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Neurology and Special Senses > Stroke > Flashcards

Stroke Flashcards

1
Q

What are some key questions to consider when suspecting a stroke?

A

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

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2
Q

What tools are used to assess stroke?

A 
ABCD2
CHA2DS2VASc - AF stroke risk
HASBLED - major bleed risk
NIHSS
Oxford Stroke Classification (OCSP)
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3
Q

What is ABCD2 used for?

A

Assessing risk of stroke after TIA

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4
Q

What is the pathophysiology of stroke?

A

Hypoperfusion leads to depletion of ATP which impaids membrane transport which is key to neuronal function.

If ATP too low, action potential activity stop

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5
Q

What are the 4 key concepts of stroke?

A

Neurological disturbance evolve suddenly
Focal -vascular territory effected
Loss of function (negative signs)
Symptoms should fit vascular territory

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6
Q

What signs would point towards a stroke mimic rather than a stroke?

A 
Gradual onset
Non-focal
Not fitting to vascular territory
Positive signs - white spots in eyes
Stereotyping
Migration
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7
Q

What is stereotyping?

A

Episodic reoccurence of neurological disturbance which is identical in fashion and has complete recovery in between

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8
Q

How can haemorrhagic strokes be split?

A

Intracerebral - Extradural, Subdural, Intraparenchymal

Subarachnoid

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9
Q

How can Ischaemic strokes be split?

A 
Atherosclerosis - carotid artery stenosis/hypertension
Emboli - cardiac/large vessel
Small vessel disease (inflammation)
Vasculitis
Prothrombotic state
Dissection
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10
Q

How can atherothromboemboli ischaemic strokes be split?

A

PACI - partial anterior
TACI - total anterior
POCI - posterior
Lacunar Infarct

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11
Q

What are some causes of cardiac emboli?

A 
AF
Prosthetic valve
Cardiomegaly
HF
Endocarditis
Acute MI
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12
Q

Name some complications of stroke

A

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

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13
Q

What are the key aims to management?

A

Revascularise
Optimise physiology
Secondary prevention
Rehab and reablement

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14
Q

What investigations are done along with thrombolysis?

A

CT+angio

FAST, NIHSS, modified rankin and ASPECTS scores

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15
Q

What thromolysis therapy is there and what are its indications?

A

IV alteplase - within 4.5 hrs of stroke + not CI

Mechanical thromectomy - within 6hrs of symptoms + large vessel occlusion

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16
Q

When is a decompressive hemicraniectomy done?

A

Large MCA infarct
>60yo
NIHSS score of >15

Refer within 24hr and surgery <48hr

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17
Q

What is important to know about decompressive hemicraniectomies?

A

They preserve life but lead to severe dependency so family must be aware

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18
Q

What interventions are used for intracerebral haemorrhage and why?

A

Haematoma evacuation and ventricular drains

Raised ICP is a concern

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19
Q

What antithrombotic therapy is used?

A

Anticoag - patients with AF, LVF, thrombophilia, venous sinus thrombosis
SC Heparin
Warfarin
DOAC’s

Antiplatelet - immediately given to all suspected TIA or confirmed stroke

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20
Q

When is a carotid endarterectomy carried out?

A

Carotid disease >50%

Surgery is ASAP if symptomatic

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21
Q

What is used alongside a carotid endarterectomy?

A

HTN control

Statins

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22
Q

When is a nasogastric or PEG inserted?

A

Unsafe swallow - assessed with FEES

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23
Q

How is physiology optimised post stroke?

A 
Smoking cessation
BP<120/80
HbA1c <7
Cholesterol <4
LDL <2
BMI < 25
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24
Q

What is targeted in rehabilitation and reablement?

A

Mobility
Activities of daily living
Speech and Cognitive therapy

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25
Q

How can you classify patients prognosis?

A

Early, high functioning plateau (EHP)
Early, low functioning plateau (ELP)
Delayed and medium functioning (DMF)

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26
Q

What is the prognosis for each classification?

A

EHP - excellent prognosis e.g. TIA
ELP - poor functional prognosis e.g. TAC stroke with no improvement
DMF - benefit from sustained rehab (most strokes)

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27
Q

What can reduce chance of long-term independent living and leads to a poor prognosis?

A

Dense hemiparesis
Inattention
Receptive dysphasia
Cognitive dysfunction

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28
Q

What driving advice is given post stroke?

A

4 weeks off driving

1 year for trucks

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29
Q

What different symptoms can be seen in LACI’s?

A

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

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30
Q

Where would the stroke be to cause ataxic hemiparesis?

A

Posterior limb of internal capsule

corona radiata

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31
Q

Where would the stroke be for pure sensory symptoms?

A

Ventral posterolateral nucleus of the thalamus
Posterior Limb of internal capsule that carry spinothalamic/dorsal column fibres
Corona radiata

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32
Q

Where would the stroke be for pure motor symptoms?

A

Posterior limb of internal capsule that carries corticospinal fibres

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33
Q

How would a TACI present?

A

New higher dysfunction - dysphasia

Homonymous visual field defect

Ipsilateral motor or snsory defecit

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34
Q

How would a PACI present?

A

2/3 of TACI

Motor/sensory deficit more restricted than lacunar - only 1 limb

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35
Q

How would a POCI present?

A 
Ipsilateral CN palsy
Contralateral or bilateral motor/sensory defect
Disorder of conjugating eye movement
Cerebellar dysfunction
Visual field defect
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36
Q

What are the signs of cerebellar dysfunction?

A 
Dysdiadocokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
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37
Q

What is the Modified Rankin Scale used for?

A

Scale for measuring the degree of disability and monitor response to treatment

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38
Q

Describe the Modified Rankin Scale

A

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

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39
Q

What are the 3 categories to split stroke mimics into?

A

Show up on imaging
Clear non-stroke symptoms
Clinical recognition but need specialist assessment

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40
Q

Which stroke mimics show up on imaging?

A

MS
Subdural Haematoma
Space Occupying Lesion

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41
Q

What stroke mimics have clear non-stroke symptoms?

A

Vertigo
Vestibular neuronitis
Syncope syndrome
Transient Global Amnesia

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42
Q

What stroke mimics req. special assessment

A

Migraine with aura
Focal seizure
Functional syndrome
Amyloid spells

43
Q

What is a stroke?

A

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

44
Q

Without imaging, what would point to stroke symptoms being ishaemic or haemorrhagic?

A

Ischaemic - atherosclerotic risk factors, previous TIA, carotid bruit, AF

Haemorrhagic - severe headache, meninges, Loss of consciousness, Hypertension

45
Q

What areas are affected by an anterior cerebral artery stroke and how would this manifest?

A

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

46
Q

What areas are affected by an middle cerebral artery stroke and how would this manifest?

A

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

47
Q

What is the difference between Broca’s and Wernicke’s aphasia?

A

Broca - Know what to say but can’t

Wernicke - Talk fluently but gibberish

48
Q

What areas are affected by an posterior cerebral artery stroke and how would this manifest?

A

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)

49
Q

What areas are affected by an vertebrobasilar artery stroke and how would this manifest?

A

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

50
Q

What happens if the main trunk of the middle cerebral artery is affected in a stroke?

A

Considerable brain infarct leading to oedema, RICP, coma and death

51
Q

What is affected in Wallenberg syndrome?

A

Lateral Medulla

Posterior Inferior Cerebellar Artery

52
Q

How does a lateral medullary infarct present?

A

Ipsilateral facial loss of pain and temperature
Contralateral limb/trunk loss of pain and temperature
Ataxia
Nystagmus

53
Q

What is affected in Marie Foix syndrome?

A

Lateral Pons

Anterior Inferior Cerebellar Artery

54
Q

How does Marie Foix syndrome present?

A

Ipsilateral facial loss of pain and temperature
Contralateral limb/trunk loss of pain and temperature
Ataxia
Nystagmus
+ Ipsilateral facial paralysis
+ Ipsilateral Deafness
+ Ipsilateral Hornerys

55
Q

What artery is impacted in medial medullary syndrome?

A

Anterior Spinal Artery

56
Q

How does medial medullary syndrome present?

A

Contralateral hemiplegia
Contralateral loss of fine touch, vibration etc. with facial sparing (trigeminal unaffected)
Ipsilateral hypoglossal nerve loss

57
Q

What is impacted in Foville’s syndrome?

A

Medial Pons

Branches of basilar artery

58
Q

How does Foville’s syndrome present?

A

Contralateral hemiplegia
Contralateral loss of fine touch, vibration etc
Facial nerve paralysis
Internuclear ophthalmoplegia

59
Q

What is affected in Weber’s syndrome?

A

Midbrain

Branches of PCA

60
Q

How does Weber’s syndrome present?

A

Ipsilateral CN3 palsy

Contralateral Hemiparesis

61
Q

What arteries are commonly affected in a lacunar infarct?

A

Small penetrating arteries such as Lenticulostriate

62
Q

What is the NIHSS score used for?

A

Measure of neurological deficit and used to assess need for different therapies, prognosis and also as a way of monitoring

63
Q

What is the ROSIER score used for?

A

Differentiate between stroke and stroke mimics (after exclusion of hypoglycaemia)

64
Q

What is in the ROSIER score?

A

-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
65
Q

What investigations are requested for a ?stroke?

A

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
66
Q

When is imaging indicated for a stroke?

A

Indication for immediate thrombolysis
Known bleeding tendency inc. anticoagulants
GCS <13
Unexplained progressive or fluctuating symptoms
Severe headache, neck stiffness, papilloedema, fever

67
Q

How would an ischaemic stroke appear on non-contrast CT?

A

Hypodense brain tissue

Hyperdense occluded vessel
Loss of grey-white matter interface
Loss of sulk
Loss of insular ribbon

68
Q

How would a haemorrhagic stroke appear on non-contrast CT?

A

Hyperdense

Midline shift

69
Q

How are strokes managed in general?

A

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

70
Q

How is a haemorrhagic stroke managed immediately?

A 
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

71
Q

What is the secondary prevention management for haemorrhagic strokes?

A

Lifestyle advice
BP kept at 130/80

Restart anti-coag should balance risks and benefits. Generally avoid unless artificial heart or other large risk

72
Q

How are ischaemic strokes managed?

A

Thrombolyse with Alteplase if:

<4.5hrs of symptom onset
No haemorrhage on CT
No CI
BP<185/110

After 24hr antiplatelet

73
Q

How should ischaemic strokes be managed if alteplase is not recommended?

A

Aspirin 300mg for 2 weeks
Clopidogrel 75mg for life

Can add Ranitidine for dyspepsia or if PPI not tolerated, add 75mg aspirin OD + dipyridamole.

74
Q

What are the CI’s for thrombolysis?

A 
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
75
Q

What outcomes are expected from thrombolysis?

A

5% deteriorate due to thrombolysis

30% make full neurological recovery

76
Q

What complications are you worried about with thrombolysis?

A

Haemorrahge

Angio-oedema

77
Q

What other important information should you know about thrombolysis?

A

Don’t catheterise or insert NG tube for 24 hrs

78
Q

When and how is blood pressure treated in an acute ischaemic stroke?

A
  • 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

79
Q

What secondary prevention is recommended for an ischaemic stroke?

A

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
80
Q

What is a TIA?

A

Transient neurological deficit where there is no long term ischaemic damage

81
Q

How is a TIA managed?

A

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)

82
Q

What secondary prevention is recommended for a TIA?

A

Put in place within 2 days:

  • Statins
  • BP control for anyone >120/80
  • Lifestyle modifications
  • Possible carotid endarterectomy/stenting
83
Q

How is the risk of stroke following TIA calculated?

A

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
84
Q

What does the CHA2DS2Vasc score estimate?

A 
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
85
Q

What does the HASBLED score estimate?

A 
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
86
Q

What are some examples of stroke mimics?

A 
Seizure
Syncope
Sepsis
Functional
Migraines
Space occupying lesions
Toxins/drugs/alcohol
Vestibular disorders
Dementia
87
Q

What are some examples of stroke chameleons?

A

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

88
Q

What symptoms would there is an issue with the basal ganglia?

A

Chorea
Athetosis
Dystonia
Tremor

89
Q

What symptoms would indicate there is an issue with the spinal cord?

A

Dermatomal/myotomal distribution
Bilateral
UMN signs below the lesion
LMN at the level of the lesion

90
Q

What symptoms would indicate there is an issue with the nerve roots?

A

Dermatomal/myotomal distribution

Shooting pain

91
Q

What symptoms would indicate there is an issue with the nerve plexus?

A

Complex picture of mixed nerve and root picture

LMN

92
Q

What symptoms would indicate there is an issue with the peripheral nerves?

A

Distal motor and sensory symptoms

LMN

93
Q

What symptoms would indicate there is an issue with the neuromuscular junction?

A

Fatigability

No sensory involvement

94
Q

What symptoms would indicate it is due to a muscle disease?

A

Proximal

No sensory involvement

95
Q

What can cause acute neurological issues?

A

Ischaemia
Seizure
Trauma

96
Q

What can cause subacute neurological issues?

A

Expanding lesions - tumours and abscesses

97
Q

What can cause chronic neurological issues?

A

Degenerative diseases such as dementia and Huntington’s

98
Q

What can cause recurrent-remitting neurological issues?

A

TIA
Seizure
MS
Migraine

99
Q

If a brainstem lesion is medial, what would be affected?

A

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
100
Q

If a brainstem lesion if lateral, what would be affected?

A

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
101
Q

How would you work out which part of the brainstem is affected?

A 
Motor = medial
Lateral = S's 
Forebrain = CN1,2 
Midbrain = CN3,4
Pons = CN5,6,7,8
Medulla = CN9,10,11,12
102
Q

What is the frontal lobe responsible for?

A 
Motor
Behaviour
Cognition
Speech expression
Continence
103
Q

What is the temporal lobe responsible for?

A

Hearing
Olfaction
Memory
Emotion

104
Q

What is the parietal lobe responsible for?

A 
Sensory
Speech comprehension
Body image
Awareness of environment
Calculation and writing

Neurology and Special Senses (28 decks)

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