Stroke Flashcards
What are some key questions to consider when suspecting a stroke?
Is it a stroke?
What is the cause?
Are there any complications? - How to minimise
What treatment?
Prognosis?
When can they leave?
Third party involvement - DVLA, employers
What tools are used to assess stroke?
ABCD2 CHA2DS2VASc - AF stroke risk HASBLED - major bleed risk NIHSS Oxford Stroke Classification (OCSP)
What is ABCD2 used for?
Assessing risk of stroke after TIA
What is the pathophysiology of stroke?
Hypoperfusion leads to depletion of ATP which impaids membrane transport which is key to neuronal function.
If ATP too low, action potential activity stop
What are the 4 key concepts of stroke?
Neurological disturbance evolve suddenly
Focal -vascular territory effected
Loss of function (negative signs)
Symptoms should fit vascular territory
What signs would point towards a stroke mimic rather than a stroke?
Gradual onset Non-focal Not fitting to vascular territory Positive signs - white spots in eyes Stereotyping Migration
What is stereotyping?
Episodic reoccurence of neurological disturbance which is identical in fashion and has complete recovery in between
How can haemorrhagic strokes be split?
Intracerebral - Extradural, Subdural, Intraparenchymal
Subarachnoid
How can Ischaemic strokes be split?
Atherosclerosis - carotid artery stenosis/hypertension Emboli - cardiac/large vessel Small vessel disease (inflammation) Vasculitis Prothrombotic state Dissection
How can atherothromboemboli ischaemic strokes be split?
PACI - partial anterior
TACI - total anterior
POCI - posterior
Lacunar Infarct
What are some causes of cardiac emboli?
AF Prosthetic valve Cardiomegaly HF Endocarditis Acute MI
Name some complications of stroke
Premature death
Recurrent stroke
Extension of stroke - suboptimal physiology
Raised ICP
Infections - aspiration/incomplete bladder emptying
Mood and cognitive dysfunction
Post stroke pain and fatigue
Spasticity, contractures and secondary epilepsy
Immobility
What are the key aims to management?
Revascularise
Optimise physiology
Secondary prevention
Rehab and reablement
What investigations are done along with thrombolysis?
CT+angio
FAST, NIHSS, modified rankin and ASPECTS scores
What thromolysis therapy is there and what are its indications?
IV alteplase - within 4.5 hrs of stroke + not CI
Mechanical thromectomy - within 6hrs of symptoms + large vessel occlusion
When is a decompressive hemicraniectomy done?
Large MCA infarct
>60yo
NIHSS score of >15
Refer within 24hr and surgery <48hr
What is important to know about decompressive hemicraniectomies?
They preserve life but lead to severe dependency so family must be aware
What interventions are used for intracerebral haemorrhage and why?
Haematoma evacuation and ventricular drains
Raised ICP is a concern
What antithrombotic therapy is used?
Anticoag - patients with AF, LVF, thrombophilia, venous sinus thrombosis
SC Heparin
Warfarin
DOAC’s
Antiplatelet - immediately given to all suspected TIA or confirmed stroke
When is a carotid endarterectomy carried out?
Carotid disease >50%
Surgery is ASAP if symptomatic
What is used alongside a carotid endarterectomy?
HTN control
Statins
When is a nasogastric or PEG inserted?
Unsafe swallow - assessed with FEES
How is physiology optimised post stroke?
Smoking cessation BP<120/80 HbA1c <7 Cholesterol <4 LDL <2 BMI < 25
What is targeted in rehabilitation and reablement?
Mobility
Activities of daily living
Speech and Cognitive therapy
How can you classify patients prognosis?
Early, high functioning plateau (EHP)
Early, low functioning plateau (ELP)
Delayed and medium functioning (DMF)
What is the prognosis for each classification?
EHP - excellent prognosis e.g. TIA
ELP - poor functional prognosis e.g. TAC stroke with no improvement
DMF - benefit from sustained rehab (most strokes)
What can reduce chance of long-term independent living and leads to a poor prognosis?
Dense hemiparesis
Inattention
Receptive dysphasia
Cognitive dysfunction
What driving advice is given post stroke?
4 weeks off driving
1 year for trucks
What different symptoms can be seen in LACI’s?
Pure motor stroke - contralateral hemiparesis of face, arm and leg
Pure sensory stroke - contralateral paraesthesia of face arm and leg
Sensorimotor - contralateral sensory and motor loss of face arm and leg
Ataxic hemiparesis - ipsilateral weakness and ataxia
Dysarthria and clumsy hand (base of pons) - dysarthria and clumsiness of hand when writing
Where would the stroke be to cause ataxic hemiparesis?
Posterior limb of internal capsule
corona radiata
Where would the stroke be for pure sensory symptoms?
Ventral posterolateral nucleus of the thalamus
Posterior Limb of internal capsule that carry spinothalamic/dorsal column fibres
Corona radiata
Where would the stroke be for pure motor symptoms?
Posterior limb of internal capsule that carries corticospinal fibres
How would a TACI present?
New higher dysfunction - dysphasia
Homonymous visual field defect
Ipsilateral motor or snsory defecit
How would a PACI present?
2/3 of TACI
Motor/sensory deficit more restricted than lacunar - only 1 limb
How would a POCI present?
Ipsilateral CN palsy Contralateral or bilateral motor/sensory defect Disorder of conjugating eye movement Cerebellar dysfunction Visual field defect
What are the signs of cerebellar dysfunction?
Dysdiadocokinesia Ataxia Nystagmus Intention tremor Slurred speech Hypotonia
What is the Modified Rankin Scale used for?
Scale for measuring the degree of disability and monitor response to treatment
Describe the Modified Rankin Scale
0 - no symptoms
1 - no disability, symptoms but carry out ADL’s
2 - slight disability, can look after affairs without assistance but cant do everything
3 - moderate disability, some help but can walk
4 - moderate severe disability, unable to attend to own bodily needs without assistance and can’t walk alone
5 - severe disability - constant nursing care and attention, bedridden, incontinent
6 - dead
What are the 3 categories to split stroke mimics into?
Show up on imaging
Clear non-stroke symptoms
Clinical recognition but need specialist assessment
Which stroke mimics show up on imaging?
MS
Subdural Haematoma
Space Occupying Lesion
What stroke mimics have clear non-stroke symptoms?
Vertigo
Vestibular neuronitis
Syncope syndrome
Transient Global Amnesia
What stroke mimics req. special assessment
Migraine with aura
Focal seizure
Functional syndrome
Amyloid spells
What is a stroke?
Cerebrovascular event characterised by disruption of blood supply to the brain leading to focal or global disturbance in cerebral function lasting >24hrs or leading to death
Without imaging, what would point to stroke symptoms being ishaemic or haemorrhagic?
Ischaemic - atherosclerotic risk factors, previous TIA, carotid bruit, AF
Haemorrhagic - severe headache, meninges, Loss of consciousness, Hypertension
What areas are affected by an anterior cerebral artery stroke and how would this manifest?
Medial parts of frontal and parietal lobe –> Contralateral UMN signs and loss of all sensory modality - leg>arm
Paracentral Lobules –> Urinary Incontinence
Corpus Callosum –> split brain and alien hand syndrome
What areas are affected by an middle cerebral artery stroke and how would this manifest?
Majority of hemisphere affected:
- Contralateral UMN
- loss all sensory (lower face and arm>leg)
- Vision - contralateral homonymous hemianopia
Dominant side:
- frontal lobe - Broca’s aphasia
- temporal lobe - Wernicke’s aphasia
Non-dominant - Hemispatial neglect, tactile/visual extinction, anosognosia, constructional apraxia
What is the difference between Broca’s and Wernicke’s aphasia?
Broca - Know what to say but can’t
Wernicke - Talk fluently but gibberish
What areas are affected by an posterior cerebral artery stroke and how would this manifest?
Occipital lobe –> Contralateral homonymous hemianopia with macular sparing
Thalamus (depend if before or after thalamoperforater branch) –> contralateral hemisensory loss
Left PCA - Alexia (can’t comprehend writing but can still write)
Right PCA - Prosopagnosia (can’t recognise faces)
What areas are affected by an vertebrobasilar artery stroke and how would this manifest?
Brainstem - vertigo, tinnitus, drop attacks, ipsilateral CN lesions, gait and vision problems
Cerebellar syndromes - DANISH
Pons - locked in syndrome - paralysis of all voluntary muscles except CNI-IV
What happens if the main trunk of the middle cerebral artery is affected in a stroke?
Considerable brain infarct leading to oedema, RICP, coma and death
What is affected in Wallenberg syndrome?
Lateral Medulla
Posterior Inferior Cerebellar Artery
How does a lateral medullary infarct present?
Ipsilateral facial loss of pain and temperature
Contralateral limb/trunk loss of pain and temperature
Ataxia
Nystagmus
What is affected in Marie Foix syndrome?
Lateral Pons
Anterior Inferior Cerebellar Artery
How does Marie Foix syndrome present?
Ipsilateral facial loss of pain and temperature
Contralateral limb/trunk loss of pain and temperature
Ataxia
Nystagmus
+ Ipsilateral facial paralysis
+ Ipsilateral Deafness
+ Ipsilateral Hornerys
What artery is impacted in medial medullary syndrome?
Anterior Spinal Artery
How does medial medullary syndrome present?
Contralateral hemiplegia
Contralateral loss of fine touch, vibration etc. with facial sparing (trigeminal unaffected)
Ipsilateral hypoglossal nerve loss
What is impacted in Foville’s syndrome?
Medial Pons
Branches of basilar artery
How does Foville’s syndrome present?
Contralateral hemiplegia
Contralateral loss of fine touch, vibration etc
Facial nerve paralysis
Internuclear ophthalmoplegia
What is affected in Weber’s syndrome?
Midbrain
Branches of PCA
How does Weber’s syndrome present?
Ipsilateral CN3 palsy
Contralateral Hemiparesis
What arteries are commonly affected in a lacunar infarct?
Small penetrating arteries such as Lenticulostriate
What is the NIHSS score used for?
Measure of neurological deficit and used to assess need for different therapies, prognosis and also as a way of monitoring
What is the ROSIER score used for?
Differentiate between stroke and stroke mimics (after exclusion of hypoglycaemia)
What is in the ROSIER score?
-1 point for: Loss of Consciousness/syncope, seizure activity
+1 point for - New acute onset of:
- asymmetric facial weakness
- asymmetric arm weakness
- asymmetric leg weakness
- speech disturbance
- visual field defect
What investigations are requested for a ?stroke?
Imaging - non-contrast CT gold standard. MRI diffusion weighted imaging more sensitive and specific for ischaemic damage but take longer
Risk factor identification - Hx and Examination Signs of large vessel occlusion ECG - look for AF ESR - temporal arteritis Carotid duplex USS - anterior stroke Glucose and oxygen sats - rule out differentials Coagulation studies Troponin - prognostic indicator
When is imaging indicated for a stroke?
Indication for immediate thrombolysis
Known bleeding tendency inc. anticoagulants
GCS <13
Unexplained progressive or fluctuating symptoms
Severe headache, neck stiffness, papilloedema, fever
How would an ischaemic stroke appear on non-contrast CT?
Hypodense brain tissue
Hyperdense occluded vessel
Loss of grey-white matter interface
Loss of sulk
Loss of insular ribbon
How would a haemorrhagic stroke appear on non-contrast CT?
Hyperdense
Midline shift
How are strokes managed in general?
Specialist stroke unit, Swallowing screen, Mobilise ASAP
O2 - if <95%
Blood sugar - maintain between 4-11
DVT prophylaxis - dont routinely start LMWH. need review by senior stroke team at 48hr if ischaemic and immobile
Visual neglect - bright coloured lines at edge of page, repetition of tasks, prism glasses
Memory deficit - mnemonics, awareness of deficit, diaries, alarms etc.
Attention deficit - attention training, prompts
Vision - eye movement therapy, orthoptics review
Dysphagia - swallow therapy, modify diet, mouth care
Language - SALT, aids of computers/smartphone, educate family
Weakness - physio, hand/wrist/ankle splints
How is a haemorrhagic stroke managed immediately?
A-E and stabilise Admit to neuro ICU BP - IV labetalol if >180 O2 - oxygen if <94% Fever - paracetamol Hyperglycaemia management
Surgical evacuation isn’t routinely done unless >3cm cerebellar haemorrhage
RICP - Raise head of bed 30 degrees, intubate if needed, CSF drainage, mannitol
Stop anticoagulant - if warfarin then give Vit K and FFP
What is the secondary prevention management for haemorrhagic strokes?
Lifestyle advice
BP kept at 130/80
Restart anti-coag should balance risks and benefits. Generally avoid unless artificial heart or other large risk
How are ischaemic strokes managed?
Thrombolyse with Alteplase if:
<4.5hrs of symptom onset
No haemorrhage on CT
No CI
BP<185/110
After 24hr antiplatelet
How should ischaemic strokes be managed if alteplase is not recommended?
Aspirin 300mg for 2 weeks
Clopidogrel 75mg for life
Can add Ranitidine for dyspepsia or if PPI not tolerated, add 75mg aspirin OD + dipyridamole.
What are the CI’s for thrombolysis?
Previous intracranial haemorrhage Seizure at onset of stroke Intracranial neoplasm Suspected subarachnoid haemorrhage Stroke/brain injury in previous 3 months Lumbar puncture in previous 7 days GI haemorrhage in ast 3 weeks Active bleeding Pregnancy Oesophageal varices Uncontrolled hypertension >200/120
What outcomes are expected from thrombolysis?
5% deteriorate due to thrombolysis
30% make full neurological recovery
What complications are you worried about with thrombolysis?
Haemorrahge
Angio-oedema
What other important information should you know about thrombolysis?
Don’t catheterise or insert NG tube for 24 hrs
When and how is blood pressure treated in an acute ischaemic stroke?
- Hypertensive encephalopathy, nephropathy or cardiac failure
- Aortic dissection
- Pre-eclampsia
- Intra-cerebral haemorrhage with BP>200
Labetalol IV if dysphagia
Ramipril or Amlodipine if swallowing
What secondary prevention is recommended for an ischaemic stroke?
Lifestyle advice - diet, weight, exercise, smoking, alcohol
Antiplatelets - clopidogrel
BP management - systolic of 130
Statins - atorvastatin
If AF, cardiac emboli, aortic dissection, central venous thrombosis:
- ECG confirmation
- Warfarin started 2 weeks post stroke - INR target 2-3
If Carotid artery stenosis >50% occlusion
- assess for carotid endarterectomy
- surgery within 2 weeks
What is a TIA?
Transient neurological deficit where there is no long term ischaemic damage
How is a TIA managed?
Generally as outpatient unless high risk of stroke
Atherosclerotic disease - aspirin or clopidogrel started within 24hrs once haemorrhage ruled out
Cardioembolic disease/AF - anticoagulate with warfarin or NOAC (if contraindicated then anti platelet therapy)
What secondary prevention is recommended for a TIA?
Put in place within 2 days:
- Statins
- BP control for anyone >120/80
- Lifestyle modifications
- Possible carotid endarterectomy/stenting
How is the risk of stroke following TIA calculated?
ABCD2 score - if score >4 or 2 TIA’s in week then specialist review within 24 hrs. <4 = review within week
Risk of stroke post TIA = 10%
Factors in ABCD2: Age>60 = 1 BP>140/90 = 1 Unilateral weakness = 2 Isolated speech disturbance = 1 Symptoms >60mins = 2 Symptoms 10-59 mins = 1 Diabetic = 1
What does the CHA2DS2Vasc score estimate?
Risk of stroke in AF patients: Congestive heart failure - 1 Hypertension - 1 Age >= 75 - 2 Age 65-74 = 1 Diabetes = 1 Stroke/TIA/Thromboemboli = 2 Vascular disease = 1 Female = 1
What does the HASBLED score estimate?
Risk of major bleeding in anti-coagulated AF patients 1 point each for: Hypertension Abnormal liver function Abnormal Kidney function Stroke Bleeding Labile INR Age>65 Drugs Alcohol
What are some examples of stroke mimics?
Seizure Syncope Sepsis Functional Migraines Space occupying lesions Toxins/drugs/alcohol Vestibular disorders Dementia
What are some examples of stroke chameleons?
Posterior circulation strokes can look like labyrthinitis/BPPV
Focal cortical strokes giving mono paresis - spinal cord/peripheral nerve issue
Focal cortical stroke - acute confusion - delirium
Bilateral thalamic stroke - acute memory disturbance
Limb shaking TIA - focal seizure
Spinal stroke - bilateral leg weakness - spinal cord issue
What symptoms would there is an issue with the basal ganglia?
Chorea
Athetosis
Dystonia
Tremor
What symptoms would indicate there is an issue with the spinal cord?
Dermatomal/myotomal distribution
Bilateral
UMN signs below the lesion
LMN at the level of the lesion
What symptoms would indicate there is an issue with the nerve roots?
Dermatomal/myotomal distribution
Shooting pain
What symptoms would indicate there is an issue with the nerve plexus?
Complex picture of mixed nerve and root picture
LMN
What symptoms would indicate there is an issue with the peripheral nerves?
Distal motor and sensory symptoms
LMN
What symptoms would indicate there is an issue with the neuromuscular junction?
Fatigability
No sensory involvement
What symptoms would indicate it is due to a muscle disease?
Proximal
No sensory involvement
What can cause acute neurological issues?
Ischaemia
Seizure
Trauma
What can cause subacute neurological issues?
Expanding lesions - tumours and abscesses
What can cause chronic neurological issues?
Degenerative diseases such as dementia and Huntington’s
What can cause recurrent-remitting neurological issues?
TIA
Seizure
MS
Migraine
If a brainstem lesion is medial, what would be affected?
Medial = M’s
- Motor - corticospinal tract - contralateral weakness
- dorsal column Medial lemniscus - contralateral proprioception and vibration loss
- Medial longitudinal fascicles - ipsilateral internuclear ophthalmoplegia
- Motor nuclei - ipsilateral loss of 3,4, 6 and 12
If a brainstem lesion if lateral, what would be affected?
Lateral = S’s
- Spinocerebellar - ipsilateral ataxia
- Spinothalamic - contralateral pain and temperature
- Sensory nucleus of CNS - ipsilateral loss of pain and temp of face
- Sympathetics - Ipsilateral Horners
How would you work out which part of the brainstem is affected?
Motor = medial Lateral = S's
Forebrain = CN1,2 Midbrain = CN3,4 Pons = CN5,6,7,8 Medulla = CN9,10,11,12
What is the frontal lobe responsible for?
Motor Behaviour Cognition Speech expression Continence
What is the temporal lobe responsible for?
Hearing
Olfaction
Memory
Emotion
What is the parietal lobe responsible for?
Sensory Speech comprehension Body image Awareness of environment Calculation and writing
