Subarachnoid haemorrhage

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19
Q

Unique clinical features of subarachnoid stroke

A
  • Sudden severe headache
  • Worsening nausea and vomiting
  • Cardiovascular deterioration
  • Unconscious/coma
  • Neck stiffness
  • Pupils not reactive to light
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20
Q

Clinical features - affected MIDDLE CEREBRAL ARTERY

A
  • Contralateral sensory loss
  • Paralysis - arms, lower face, legs
  • Gaze - towards infarct side
  • Aphasia
21
Q

Clinical features - affected ANTERIOR CEREBRAL ARTERY

A
  • Contralateral paralysis - Lower > Upper
  • Minimal sensory loss
  • Dysarthria
  • Dyphasia
  • Urinary incontinence
  • Abulia (lack motivation)
22
Q

Clinical features - affected POSTERIOR CEREBRAL ARTERY

A
  • Visual field defects
  • Contralateral hemisensory loss
  • Memory deficits
  • Vertigo
  • Nausea
23
Q

Clinical features - affected COMMON CAROTID

A
  • Horner’s syndrome
24
Q

Define lacunar stroke

A
  • Ischaemic stroke
  • Blood flow to one of the small arteries deep within the brain becomes blocked
  • 1/5 all strokes
  • Found in deep cerebral white matter, basal ganglia or pons
25
Q

Initial evaluation of possible stroke

A
  • Risk factors
  • Signs of an affected vessel/area
  • Onset of symptoms
  • Rule out other causes of neurological deficits and AF (using ECG)
  • FBC, coags, electrolytes, troponin
26
Q

Imaging for suspected stroke

A
  • Non-contrast CT (gold-standard) (can see acute haemorrhage)
  • MRI (identifies earlier than CT)
27
Q

Occluded vessels on CT - appearance

A
  • Hyperdense
  • Parenchyme hypodense
  • Loss of corticomedullary differentiation
28
Q

CT - 12-24 hours post ischaemic stroke

A
  • Hypodense
29
Q

CT - many days post-ischaemic stroke

A
  • Hyperdense
30
Q

Neurovascular studies for stroke

A

CTA/MRA - CT/MRI angiogram

- Find exact location of defect

31
Q

Lumbar puncture and stroke

A
    • Definitive diagnosis for subarachnoid haemorrhage
  • Do if CT is inconclusive
  • Yellow or red discolouration
  • Increased or no change in opening pressure
  • Normal glucose
  • Increased RBC/WCC/protein
32
Q

Pan necrosis

A
  • Death of all cells

- Complete or permanent ischaemia

33
Q

Selective neuronal necrosis

A
  • Hypoxia induced selective destruction of individual nerve cells
  • Ischaemia with subsequent reperfusion
34
Q

DDx for ischaemic stroke

A
  • Seizure
  • Metabolic disorders - eg. hyponatraemia, hypoglycaemia
  • Migraine aura
  • Systemic infection
  • Brain infection
  • Brain tumour
  • Psychiatric conversion disorder
  • Peripheral vestibulopathy
  • Traumatic intracranial injury
35
Q

Initial supportive management for stroke

A
  • Resus - fluid replacement, sufficient oxygen, maintain BGL, analgesia
  • Control elevated intracranial pressure/cerebral oedema
  • Monitor for signs of brain herniation (elevate head 30 degrees and IV mannitol)
  • Maintain sufficient cerebral perfusion (anti-HTN and cardiac monitoring)
36
Q

TREATMENT

  • Ischaemic stroke
  • No cerebral venous sinus thrombolysis
  • <4.5 hours, no thrombolysis contraindications
A 
1. Alteplase (r-tPA)
\+ Aspiring 24 hours later
\+ Endovascular intervention
\+ Supportive care and swallowing assessment
\+ VTE prophylaxis and early mobilisation
37
Q

TREATMENT

  • Ischaemic stroke
  • No cerebral venous sinus thrombolysis
  • > 4.5 hours, thrombolysis contraindcated
A
  1. Aspirin
    + Supportive care and swallowing assessment
    + VTE prophylaxis and early mobilisation
38
Q

TREATMENT

  • Ischaemic stroke
  • Central venous sinus thrombosis
A
  1. Anticoagulation (eg. Warfarin, Heparin)

+ Supportive care and swallowing assessment

39
Q

TREATMENT

- Haemorrhagic

A
  1. Neurosurgical and neurocritical care evaluation
    + Admission to ICU or stroke unit
    + Airway protection (endotracheal intubation)
    + Aspiration precautions

*** Often need intubation and invasive monitoring of BP

40
Q

Predicted haemorrhagic stroke and pyrexic

A
  • Paracetamol

- Cooling blankets

41
Q

If on pre-existing warfarin with predicted haemorrhagic stroke

A
  • Cease warfarin
  • Phytomenadione
  • Fresh frozen plasma OR prothrombin complex concentrate
  • Platelet transfusion
42
Q

If on pre-existing heparin with predicted haemorrhagic stroke

A
  • Cease heparin
  • Protamine sulfate
  • Platelet transfusion
43
Q

If on pre-existing dabigatran with predicted haemorrhagic stroke

A
  • Cease dabigatran

- Idarucizumab

44
Q

Predictor lobar haemorrhage stroke treatment

A
  • Anticonvulsants - Phenytoin

- Seizures complicate acute intracranial haemorrhage management

45
Q

Prognosis ischaemic stroke

A
  • Leading cause of serious LT disability
  • Prognostic scores - ASTRAL and iScore
  • 1990-2010 - decreased mortality by 14-37%
  • Better outcomes with tPA
46
Q

Complications with ischaemic stroke

A
  • DVT
  • Seizure
  • Haemorrhagic transformation
  • Oedema (due to tPA)
  • Brain oedema and increased intracranial pressure
  • Depression
  • Aspiration pneumonia
47
Q

Prognosis haemorrhagic stroke

A
  • Mortality 35-40% (much higher than ischaemic)
  • > 70% severe morbidity
  • Haemorrhagic volume is the strongest predictor of outcome
  • Worse outcomes - increased age, increased consciousness on presentation, ruptured haematoma into ventricular system
  • Intracerebral haemorrhage score - 3-month functional outcomes
48
Q

Complications with haemorrhagic stroke

A
  • DVT
  • Infection
  • Seizures
  • Delirium
  • Hydrocephalis

INTERNAL MED 3+ conditions (18 decks)

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