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Year 4 - Neurology and Special Senses > Stroke > Flashcards

Stroke Flashcards

1
Q

Cerebellar stroke - pathophysiology

A

Circulation to the cerebellum is impaired due to a lesion of:

  • the superior cerebellar artery,
  • anterior inferior cerebellar artery or
  • the posterior inferior cerebellar artery (also known as lateral medullary syndrome)
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2
Q

Features of cerebellar stroke?

A

It may present similarly to vestibular neuritis

  • vertical nystagmus
  • patients can’t stand without support - even with eyes open
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3
Q

What is vertical nystagmus suggestive of?

A

A CENTRAL cause of vertigo

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4
Q

Criteria of Total anterior circulation infarct

A
  1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  2. homonymous hemianopia
  3. higher cognitive dysfunction e.g. dysphasia

involves middle and anterior cerebral arteries
all 3 of the above criteria are present

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5
Q

Criteria of Partial anterior circulation infarcts

A

involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of the criteria are present

  1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  2. homonymous hemianopia
  3. higher cognitive dysfunction e.g. dysphasia
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6
Q

Criteria of lacunar infarcts

A

involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:

  1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
  2. pure sensory stroke.
  3. ataxic hemiparesis

Most commonly presents as a pure MOTOR HEMIPARESIS, pure SENSORY stroke
SENSOTIMOTOR stroke
ATAXIC hemiparesis or dysarthria/clumsy hand syndrome

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7
Q

Criteria of posterior circulation infarcts

A 
involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
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8
Q

Lateral medullary syndrome?

A

(posterior inferior cerebellar artery)
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss

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9
Q

Weber’s syndrome

A 
type of stroke 
midbrain stroke syndrome
ipsilateral III palsy - diplopia; ptosis; afferent pupillary defect
contralateral weakness (contralateral hemiplegia)
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10
Q

Indications a stroke is ischaemic rather than haemorrhagic?

A

Carotid bruit
previous TIA
atrial fibrillation
ischaemic heart disease

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11
Q

What is the ROSIER score

A

A variant of the FAST screening tool which is useful for medical professionals

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12
Q

What is incorporated in the ROSIER score

A

Loss of consciousness or syncope = - 1 point
Seizure activity = - 1 point

New, acute onset of:	
• asymmetric facial weakness	= + 1 point
• asymmetric arm weakness= 	+ 1 point
• asymmetric leg weakness	= + 1 point
• speech disturbance = + 1 point
• visual field defect = + 1 point
A stroke is likely if >0.
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13
Q

What is the first investigation fro a suspected stroke ?

A

A NON contrast CT head scan

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14
Q

DVLA - stroke or TIA

A

1 month off driving, may not need to inform DVLA if no residual neurological deficit

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15
Q

DVLA - multiple TIAs

A

3 months off driving and inform DVLA

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16
Q

Management of a TIA

A

Immediate antithrombotic therapy:
give ASPIRIN 300 mg immediately, unless:
1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
3. Aspirin is contraindicated: discuss management urgently with the specialist team

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17
Q

If patient has had more than 1 TIA, or a cardioembolic source or severe carotid stenosis…

A

(Crescendo TIA)

Discuss the need for admission or observation urgently with a stroke specialist

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18
Q

If the patient has had a suspected TIA in the last 7 days…

A

Arrange urgent assessment (within 24 hours) by a specialist stroke physician

Advise the person not to drive until they have been seen by a specialist.

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19
Q

If the patient has had a suspected TIA which occurred more than a week previously…

A

Refer for specialist assessment as soon as possible within 7 days

Advise the person not to drive until they have been seen by a specialist.

20
Q

Further management for a stroke…

A

After initial management
Antithrombotic therapy:
- clopidogrel is recommended first-line (as for patients who’ve had a stroke)
- aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel

21
Q

Definition of TIA

A

The definition of a TIA is now TISSUE-based, not time-based: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, WITHOUT acute infarction
It is no longer a focal ischaemic event with symptoms lasting <24 hours.

(Even if symptoms have resolved, evidence of infarct on imaging leads to a diagnosis of stroke rather than a TIA.)

22
Q

Management of acute ischaemic stroke

A

Aspirin 300mg immediately
Continued for 2 weeks after which time long - term antithrombotic treatment should be initiated.
- Clopidogrel
- Aspirin + dipyridamole if clopidogrel

23
Q

Lacunar stroke pathophysiology

A

Occlusion of one of the penetrating arteries that provides blood to the brain’s deep structures.

24
Q

Thrombectomy in acute ischaemic stroke

A

An extended target time of 6-24 hours may be considered if there is the POTENTIAL TO SALVAGE BRAIN TISSUE, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing LIMITED INFARCT core volume

NICE recommends to offer thrombectomy and thrombolysis to people who have had an ischaemic stroke with CT evidence within 6 hours of symptom onset

25
Q

Mechanical thrombectomy

A

NICE recommend that all decisions about thrombectomy take into account a patient’s overall clinical status:
- NICE recommend a pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS)

Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
- confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):

  • confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
  • if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Consider thrombectomy together with intravenous thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes):
who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

26
Q

Stroke by anatomy - Anterior cerebral artery

A

Contralateral hemiparesis and sensory loss, lower extremity > upper

27
Q

Stroke by anatomy - Middle cerebral artery

A

Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia

28
Q

Stroke by anatomy - Posterior cerebral artery

A

Contralateral homonymous hemianopia with macular sparing

Visual agnosia

29
Q

Stroke by anatomy - Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)

A

Ipsilateral CN III palsy

Contralateral weakness of upper and lower extremity

30
Q

Stroke by anatomy - Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)

A

Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus

31
Q

Stroke by anatomy - Anterior inferior cerebellar artery (lateral pontine syndrome)

A

Symptoms are similar to Wallenberg’s (Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus),

but:
Ipsilateral: facial paralysis and deafness

32
Q

Stroke by anatomy - Retinal/ophthalmic artery

A

Amaurosis fugax

33
Q

Stroke by anatomy - Basilar artery

A

‘Locked-in’ syndrome

34
Q

What can mimic a TIA?

A

hypoglycaemia - can lead to focal neurological symptoms

35
Q

TIA - first line for further management?

A

clopidogrel

36
Q

If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, what should occur?

A

They should be admitted immediately for imaging to exclude a haemorrhage

Other patients should be given 300mg of aspirin immediately then assessed by a specialist within 24 hours. First-line secondary prevention is clopidogrel 75mg once daily.

37
Q

thrombectomy in acute ischaemic stroke

A

Thrombectomy should be offered as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
-Acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

therefore thrombolysis and thrombectomy if less than 4.5hrs

38
Q

Lower extremities affected more than upper - what type of stroke

A

Anterior cerebral artery

39
Q

Who is eligible for a carotid artery endarterectomy?

A
  • recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled
  • should only be considered if carotid stenosis > 70%
40
Q

Contraindications to thrombolysis

A
  • Previous intracranial haemorrhage
  • Seizure at onset of stroke
  • Intracranial neoplasm
  • Suspected subarachnoid haemorrhage
  • Stroke or traumatic brain injury in preceding 3 months
  • Lumbar puncture in preceding 7 days
  • Gastrointestinal haemorrhage in preceding 3 weeks
  • Active bleeding
  • Pregnancy
  • Oesophageal varices
  • Uncontrolled hypertension >200/120mmHg

Relative:

  • Concurrent anticoagulation (INR >1.7)
  • Haemorrhagic diathesis
  • Active diabetic haemorrhagic retinopathy
  • Suspected intracardiac thrombus
  • Major surgery / trauma in the preceding 2 weeks
41
Q

If the patient has had a suspected TIA in the last 7 days, what is the Mx?

A

should have 300mg aspirin immediately

arrange urgent assessment (within 24 hours) by a specialist stroke physician

42
Q

Secondary prevention for ischameic stroke

A
  1. Clopidogrel
  2. If not tolerated - aspirin + dipyridamole
  3. MR dipyridamole alone is recommended after an ischaemic stroke only if aspirin or clopidogrel are contraindicated or not tolerated, again with no limit on duration of treatment
43
Q

Up to what time can thrombectomy be offered?

A

For acute ischaemic stroke

Standard target time for thrombectomy is within 6 hours.

However:
Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes)
-IF there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

44
Q

What is thrombolysis and what is the latest time it can be administered?

A

Alteplase

Within 4.5 hours of onset of stroke symptoms

45
Q

After 14 days, what medication should be given for ischaemic stroke?

A
  • Clopidogrel
  • if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation

Year 4 - Neurology and Special Senses (6 decks)

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