Stroke Flashcards by Philip Meakin

What is the definition of a stroke?

Rapidly deteriorating clinical signs of focal disturbance of cerebral function- lasting more than 24 hours or leading to death with no other cause other than that of vascular origin

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What is a TIA?

Stroke symptoms that resolve within 24 hours- majority resolve within hours

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What does the anterior circulation supply?

Frontal lobe
Parietal lobe
Temporal lobe
Eyes

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What does the posterior circulation supply?

Occipital lobe
Cerebellum
Brainstem
Thalamus

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What are the associated effects of an anterior cerebral artery stroke?

Contralateral hemiparesis and sensory loss

Lower extremity affected more than upper extremity

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What are the associated effects of a middle cerebral artery stroke?

Contralateral hemiparesis and sensory loss
Upper extremity affected more than lower extremity
Aphasia
Homonymous hemianopia

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What are the features of a posterior cerebral artery stroke?

Contralateral homonymous hemianopia

Macular sparing

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What are the features of an anterior circulation stroke?

Contralateral hemiparesis and sensory loss
Homonymous hemianopia
Dysphagia
Dysphasia (If the dominant, most of the time on the left)
Dysarthria

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What are the features of a posterior circulation stroke?

Ataxia
Diplopia
Vertigo
Hemiparesis or tetraparesis

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How do lacunar strokes present?

One of:
Unilateral weakness (and or sensory deficit) of face and arm, arm and leg or all three
Pure sensory stroke
Ataxic hemiparesis

Motor hemiparesis is due to lacunar infarction in the internal capsule or pons
Pure hemisensory pattern is due to lacunar infarction in the thalamus

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What causes a lacunar stroke?

Damage to the internal capsule, thalamus and basal ganglia

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What are some risk factors for stroke?

Hypertension
Smoking
Hyperlipidaemia
Atherscleoritc disease
FHx of stroke
Previous stroke or TIA
AF, Mitral Valve disease, Carotid atheroma

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What are the two main types of hemorrhagic stroke?

Subarachnoid haemorrhage

Intracerebral haemorrhage

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What is the most common cause of intracerebral haemorrhage?

Hypertension leading to rupture of the small penetrating arteries- most often occurs at the basal ganglia.

AVM or anticoagulants can also cause it.

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How does an intracerebral haemorrhage usually present?

Sudden onset neurological deficit with headache

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How does a subarachnoid haemorrhage usually present?

Worst ever headache like someone has hit me with a bat on the back of the head.
Vomiting
Neck stiffness
May have neurological defecit

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What causes subarachnoid haemorrhage?

Rupture of an intracranial aneurysm

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If suspecting a subarachnoid haemorrhage what tests should be done?

Urgent head CT

LP to check for bilirubin

What medication should be given for subarachnoid haemorrhage?

Nimodipine- it reduces vasospasm and reduces mortality

It is a calcium channel antagonist

What is the management for subarachnoid haemorrhage?

Close monitoring
Keep hydrated but SBP below 160 mmHg
Nimodipine- to prevent vasospasm
Surgery to correct the aneurysm

Stop anticoagulation and platelets

What investigation should be done for all strokes?

CT Head- rules out haemorrhagic stroke and guides management

What is included in the Oxford or Bamford Classification of stroke?

Unilateral hemiparesis and/or hemisensory loss
Homonymous hemianopia
Higher cognitive dysfunction e.g. disturbance

Total anterior circulation stroke = 3/3
Partial anterior circulation stroke = 2/3

What is the cut off for thrombolysis for stroke management?

4.5 hours from onset of symptoms

What is the management for ischaemic stroke?

300mg Aspirin should be given as soon as haemorrhagic stroke has been ruled out
If presenting within 4.5 hours- Thrombolysis with alteplase

What is recommended for secondary prevention of stroke?

Clopidogrel If AF long-term anticoagulation is indicated

What investigations should be done in someone presenting with stroke features?

CT Head Bloods- FBC, U&Es, CRP, ESR, Glucose, Lipids, Cholesterol ECG- AF is a cause of embolic stroke, or ECHO CXR Carotid doppler US if in the carotid territory- could reveal carotid plaques

Where should stroke patients be managed?

On a stroke unit as it is associated with much better outcomes.

What should be done after the initial treatment for stroke?

``` Risk reduction: Long term antiplatelet- Clopidogrel Treat HTN- ACEi, ARBs Reduce cholesterol- Statins Diabetes management Stop Smoking Services Check swallowing and assessment by SALT Early mobilisation ```

What drug is used for thrombolysis?

Alteplase

When should a carotid endarterectomy be considered?

Patients with carotid stenosis >70% Carotid Doppler should be done after stroke or TIA in anterior circulation territory

What drug is given after hemorrhagic stroke?

Nimodipine

What is the management for hemorrhagic stroke?

Largely conservative- Fluids Nimodipine Maintain BP but keep systolic below 160 Surgical intervention- clipping and coiling

How might patients present with a central venous sinus thrombosis?

Headache Seizure Focal neurological signs

What is the general prognosis of stroke?

30% die within 1 year 30% dependant at 1 year 30% have a further stroke within 5 years

What are the two main causes of ischemic stroke?

Thrombosis | Embolism

What layers is the bleeding in a subarachnoid haemorrhage?

Pia mater Arachnoid mater Often caused by a ruptured aneurysm

What is the first thing to do if someone comes in with a focal neurological deficit?

Remember that this is a medical emergency and requires an ABC approach. GCS less than 8 can indicate a need for intubation.

What is used for thrombolysis?

Alteplase- tissue plasminogen activator To be given with 4.5 hours of symptoms onset. Difficulty if occured during sleep.

What should be is the name for blood stained CSF?

Xanthochromia- it's yellowish due to red cell breakdown

What are some contraindications to thrombolysis?

``` Known bleed Cerebral malignancy Surgery in last 14 days GI bleed in last 3 weeks Ischaemic stroke or head trauma in past 3 months ```

What is the management for a TIA?

``` Aspirin 300mg (unless bleeding disorder, anti-coagulated as could be haemorrhage, already taking aspirin, aspiring CIA) Referral to stroke team or admit if more than 1 TIA/cardioembolic source or severe cardiac stenosis ``` Management of risk factors - Reduce blood pressure with antihypertensives - Statins - Long term antiplatelet therapy (clopidogrel) - Manage hyperglycemia - Stop smoking programmes - Carotid US to check for stenosis or plaques- endarterectomy - ECG/ECHO- May need long term anticoagulation

Without intervention how many TIA patients will go on to have a stroke?

1 in 12

Can patients drive after a TIA?

Must wait for at least 1 month

What scoring system may be used to assess a patient's risk of having a stroke after TIA?

ABCD- But no longer recommended by NICE