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CVS Pathology > Stroke > Flashcards

Stroke Flashcards

1
Q

Definition of stroke

A

Neurological deficit (loss of function) of sudden onset, lasting more than 24 hours, of vascular origin

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2
Q

What time defines a TIA?

A

< 24 hours

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3
Q

What does TIA stand for?

A

Transient ischaemic attack

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4
Q

Two types of causes of stroke

A
  1. Ischaemic stroke

2. Haemorrhagic stroke

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5
Q

What is the penumbra?

A

Area of tissue in the brain that can get some oxygen from other places and so is “asleep” - not dead

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6
Q

Causes of haemorrhage in stroke

A

Congenital weakness
HTN
Aneurysm

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7
Q

What do the symptoms of stroke correlate to?

A

Part of the brain affected

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8
Q

Main anatomical vessels of the brain

A

Anterior circulation
Posterior circulation
Circle of willis

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9
Q

What supplies the anterior part of the brain?

A

Two carotid arteries

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10
Q

What joins together to form the circle of willis?

A

Anterior and posterior circulations

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11
Q

Where is a clot most likely to go in the circle of willis?

A

Middle cerebral artery (MCA)

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12
Q

What does the carotid system supply?

A

Most of the hemispheres

Cortical deep white matter

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13
Q

What does the vertebra-basilar system supply?

A

Brainstem
Cerebellum
Occipital

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14
Q

What is found anterior to the central sulcus?

A

Motor cortex

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15
Q

What is found posterior to the central sulcus?

A

Sensory cortex

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16
Q

Function of motor cortex

A

Movement

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17
Q

Function of sensory cortex

A

Pain, heat and other sensations

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18
Q

Function of parietal lobe

A

Comprehension of language

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19
Q

Function of temporal lobe

A

Hearing

Intellectual and emotional functions

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20
Q

Function of occipital lobe

A

Primary visual area

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21
Q

Function of wernickes area

A

Speech comprehension

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22
Q

Function of cerebellum

A

Coordination

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23
Q

Function of brainstem

A 
Breathing
Swallowing
Heartbeat 
Wakefullness centre
Involuntary functions
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24
Q

Function of Brocas area

A

Speech

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25
Q

Function of frontal lobe

A

Smell
Judgement
Foresight
Voluntary movement

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26
Q

Definition of TIA

A

Warning stroke or mini stroke, with stroke like symptoms persisting less than 24 hours, that clears without residual ability

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27
Q

How many patients who have a TIA will have an acute stroke at some point?

A

1/3rd

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28
Q

Causes of stroke

A

Blockage of vessel with thrombus or clot
Disease of vessel wall e.g. atheroscleroma
Disturbance of normal properties of the blood e.g. leukaemia
Rupture of the vessel wall (haemorrhage)

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29
Q

What % of strokes are due to infarction?

A

85%

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30
Q

What % of strokes are due to haemorrhage?

A

15%

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31
Q

Causes of ischaemic stroke

A 
Large artery atherosclerosis (e.g. carotid)
Cardioembolic (e.g. AF)
Small artery occlusion (lacunar)
Undetermined/cryptogenic
Rare causes 
- arterial dissection 
- venous sinus thrombosis
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32
Q

Causes of haemorrhagic stroke

A

Primary ICH
Secondary haemorrhage
- SAH
- AV malformation

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33
Q

How does a haemorrhagic stroke affect the brain?

A

Blood causes pressure effects and squashes the surrounding brain tissue

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34
Q

Where do most carotid stenosis occur?

A

Bifurcation

35
Q

Commonest cause of cardioembolic stroke

A

AF

36
Q

What does AF stand for?

A

Atrial fibrillation

37
Q

What does a carotid dissection look like on angiogram?

A

Rat tail appearance

38
Q

Risk factors for stroke

A 
High BP
AF
Age
Race
FH
39
Q

Which type of stroke is more prevalent in high income countries?

A

Ischaemic

40
Q

Risk factors for haemorrhage after stroke

A 
Infarct size
Vessel occlusion 
DM
BP
Age
Stroke severity
Tissue changes
Antiplatelets
41
Q

What is the time frame for giving someone thrombolysis when admitted with stroke?

A

4.5 hours

42
Q

What should not be used for treatment of patients in the acute phase for stroke?

A

Streptokinase

43
Q

Examples of neurological deficits seen in stroke

A

Facial weakness
Limb weakness
Speech disturbances (dysphasia or dysarthria)
Hemianopia

44
Q

Contraindications to thrombolysis

A

Minor neurological deficit or symptoms rapidly improving before the start of infusion
Symptoms of ischaemic attack began more than 4 hours prior to referral, or when time of symptom onset is unknown
Severe stroke
Seizure at onset of stroke
Symptoms suggestive of SAH, even if CT scan is normal
On warfarin or administration of heparin within the previous 48 hours and a thromboplastin time exceeding upper limit
Patients with history of prior stroke AND concomitant stroke
Prior stroke within last 3 months
Platelet count below 100,000/mm3
Systolic BP >185mmHg or diastolic >100mmHg or aggressive meds needed to reduce BP to these limits
BG < 3 or > 20
Known haemorrhagic diathesis , recent severe or dangerous bleeding, known ICH
age > 16 and < 80

45
Q

Who needs a hemicraniectomy in stroke?

A

Patients up to age 60, who suffer acute MCA territory ischaemic stroke complicated by massive cerebral oedema

46
Q

When should a hemicraniectomy be given?

A

Within 48 hours of stroke onset

47
Q

Why do stroke units improve morbidity and mortality?

A

Mobilise early
Swallowing, positioning focus
Early therapy
Concentrating of expertise

48
Q

What % of stroke patients get swallowing problems?

A

50%

49
Q

What is the Neumonic used by the public to remember stroke symptom recognition?

A

FAST

50
Q

Secondary prevention of stroke

A

Clopidogrel or aspirin 75mg plus dipyridamole MR 200mg bd
Statin
BP drugs (even if in normal range)
Carotid endarterectomy

51
Q

Presentation of stroke

A 
Dead numbness
Loss of vision 
Loss of speech (fluid or comprehensive)
Loss of power
Loss of sensation 
Loss of coordination
52
Q

What may the neurological exam of a stroke show?

A 
Clumsy or weak limb 
Loss of sensation 
Dysarthria/dysphagia 
Neglect/visuospatial problems 
Loss of vision in one eye
Hemianopia 
Gaze palsy
Ataxia/vertigo/incoordination/nystagmus
53
Q

If there is a left optic nerve compression, what visual field defect would be present?

A

Unilateral field loss

54
Q

If there is chiasmal compression from a pituitary tumour, what visual field defect would be present?

A

Bitemporal hemianopia

55
Q

If there is a left cerebrovascular event, what visual field defect will be present?

A

Homonymous hemianopia

56
Q

What parts of the brain can a stroke be localised to?

A

Left or right
Carotid territory or vertebrobasilar territory
Cerebral hemispheres or brainstem
Cortex or deep white matter

57
Q

Subtypes of stroke

A

TACS
PACS
LACS
POCS

58
Q

What does TACS stand for?

A

Total anterior circulation stroke

59
Q

What does PACS stand for?

A

Partial anterior circulation stroke

60
Q

What does LACs stand for?

A

Lacunar stroke

61
Q

What does POCS stand for?

A

Posterior circulation stroke

62
Q

What % of strokes are TACS?

A

20%

63
Q

Presentation of TACS

A

Weakness
Sensory deficit
Homonymous hemianopia
Higher cerebral dysfunction (e.g. dysphagia, dyspraxia)

64
Q

What are TACS usually due to?

A

Occlusion of

  • proximal MCA or
  • ICA
65
Q

What % of strokes are PACS?

A

35%

66
Q

Presentation of PACS

A

2/3 of TACS criteria OR

Restricted motor/sensory deficit e.g. one limb, face and hand or cerebral dysfunction alone

67
Q

What is usually affected in PACS?

A

More restricted cortical infarcts - occlusion of branches of MCA

68
Q

Presentation of LACS

A

Since motor fibres travel together and sensory fibres travel together can be either PURE SENSORY or PURE MOTOR
PURE MOTOR is commonest; complete or incomplete weakness of one side, involving 2 or 3 body areas (face/arm/leg)
Ataxic hemiparesis

69
Q

What is ataxic hemiparesis?

A

Hemiparesis and ipsilateral cerebellar ataxia

70
Q

What causes ataxic hemiparesis in LACS?

A

Small infarcts in basal ganglia or pons

Intrinsic disease of single basal perforating artery

71
Q

What % of strokes are POCS?

A

25%

72
Q

What areas can POCS affect?

A

Brainstem
Cerebellum
Occipital lobe

73
Q

Presentation of POCS

A 
Variable, frequently complex
Bilateral motor / sensory deficit 
Disordered conjugate eye movement 
Isolated  homonymous hemianopia
Ipsilateral CN palsy with contralateral sensory / motor deficit 
Coma
Disordered breathing 
Tinnitus 
Vertigo 
Horner's
74
Q

Which type of stroke has the highest mortality?

A

TACS

75
Q

Which type of stroke has the highest recurrence rate at 1 year?

A

POCS

76
Q

Investigations for stroke

A 
FBC
Lipids
ECG
CT 
MRI 
Carotid doppler
ECHO
77
Q

What should patients with AF post stroke be started on?

A

Anticoagulation with warfarin or another anticoagulant

78
Q

What to do with haemorrhagic stroke if on warfarin?

A

Stop warfarin
Give IV Vit K
Prothrombin complex concentrate

79
Q

Management of a patient with AF who has a stroke/TIA

A

Warfarin or a direct thrombin or factor Xa inhibitor

80
Q

What should be started in a patient with a TIA in the absence of AF?

A

Clopidogrel

81
Q

When should a patient with acute stroke (not haemorrhagic) have their anticoagulation started? Why?

A

2 weeks after the event

Due to the risk of hae morrhagic transformation

82
Q

What anti-platelet medication should a patient be put on following a stroke?

A

Aspirin 300mg daily for 2 weeks THEN

Clopidogrel 75mg daily lifelong

83
Q

What does the ABCD2 score look at?

A

Predicts stroke risk following TIA

CVS Pathology (19 decks)

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