Stroke Flashcards
What are the 4 characteristic features of a stroke syndrome?
- neurological distruption evolves suddenly
- deficit is focal
- neuological symptoms are predominantly negative (loss of movement/ sensation rather than gain eg tremour)
- symptoms should fit into a vascular territory- almost impossible to get two strokes at the same time
Describe the clinical features required for a total anterior circulation stroke (proximal MCA or ICA occulsion) and partial anterior circulation stroke syndrome (branch of MCA)
TACS: hemiparesis AND higher cortical dysfunction (dysphasia/ neglect) AND homonymous hemianopia
PACS: isolated higher cortical dysfunction OR any two of: hemiparesis, higher cortical dysfunction and hemianopia
What sides of the brain are affected to cause neglect/ alien hand/ visual or tactile extinction and to cause dysphasia
dysphasia: left/ dominant hemisphere
neglect: right hemisphere (parietal lobe
Describe the clincial features for posterior circulation stroke? (PCA, cerebellar, vertebral or cerebellar vessels)
POCS: isolated hemianopia (PCA), brainstem (bulbar) or cerebellar syndromes
Describe the clinical features of a lacunar stroke syndrome (lenticulostiate or thalamoperforator vessel occlusion)
LACS: pure motor stroke OR pure sensory stroke OR sensorimotor stroke OR ataxic hemiparesis OR clumsy hand dysarthria
What is stereotyping and migration of symptoms?
- stereotyping: episodic recurrance of symptoms- more likley migraine or seizure
- migration of symptoms: slow sequential change of symptoms as different parts of brain are affected, again more likely to be migraine or seizure
List 5 differentials for stroke
- seizure
- migraine
- space occupying lesions
- MS
- subdural haematoma
- BPPV/ vestibular neuronitis
- transient global amnesia
- functional syndrome
- amyloid spells
What is apparent neurological deficit?
Neuro dysfunction in pts with chronic stroke but seemingly good recovery and residual areas of scar tissue. Symptoms can return (ie become apparent) due to underperformance of the scar tissue in context of suboptimal physiology eg infection, low BP, hypoglycaemia, hypoxia, fatigue etc. They go back to normal with return of baseline function.
List 5 stoke charmelons (atypical strokes)
- venous infarcts (gradual onset, ++ seizure activity)
- small cortical strokes (cause peripheral nerve lesions)
- limb shaking TIA (mistaken for seizure)
- occipital strokes (predominantly presents with confusion and visual feild defect is often missed)
- stroke amnestic syndromes
- stroke mimicking vestibular dysfunction
What is the NIHSS assessment used for?What broad areas does it test?
- score for severity of stroke
- assesses level of consciousness, gaze, visual feilds, facial paresis, motor function, limb ataxia, sensation, language, dysarthria, extinction and inattention
Describe the findings of non contrast CT in ischaemic and haemorrhagic strokes
- ‘stroke protocol’ MRI will also be done
- Early signs of ischaemia: effacement (loss of grey/ white matter distinction) due to electrolyte shifts and brain swelling, as well as increased density of the relevant blood vessel
- Haemorrhage: increased attenuation (density)- need to report on the location, size, age and presence of complications eg hydrocephalus
What is are the commonest underlying cause of deep (basal ganglia or cerebellum) and peripheral/ lobar bleeds?
Deep bleeds usually due to HTN
Lobar/ peripheral bleeds have variety of causes: underlying tumour, vascular abnormality eg AVM or aneurysm, vascular degeneration eg cerebral amyloid angiopathy
What is cerebral amyloid angiopathy
deposits of amyloid in blood vessel walls which weakens them- seen with age and dementia. cause of peripheral strokes
What type of strokes are commonly caused by cardiac emboli and how should these strokes be investigated for the exact source?
- cause partial anterior circulation strokes, multifocal and lacuna strokes
- from AF–> do 24-72 hr ecg
- valvular heart disease/ endocarditis–> ascultation and echo
- post MI–> PMH. ecg,echo
What type of strokes are caused by large vessel emboli and how should they be investigated?
- PACs and TACS
- carotid duplex USS
When should vasculitis be suspected as a cause of stroke
suspect in elderly lady with history of headache for few months, weightloss, lethargy, pallor, temporal arteritis symptoms or the pt with history of SLE or young and no other RFs
when should thrombophilia be suspected as a cause of stroke?
- in pregnancy
- hx VTE
- multiple miscarriages
- active cancer
What type of stroke does arteriosclerosis cause and which pts tend to get them
- LACS
- diabetic and/ or hypertensive pts
What stroke classication relates to the cause of strokes
TOAST classification
What background factors predispose someone to a stroke and should be checked in all pts
- diabetes
- htn
- obesity
- dyslipidaemia
- age
- fhx
What complications are important to consider post stroke (9)
- death
- raised ICP
- reoccurrance and extension of stroke
- complications of immobility (VTE, constipation, bed sores)
- infections (resp common due to aspiration, UTIs due to incomplete bladder emptying, constipation and bed bound posture)
- mood and cognitive disorders (delerium, depression)
- pain and fatigue
- secondary epilepsy
When does stroke reoccurance and extension occur?
- when cause not addressed or secondary prevention not put in place
- when havent maximised physiology fast enough so stroke extends
What can caused raised ICP in stroke
- haematoma expansion
- malignant odema
- haemorrhagic transformation
- hydrocephalus
How should pain and fatigue be managed post stroke
- related to spasticity (splints, physio, botulinum, antispasmodics)
- joint dislocation (relocate, WHO pain ladder)
- neuropathic (pregabalin, gabapentin, amitriptyline)
When can IV alteplase be used
- ischaemic stroke
- when some brain tissue damaged but not dead (penumbra)
- within 4.5 hrs onset symptoms
- no contraindications
- disabling impairment so worth risk
- able to monitor during bolus with regular haemodynamic and neuro obs
give 5 contraindications for fibrinolysis
- BP> 185/110 after attempts to reduce
- Surgery or trauma in last 14 days
- Stroke in last 14 days
- Active internal bleeding
- Haematological abnormalities
- INR >1.7 or APTT >40, platelets <40
- On anticoag or LMWH
- LP or ABG at non compressable site in last 7 days
- SAH symptoms even if CT normal
- Infective endocarditis
- Childbirth within 1 month
- Acute pancreatitis
- Severe liver disease
- Many other relative contraindications
What is an ASPECTS score?
a 10-point quantitative topographic CT scan score used in patients with middle cerebral artery (MCA) stroke. Segmental assessment of the MCA vascular territory is made and 1 point is deducted from the initial score of 10 for every region involved. Used in revascularisation therapies for patient selection and outcome prediction.
How should haemorrhagic strokes be managed?
- BP control
- Correct clotting derangement
- Decompressive hemicraniotomy (for malignant odema in pts <60, needs to be done within 48 hrs and pt will have large deficit after so dicuss carefully)
- Interventions for intracerebral haemorrhage (ventricular drains or evacuation of haematomas)
how should physiology be optomised post stroke? (5)
- good glycaemic control (brain needs glucose)
- May need ng or peg feed if swallow isnt safe but avoid if end of life as risky and little to gain
- swallow assesment by salt and may inc video fluoroscopy
- treat infections and metabolic derangement
- good BP control
What lifestyle modifications should be made for secondary prevention of stroke?
- stop smoking
- BMI <25
- avoid alcohol
- low fat, salt and sugar diet, high fibre
- 2-5x 30min aerobic exercise a week
What antiplatelet therapy should be given for strokes and for TIAs?
- 300mg aspirin for suspected TIAs
- confirm ischaemic stroke or TIA confirmed by imaging should getb 75mg clopidogrel
- start clopidogrel 24 hrs after thrombolysis
- think about anticoagulation or appendage closures if contraindicated in AF
- do CHADS VASC to assess need
Other than antiplatelets what pharmacological secondary prevention may be considered?
- BP control (130/80 target)
- statins (TC <4 and LDLs<2 target)
- glycaemic control (HbA1c >7 target)
What are important considerations for post stroke rehab?
- goal orientated exercises to maximise independence
- mobility, ADL, speech and cognitive rehab
- prosthesis
- botulinum toxin injections
- environmental modification
How long must you stop driving for after TIA/ stroke?
4 week, 1 yr for HGV
How are suspected TIAs managed?
2 prevention
300mg aspirin until confirmed (then clopidogrel)
all referred to TIA clinic within 24hrs (unless presents after more than 7 days, in which case see within 7 days)
driving rules if confirmed
carotid doppler- if >70% stenossi then CT/MR angiogram and carotid endartectomy
What factors can indicate how well a pt is likely todo after a stroke?
- NIHSS score
- OSCP class
- complications
- recovery trajectory
- type of deficit
how should TIA be investigated?
- carotid doppler- CT or MR angiography for further evaluation of stenosis
- ESR for vaculitis
- FBC for hypercoagulable states
- Hba1c
- lipids
- clotting studies
- CT brain not routinely indicated, MRI in some cases is
- Echo/ ECG
When is carotid enarterectomy indicated?
- fit pts who can tolerate surgery
AND - symptomatic TIA/ stoke with good recovery in last 6 months involving anterior circulation
AND - > 70% carotid stenosis
(absence of bruit doesnt exclude stenosis)
What vessels are affected if the pt has wernickers and brocas aphasia?
Wernickers (receptive)= Inferior division of left MCA
Brocas (expressive)= Superior division of left MCA
Where do the lenticulostriate and thalamoperforator arteries come from?
Lenticulostriate branches off proximal part of MCA
thalamoperforator is branch of PCA
What deficits can you get from a anterior cerebral artery stroke?
- Loss of medial motor and sensory homonculus: contralateral motor and sensory loss in lower limbs (if upper limb and/or face then due to proximal mca taking out lenticulostriate or lateral motor homonculus)
- loss of l centre so loss of voluntary control of micturition
- split brain and alien hand due to loss of anterior corpus callosum
