Stroke Flashcards
What are the 4 constitutional presentations of a posterior circulation stroke?
Why do we see these symptoms
Ataxia and the 4 D’s:
- Dysphagia
- Dysarthria
- Dizziness
- Diploplia
We see these symptoms as it is the posterior circulation that is affected hence the visions and speech issues and also there is brainstem involvement hence gait issues.
Posterior circulation arises from vertebral arteries.
What are the 4 constitutional presentations of an anterior circulation stroke?
What vessels would be occluded to cause this?
ANAH;
Apraxia - loss of information as to how to conduct actions despite preserved motor neurone
Neglect
Aphasia - eg broca/wernicke
Hemiparesis
Carotid artery! (internal?)
What is apraxia?
Which part of the body is usually the most common apraxia presentation?
Apraxia is a motor disorder caused by damage to the brain (specifically the posterior parietal cortex) in which the individual has difficulty with the MOTOR PLANNING to perform tasks or movements when asked.
Speech apraxia is most commonly seen, its not that the muscles are weak but rather that there is a failure of signals coming from that part of the brain.
Which part of the brain is usually affected by lesions resulting in apraxia?
Usually the dominant hemisphere ; in most people (right handed) that is the left lobe.
It can sometimes be on the right
Which other speech issue must speech apraxia not be confused with?
Broca’s aphasia!
This is when comprehension is okay but there is difficulty producing speech.
What is the differnece between apraxia and aphasia?
Aphasia is all to do with speech and language where apraxia is about motor planning so can affect anywhere
What is most important ivx to do when patient has stroke?
CT Head;
because NEED to exclude a haemmorhage. Once done, start THROMBOLYSIS straight away.
——-
CT head, + CTA first
Then MRI + MRA - if diagnostic uncertsininty or unable to visualise on ct
Management of ischaemic stroke with No contraindications to thrombolysis?
Thrombolysis;
- Alteplase IV
1a. Aspirin 300mg PO, 24hrs after 1.
1b. Swallowing assessment
1c. Can be assessed to see if can retrieve clot with stent
1d. Heparin SC
Management of ischaemic stroke with contraindications to thrombolysis?
Aspirin, 300mg PO 1Xpd
Can add Heparin SC
Management of haemorrhagic stroke?
admit to icu, intubate etc
surgery may be required - craniotomy - to remove haematoma
blood pressure control - Labetalol IV
antipyretic measures - paracetamol PO
HTN is associated more strongly with which stroke?
Haemorrhagic
Presenting symptoms of ischaemic stroke?
risk factors?
vision loss - post circulation
weakness
aphasia - dominant hemisphere stroke
ataxia - imparied coordination
etc
FAST; face - droop arms - weak, hanging speech - difficulty time
risk factors; Hx AF Sickle cell Hypercoagulable states - F5 Leiden, protein c/s deficiency carotid artery stenosis
Presenting symptoms of haemorrhagic stroke?
risk factors?
Nick stiffness Hemianopia or Diplopia Photophobia Weakness Aphasia Ataxia
risk factors; Hx AF Hx Haematological disorder Anticoagulation therapy Haemophilia, bleeeding disroders HH Telangiectasis
Presenting symptoms of haemorrhagic stroke?
risk factors?
Nick stiffness Hemianopia or Diplopia Photophobia Weakness Aphasia Ataxia
risk factors; Hx AF Hx Haematological disorder Anticoagulation therapy Haemophilia, bleeeding disroders HH Telangiectasis
which artery indicated in lateral medulla syndrome?
signs and symptoms?
PICA
Posterior Inferior Cerebellar Artery
mainly sensory losses + eye sx
vertigo,
ipsilateral ataxia,
ipsilateral Horner’s syndrome, (+nystagmus, diplopia)
ipsilateral hemisensory loss; face
dysarthria,
contralateral spinothalamic sensory loss; pain + temp
considering the motor homunculus and the cerebral artery territories, what deficits would you see on disruption of the anterior cerebral circulation?
Lower limb weakness
Confusion
What deficits would you see on disruption of the Middle cerebral circulation?
Facial weakness
Hemiparesis (motor cortex)
Hemisensory loss (sensory cortex)
Apraxia
Hemineglect (parietal lobe)
Receptive or expressive dysphasia (due to involvement of Wernicke’s and Broca’s areas)
Quadrantopia (if superior or inferior optic radiations are affected)
What mechanism caused carotid dissections to result in stroke?
The area of dissection means the endothelium is not smooth as intimal layer is affected.
This activated the intrinsic coagulation pathway (FXII) leading to formation of clots.
What are the differentials for stroke in younger adults?
Cocaine
Aortic Dissection - most common
Trauma - can result in emboli? Or dissection
SLE Syphillis Antiphospholipid syndrome Fabrys disease Sickle cell
What screening test must you include in stroke work up in younger patients?
Lupus markers, ANA, clotting screen, haemoglobinopathirs, fabrys disease, HIV, Syphilis , homocysteine, APLS,
what meds do we use in the secondary prevention on diagnosis of ischaemic stroke or TIA without paroxysmal or permanent atrial fibrillation ?
- Clopidogrel 75mg
2nd line - Dipyridamole 200mg BD
3rd line - Aspirin
what meds do we use in the secondary prevention of stroke in the presence of atrial fibrillation ?
DOAC - Apixaban, Dabigatran, Rivaroxaban
If the chads2vasc score is 2+ - must know how to calculate by heart
unless if they have a metallic heart valve - need aspirin
how would a posterior circulation stroke present?
– Diplopia – Dysarthria; affects muscles of speech - weak or paralysed – Dizziness – Dysphagia; issues swallowing – Crossed findings
gaze palsy
cerebellar signs
cause of Lateral medullary syndrome?
Commonest brainstem stroke syndrome
what is a lacunar infarct?
type of ischaemic stroke <1.5mm
Affects branches of MCA going to below areas
affects; bassal ganglia, internal capsule
cause; HTN most likely
presentation of lacunar infarct? (a type of MCA stroke)
symptoms are either purely sensory or purely motor
sensory; contraleteral loss
motor; contralateral weakness, ataxia, dysarthria
2022- when would a carotid endarterectomy be considered?
when carotid artery stenosis is >50%
what is a hemiplegic gait?
pyramidal distribution extensors affected in legs, flexors affected in arm;
walk with lelg swinging out the side, arms and wrists flexed
Post stroke ivx?
Carotid USS for stenosis
ECG
24hr ECG - hooter
Echo - for PDA
Hx for risk factors.
