Stroke Flashcards
What is a TIA?
Transient ischaemic attack are focal neurological deficits lasting <24hrs
ABCD2 score predicts short term risk of a stroke after a TIA (>=4 - higher risk)
- age, BP, clinical features, DM, duration of symptoms
Suspected TIA
- Aspirin 300mg daily
- Carotid doppler
- CT/MRI head
Mx
- lifestyle modification
- control HTN
- control hypercholesterolemia
- surgical intervention for carotid artery disease
- antiplatelets
Do not drive for a month
Define stroke
Syndrome, focal disturbance of cerebral function, rapidly developing, lasting
>24h, no apparent cause other than vascular origin
What is the aetiology of a stroke?
Infarcts
- large vessel disease
- cardioembolic
- small vessel disease
Haemorrhage
- HTN
- Cerebral amyloid angiopathy
- Trauma
- AVM
- Anticoag-associated
Name the different types of strokes
Total anterior circulation stroke (TACS) - worst prognosis
Partial anterior circulation stoke (PACS)
Lacunar stroke (LAC)
Posterior circulation stroke (POCS)
What tools can be used to assess a stroke?
FAST = face, arms, speech, time
ROSIER = to distinguish between stroke and stroke mimic
NIHSS (NIH stroke scale) = evaluates neurological status, scores on levels of consciousness, language, neglect, visual field loss, extra ocular movement, motor strength, ataxia, dysarthria, sensory loss
Outline a stroke from the anterior cerebral artery
Supplies = Medial brain, paracentral lobules (micturition), corpus callosum
Motor/sensory = lower limb
Present = contralateral, flaccid paralysis followed by spasticity (UMN signs), loss of all sensory, loss of voluntary control of micturition, split brain syndrome, alien hand syndrome
Outline a stroke from the middle cerebral artery
Supplies = superior temporal, lateral aspect of frontal/parietal
Motor/sensory = face, upper limb
Present = contralateral, flaccid paralysis followed by spasticity (UMN signs), loss of all sensory in upper limb and face
Proximal occlusion = face/arm motor, internal capsule carrying motor fibres of face/arms/legs
Distal occlusion = face arms motor
Visual = proximal: contralateral homonymous hemianopia, distal: contralateral homonymous superior or inferior quadrantanopia
Dominant side (L) = Speech: global aphagia, brocas aphasia
Non dominant (R) = hemispatial neglect, tactile extinction, visual extinction, anosognosia, wernickes aphasia
Outline a stoke from the posterior cerebral artery
Supplies = occipital, inferior temporal, midbrain, thalamus
Present = contralateral homonymous hemianopia with macular sparing (supply by PCA + MCA), visual agnosia
Outline a stoke from the cerebellar artery
Supplies = cerebellum, brainstem
Present = distal: DANISH (Dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia), proximal: brainstem as well, ipsilateral cranial N signs
Outline a stroke from the basilar artery
Supplies = occipital lobe, midbrain, thalamus
Present = distal : bilateral, proximal: locked in syndrome
loss of blood supply to pons
Outline a stroke from the lenticulostriate artery
Supplies = internal capsule (posterior: limbs, genu: face), basal ganglia
Present = contralateral paralysis of face and limbs, parkinsonian features
PURE MOTOR
(Lacuna infarcts)
Outline a stroke from the thalamoperforator artery
Supplies = thalamus (relay station for sensory before primary sensory cortex)
Present = contralateral sensory loss of face and limbs
PURE SENSORY
How should stroke in Ix?
CT head - if acute
MRI - if longer history, if suspected stroke in posterior fossa, or brainstem involvement
Bloods = FBC, ESR, CRP, glucose, cholesterol, syphilis
INR
EEG
Carotid doppler
ECHO - valvular assessment, vegetation
CSF - presence on blood in subarachnoid haemorrhage
Serum protein electrophoresis
AutoAb screen
Urine analysis - pheochromocytoma (catecholamines)
Cerebral angiography
Haemostatic profile
Toxicology
Outline the Mx of an ischaemic stroke
Check if ischemic or haemorrhagic - CT head
Aspirin 300mg orally or rectally
Alteplase within 4.5hrs
- Contraindications = previous intracranial haemorrhage, seizure at onset of stroke, intracranial neoplasm, active bleeding, pregnancy, INR >1.7
- CHADS-VASC 2 - determine if anticoag is suitable for pt with AF and are at risk of stroke
Carotid endarterectomy
Mechanical thrombectomy (can perform up to 24h)
Sec prevention = clopidogrel, aspirin, statin, anti-HTN (aim <130), anticoag (HAS-BLED score before starting, INR target 2.5), smoking cessation, diet/exercise with rehab, GP follow up, screen for sleep apnoea, Mx co-morbidities, carotid endarterectomy
Outline the Mx of a haemorrhagic stroke
Stop antcoag
Consult neurosurgeon
Decompressive craniotomy - RICP
Coil embolisation/aneurysm clipping
Shunt insertion (hydrocephalus)
