Stroke Flashcards
What is the key feature of a stroke?
SUDDEN ONSET of neurological symptoms as a result of HAEMORRHAGE or ISCHAEMIA both leading to infarct also know as brain attack/CVA
What is a ‘stroke mimic’?
Symptoms or conditions that look like strokes such as fits, syncope, brain tumour, dementia and drug/alcohol abuse
___ of strokes are ‘stroke mimics’.
25%
Do strokes present with headaches?
Some do e.g. intracerebral haemorrhage whereas others might not e.g. ischaemic stroke
What are the risk factors for stroke?
BP Previous stroke/TIA MI, IHD AF Smoking (alcohol, lifestyle) DM FH PVD Hypercholesterolaemia
What can cause cerebral ischaemia due to perfusion failure?
Severe stenosis of the carotid and basilar artery (big arteries) OR microstenosis of the small deep arteries (cause of lacunar infarctions)
What is border zone/watershed infarction?
Where the effects of perfusion failure fall on the most distal territories before the most proximal territories
What can cause embolism to the brain form cardiac or aortic origin?
AF Recent AMI Subacute bacterial endocarditis Valvular disorders (native e.g. valve infection or artificial) Cardiac tumours
What can cause a intracerebral haemorrhage?
Raised BP (most commonly) Warfarin use Head injury/trauma Ruptured cerebral aneurysm AVM Cocaine/methamphetamine use Bleeding tumours Bleeding disorders (e.g. haemophilia)
What is the biggest cause of intracerebral haemorrhage in young adults?
Cocaine or methamphetamine use which causes severe hypertension and then haemorrhage
What are the 3 types of stroke?
- Cerebral ischaemia due to perfusion failure
- Embolism to the brain of cardiac or aortic origin
- Intracerebral haemorrhage
If a patient with a stroke has expressive aphasia, what area of the brain is this likely to be affected?
Language area in inferior frontal area
If a patient with a stroke has dysarthria, what area of the brain is this likely to be affected?
Cerebellum
How can you determine the localisation of a stroke?
Symptoms/signs and associated this with the brain area and vessels supplying this area
What type of symptoms do brainstem strokes tend to produce?
Slurred speech, balance problems, sensory symptoms on one side, contralateral motor symptoms and nystagmus in eyes for example i.e. complex brain syndrome
How are strokes classified based on the Oxford/Bamford stroke classification?
Based on vasculature:-
- TACs
- PACs
- LACs
- POCs
What are total anterior circulation strokes/infarcts(TACS/TACI)?
Larger cortical stroke in middle/anterior cerebral artery areas causing:
- Unilateral weakness +/ sensory changes (face, arm + leg)
- Homonymous hemianopia
- Higher cortical dysfunction e.g. speech + visuospatial problems
If the frontal lobe is involved in a stroke what type of symptoms may be seen?
Cognitive problems e.g. attention, reasoning and problem solving problems - most difficult to life with afterwards for them and family
What are partial anterior cortical strokes/infarcts (PACS/PACI)?
Smaller cortical stroke in middle/anterior cerebral artery areas causing 2/3 symptoms:
- Unilateral weakness +/- sensory changes (face, arm + leg)
- Homonymous hemianopia
- Higher cortical dysfunction e.g. speech + visuospatial problems
What are lacunar syndrome strokes/infarcts (LACS/LACI)?
Small vessel disruption with no evidence of larger scale cerebral dysfunction with one of the following symptoms:
- Unilateral weakness +/- sensory deficit (face + arm/arm + leg)
- Pure sensory or pure motor
- Ataxic hemiparesis
What are posterior circulation strokes/infarcts (POCS/POCI)?
Posterior circulation stroke affecting brainstem/cerebellar arteries with one of the following symptoms:
- Bilateral motor/sensory deficit
- Cerebellar/brainstem signs
- Isolated homonymous hemianopia
- CN palsy + contralateral motor/sensory deficit
What type of cerebral artery infarcts are rare?
ACA infarcts - MCA and PCA infarcts are more commonly seen
What are lacunar infarcts?
Small lesions with lake-like cavities giving focal deficits difficult to see on a CT scan that occlude smaller vessels like lenticulostriate, thalamogeniculate or brainstem perforating vessels so they are common in deep cerebral white matter (e.g. putamen nucleus of BG) and brainstem regions
What type of symptoms would a lesion of the internal capsule produce?
Purely motor symptoms as this is the region that motor tracts pass through
What causes a watershed infarct?
Systemic hypotension causing infarct in areas of overlap of supply - most commonly in ACA-MCA infarct caused by occlusion of carotid artery
What symptoms will a watershed infarct cause?
Loss of trunk sensation/motor function and aphasia (man in a barrel)
Visual processing/visuo-spatial affects if the MCA-PCA is affected - tend to go unrecognised for a while until driving for e.g.
What external factors can bring on a watershed infarct?
Out of hospital cardiac arrest (most commonly)
Post-surgery
Haemorrhage
What is another name for lateral medullary syndrome?
Posterior inferior cerebellar artery (PICA) syndrome
What are the effects of lateral medullary syndrome as a result of vestibular nuclei dysfunction?
Vomiting
Vertigo
Nystagmus
What are the effects of lateral medullary syndrome as a result of inferior cerebellar peduncle dysfunction?
Ipsilateral cerebellar signs:
- Ataxia
- Dysmetria (past pointing)
- Dysdiadochokinesia
What are the effects of lateral medullary syndrome as a result of central tegmental tract dysfunction?
Palatal myoclonus
What are the effects of lateral medullary syndrome as a result of lateral spinothalamic tract dysfunction?
Contralateral deficits in pain and temperature sensation from body (limbs and torso)
What are the effects of lateral medullary syndrome as a result of spinal trigeminal nucleus and tract dysfunction?
Ipsilateral deficits in pain and temperature sensation from face
When will the nucleus ambiguus be affected in lateral medullary syndrome?
Affected in a localizing lesion whereas other deficits will be present in lateral pontine syndrome as well
What are the effects of lateral medullary syndrome as a result of nucleus ambiguus dysfunction?
Affects CNIX + X so will cause ipsilateral laryngeal, pharyngeal + palatal hemiparalysis causing dysphagia, hoarseness and absent gag reflex (via efferent CNX limb)
What are the effects of lateral medullary syndrome as a result of descending sympathetic fibre dysfunction?
Ipsilateral Horners syndrome with symptoms:
- Ptosis
- Miosis
- Anhidrosis
What other dysfunction can give you Horners syndrome?
Dissected carotid artery as the sympathetic tract tracks around this artery - can be caused by rotation of neck followed by pain up one side (may hear carotid bruits upon listening)
List symptoms of a stroke.
Weakness/paralysis or numbness on contralateral side Vertigo/dizziness Headache Visual loss/blurred vision Faintness Confusion Speech problems Difficulty swallowing Cognitive problems Memory problems Conciousness alterations
What is the frontal lobe involved in?
Planning Reasoning Problem solving Morality Personality Social skills Recognising and regulating emotions Motor functions Motor speech area of Broca
What is the parietal lobe involved in?
Recognising sensation, body position and objects
Sense of time and space
Reading and comprehension area
Association between functions of other lobes
What is the occipital lobe involved in?
Vision and integrating visual information i.e. colour, shape and distance
What is the cerebellum involved in?
Balance
Muscular co-ordination
What is the brainstem involved in?
Regulation of heart beats, respiration, body temp and other essential body functions
What is the temporal lobe involved in?
Understanding Language Hearing Speech Memory Learning Sensory speech area of Wernicke
How would you assess a stroke patient?
- History: diagnosis and aetiology
- Examination: aetiology, localisation and function (can they walk? talk? etc.)
- Social history: function
How do you manage a stroke immediately?
ACT FAST (~4.5hr window for thrombolysis):
- Scan: ischaemic or haemorrhagic?
- Blood tests
- Clot-busting drugs in ischaemic situations or haemorrhage evacuation
- Chest X-rays, ECG, US
How do you manage the stroke long-term?
- 2ndary prevention via daily low-dose of aspirin + check for other clots
- Manage complications e.g. fits, depression/cognition, pain, contractures, swallow, nutrition + continence
- Rehabilitation
What are the causes of post-stroke pain?
- Someone moves shoulder when arm is limp dislocating it
2. Thalamic stroke
How does a stroke patient get contractures?
If patients are not encouraged to move when they are rigid they will get pulled into a position due to flexors or extensors being stronger in upper/lower limb
How do you deal with an acute ischaemic or haemorrhagic stroke?
Image Aspirin Pyrexia Glucose TEDS NBM/SALT Thrombolysis/other agents BP
When should brain imaging be performed on people with acute stroke immediately (next slot/within an hour)?
- Indications for thrombolysis or early anticoagulation treatment
- On anticoagulant treatment
- Known bleeding tendency
- Depressed level of consciousness (GCS < 13)
- Unexplained progressive or fluctuating symptoms
- Papilloedema, neck stiffness or fever
- Severe headache at onset of stroke symptoms
All other acute stroke patients should have brain imaging as soon as possible. This is defined as within _______.
Maximum of 24 hours after symptom onset
Alteplase is recommended within its market authorisation for treating acute ischaemic stroke in adults if:
Treatment is started as early as possible within 4.5 hours of onset of stroke symptoms
AND
Intracranial haemorrhage has been excluded by appropriate imaging techniques
Alteplase should be administered only within a well-organised stroke service with:
- Staff trained in delivering thrombolysis and in monitoring for any association complications
- Level 1 and 2 nursing care staff trained in acute stroke and thrombolysis
- Immediate access to imaging and re-imaging, and staff trained to interpret the images
What must you manage to prevent complications of a stroke?
Swallowing DVT prophylaxis via compression socks Pressure areas Continence via pads Speech Infections Contractures Pain Depression
What is involved in secondary prevention of stroke?
- Aspirin/Clopidogrel, statin and BP control
- Manage IHD and DM
- Give AF patients anticoagulants
- Give carotid US for anterior circulatory issue
- Smoking cessation
What is a transient ischaemic attack (TIA)?
Mini-stroke usually resulting from drop in perfusion often due to carotid artery or vertebrobasilar insufficiency with symptoms same as full stroke .g. amourosis fugax being severe for less than 30 minutes and full recovery within 24 hours - use as WARNING SIGN
What is amourosis fugax?
Visual deficit described as ‘like a curtain falling over the eye/blind rolling down over eye’
What is the risk of stroke after a transient ischaemic attack (TIA)?
ABCD2 (CHADVASC scale if patient has AF):
A: Age > 60 years = 1 point
B: BP > 140/90mmHg = 1 point
C: Clinical features include unilateral weakness (2 points) or speech problems w/o weakness (1 point)
D: Duration of symptoms 10-59mins (1 point) or >60mins (2 points)
D: Diabetes = 1 point
Score > 4 = high risk
Other than the scale, what else increases a persons risk of stroke?
2 TIAs in close succession even if ABCD2 < 3 as multiple TIAs in increasingly close succession are known as ‘crescendo TIA’ so 1:10 TIAs with no treatment will have full stroke within 1 year
What is rehabilitation?
Process of active change by which a person who has become disabled acquires the knowledge + skills needed for optimum physical, psychological + social function - application of all measures aimed at reducing impact of disability/handicap + improving QoL
What is involved in the neuro-rehabilitation process?
Assessment Measurement Planning Treatment Evaluation Reassessment
What is the interaction of concepts (ICF) model?
Health condition (disease), environmental + personal factors interact with body function/structure (impairment), activities (limitations) + participation (restriction)
What impairments can occur after stroke?
Cognitive impairment (e.g. frontal executive problems + memory)
Expressive aphasia
Painful R shoulder
R hemiparesis with sensory loss worse in leg than arm
Poor balance mechanisms
Bladder dysfunction
What activities and participation issues may arise after a person has had a stroke?
Low mood + decreased confidence impacts on ADLs
Difficulty talking on phone + conversing in noisy environments
Uses rollator for walking indoors
Unable to turn in bed + difficulty getting in/out of bed
Dependent on assistance for self-care + domestic tasks
Difficulty standing for ADLs, getting in/out of car + accessing local community/leisure activities
At risk of falls
What environmental factors may affect a person after stroke?
Lives in 2 bedroom terraced house Open stairway with no rails Open plan kitchen/living room Upstairs bathroom Daughter with learning disability lives at home Enjoys do-it yourself Works as roofer
What is goal setting?
A process of discussion and negotiation in which patient and staff determine key priorities for that individual and agree the performance level to be attained by patient for defined activities within a specific time frame
What is the benefits of shared decision making?
Develop empathy and trust Negotiated agenda setting + prioritising Info sharing Communicating + managing risk Supports deliberating Summarises + makes decisions
What is an example of a long-term goal?
To go home on 24th December able to walk independently short distances indoors, able to dress self independently, having been referred to community rehab team
What are examples of short-term goals?
Transfer using sliding board with assistance of one
Transfer independently with sliding board
Pivot transfer with assistance of one
Independent step round transfer
