Stroke is: 1. An acute onset 2. Neurological deficit 3. Of vascular origin 4. Lasting \>24hrs It is subdivided into: 1. ischaemic stroke (caused by vascular occlusion or stenosis) (87%) 2. haemorrhagic stroke (caused by vascular rupture, resulting in intra-parenchymal and/or subarachnoid haemorrhage). (10% and SAH 3%)

Stroke Flashcards by Zuzanna Łoboda

Define stroke.

Stroke is:

An acute onset
Neurological deficit
Of vascular origin
Lasting >24hrs

It is subdivided into:

ischaemic stroke (caused by vascular occlusion or stenosis) (87%)
haemorrhagic stroke (caused by vascular rupture, resulting in intra-parenchymal and/or subarachnoid haemorrhage). (10% and SAH 3%)

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What are the risk factors for ischaemic stroke?

Non-modifiable:

Old age
FH

Modifiable:

HTN
Smoking
Diabetes
Dyslipidaemia
AF
Comorbid cardiac conditions - valvular disease, congestive HF
Carotid artery stenosis
Sickle cell disease

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What are the risk factors for haemorrhagic stroke?

Cerebral amyloid angiopathy (related to dementias)
Haemophilia
HTN
Smoking
FH e.g. heritable connective tissue disease
Anticoagulation
Use of illicit sympathomimetic drugs
Vascular malformations
Moyamoya syndrome

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Describe the aetiology of ischaemic stroke.

TOAST criteria classify ischaemic stroke according to pathophysiology

Large artery atherosclerosis (usually >50%) - most commonly extracranial carotid or vertebral arteries or less commonly intracranial arteries. A site for thrombus formation which embolises to distal sites.

Cardioembolism e.g. in AF a thrombus forms in heart and embolises to intracranial circulation

Small vessel occlusion (lacunar) - caused by lipid accumulation due to ageing and hypertension

Other causes: vasculitis, arterial dissection, venous thrombosis, hypercoagulable states, SCD, antiphospholipid antibody syndrome.

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What is classification of stroke based on vascular territory of infarction?

Bamford classification

Total anterior circulation infarction
Partial anterior circulation syndrome
Lacunar infarction
Posterior circulation infarction.

TACI(3/3)/PACI(⅔):

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

POCI:

Involves vertebrobasilar arteries
presents with 1 of the following:
- 1. cerebellar or brainstem syndromes
- 2. loss of consciousness
- 1. isolated homonymous hemianopia
- e.g. Cranial nerve syndromes, Horner’s syndrome, Cerebellar syndromes

LACI (involves internal capsule, thalamus, 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.
- 1. pure sensory stroke.
- 1. ataxic hemiparesis

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What type of stroke causes cranial nerve deficits and visual field defects?

Posterior circulation stroke

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Describe the cortical vascular territories of the brain.

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What type of stroke affects face and/or limbs?

Anterior circulation stroke

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Describe arm and leg involvement in a MCA and ACA strokes.

MCA - affects arm more than the leg

ACA - affects leg more than the arm

Due to the layout of the motor homunculus in the primary motor cortex.

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What are the clinical features of an MCA stroke?

Contralateral hemiparesis/hemiplegia
Contralateral sensory loss
Contralateral homonymous hemianopsia
Left hemispheric : aphasia (Broca’s)
Right hemispheric: visual perception deficits including left neglect

Left neglect (R lesion) is more common than right neglect because right hemisphere regulates attention more than left hemisphere so when it is knocked out there is nothing to compensate for left hemisphere in stroke.

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What are the different types of aphasia?

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What is the pathophysiology of haemorrhagic stroke?

Bleeding into parenchyma causes primary mechanical injury to brain tissue

Expanding haematoma may cause secondary injury due to mass effect, increased ICP and reduced perfusion causing ischaemia or even cerebral herniation

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What is the most important part of a history in stroke?

Time of onset (apart from neurological symptoms)

Seconds or minutes and may be preceded by one or more TIA

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What are the signs of stroke? Distinguish between ischaemic and haemorrhagic.

Worst at onset

Pointers to haemorrhagic: (unreliable)

Meningism
Severe headache
Coma

Pointers to ischaemia:

Carotid bruit
AF
Past TIA
IHD

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What are the signs and symptoms of cerebral infarcts?

(make up 50%)

Depending on site

Contralateral sensory loss or hemiplegia
Initially flaccid (floppy limb)
Becomes spastic (UMN)
Dysphasia
Homonymous hemianopia
Visuo-spatial deficit

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What are the signs and symptoms of brainstem infarcts?

(make up 25%)

Varied

quadriplegia
disturbances in gaze and vision
locked-in syndrome (aware but unable to respond)

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What are the signs and symptoms of lacunar infarcts? What are the locations commonly affected?

Study These Flashcards

(make up 25%)

Affect:

basal ganglia
internal capsule
thalamus
pons

Present with:

ataxic hemiparesis - dysarthria/clumsy hand
pure motor or sensorimotor
pure sensory

Intact cognition/consciousness except in thalamic strokes

CT or MRI for stroke?

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Diffusion-weighted MRI is most sensitive for acute infarct

but CT rules out primary haemorrhage

List some contraindications to thrombolysis.

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What is the acute management of ischaemic stroke?

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Admission to acute stroke unit

Strict supportive management -

Glucose - 4-11mmol/L
Oxygen - maintain at 95%
BP - do not lower in the acute phase unless there is HTN encephalopathy; consider lowering to at least 185/110mmHg in those going for IV thrombolysis
NBM

Exclude haemorrhage (CT) and confirm stroke then:

Aspirin 300mg PO/PR ASAP and OD for 2 weeks or until discharge +/- PPI
Thrombolysis - alteplase - if <4.5hrs since symptom onset. Given by stroke team only.
+/- Thrombectomy - within 6hrs (up to 24hrs) of SO; for those with a large artery occlusion in proximal anterior circulation (on CT/MRA)

Delayed treatment

Statin - if TC >3.5mmol/L; 48hrs after acute phase unless already had a statin prescribed
Anticoagulation for AF - 14 days after acute phase
Carotid endarterectomy - if non-disabling stroke in carotid territory and occlusion >70% ECST or >50% NASCET

When would you consider thrombectomy?

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Otherwise given alone if:

SO up to 24hrs ago
Occlusion of proximal anterior circulation
Potential to salvage brain tissue

NB: thrombectomy can be given in ADDITION to thrombolysis if within 24hrs and there is a proximal POSTERIOR infarct that has hope of tissue salvage with thrombectomy.

What is the management of haemorrhagic stroke?

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Stop anticoagulants and antithrombotics

Supportive -

Glucose - 4-11mmol/L
BP - consider rapid BP lowering if BP 150-220mmHg and no CI (next card); lower to 140mmHg but by no more than 60mmHg within an hour.
Oxygen- target of 95%

Neurosurgery referral

Decompressive hemicraniectomy - within 48hrs of symptoms in certain patients

What are contraindications for lowering BP in haemorrhagic stroke? (NICE)

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Tumour, AVM etc causing the stroke
GCS <6
Candidate for surgery to evacuate haematoma
Massive haematoma with poor expected prognosis

Describe management for re-enablement after stroke.

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MDT care on a stroke unit is essential –> better patient outcomes

Formal assessment by SALT to assess swallowing
Physiotherapy - minimise spasticity
Avoid early catheterisation - ensure good bladder and bowel function
Monitor mood - help with depression in patient and carer
Involve carer/spouse in all aspects

Describe the steps taken for primary and secondary prevention of stroke.

**Primary prevention** - before any stroke correct: * **HTN** * **Hypercholesterolaemia** * Cardiac disease * Smoking * Exercise * Diabetes * Use lifelong anticoagulation in AF and prosthetic heart valves **Secondary preventio**n - to prevent further strokes: * Control above risk factors * Antiplatelets * 2 weeks aspirin 300mg * long term clopidogrel monotherapy OR dipyridamole plus aspirin

Summarise the secondary prevention management of ischaemic stroke.

**Antiplatelet agents** - aspirin 300mg immediately and for 2 weeks then clopidogrel 75mg OD long-term\* **Statin** - if cholesterol \>3.5mmol/L, delayed 48hrs after stroke **Anti-hypertensives** - aim for 130mHg (or 140mmHg if severe carotid stenosis) **Anticoagulation** (not if in sinus rhythm) - start anticoagulation at 14days ; Optimise other risk factors: DM, HTN, OSA, HF, obesity, AF, HRT, stop COCP, SCD, annual flu jab, DVLA. \*MR dipyridamole 200mg BD if aspirin/clopidogrel CI .

How is a patient's clinical status for thrombectomy assessed?

**Modified Rankin scale or National Institutes of Health Stroke Scale** - NICE recommend a pre-stroke functional status \<3 on the mRS and a score of \> 5 on the NIHSS

What is the prognosis with stroke?

* Overall mortality 60,000/yr in UK * 20% mortality at 1 month then \<10%/year * \<40% fully recover * Drowsiness = poor prognosis * Avoid pressure ulcers

How do you test for apraxia?

Dressing or copying a clock face

How do you test for agnosia?

Picking out and naming easy objects from a pile Agnosia = acuity ok, but cannot mime use; guesses are way-out, semantically, and phonetically

How do you test spatial ability?

Copying matchstick patterns

What are the different types of aphasia?

What side is the stroke on? An 84-year-old right-handed man presents to the emergency department having developed sudden onset unilateral weakness an hour ago. On examination, he is not aphasic (speech is fully intact) but he has homonymous hemianopia. CT shows anterior circulation stroke.

He is right-handed and therefore his speech centre is in the left hemisphere. The patient is not aphasic, and so, the left hemisphere of the brain is intact. He must have had a right-sided stroke which would result in contralateral, left-sided weakness.

What medications are used to control HTN after a stroke?

IV labetalol IV GTN

What are the signs of a cerebellar stroke?

**V**ertigo +/- vomiting **A**taxia (i.e. loss of coordination) **N**ystagmus (Holmes) Rebound phenomenon on examination

What kind of VTE prophylaxis is used in stroke?

IPC - intermittent pneumatic compression

What is PICA stroke syndrome?

Lateral medullary syndrome (posterior inferior cerebellar artery) = WALLENBERG'S syndrome Ipsilateral: facial numbness, ataxia/nystagmus, dysphagia, CN palsy e.g. Horner's Contralateral: limb numbness

What is Weber syndrome?

* Ipsilateral CN III palsy * Contralateral weakness

What does the FAST campaign mean?

* **F**ace - 'Has their face fallen on one side? Can they smile?' * **A**rms - 'Can they raise both arms and keep them there?' * **S**peech - 'Is their speech slurred?' * **T**time - 'Time to call 999 if you see any single one of these signs.'

At the time of writing (August 2019), the DVLA’s guidelines (available at gov.uk) state that ‘homonymous or bitemporal defects … are not usually acceptable for driving’. ## Footnote **He may not drive for the time being and must inform the DVLA who will probably not allow him to drive**

The pathology must be on the right side. It may be confined to the visual system and cause no other features, but it may extend into the right parietal lobe causing neglect, or the right frontal lobe causing left-sided weakness. Language problems are almost always due to left-sided brain lesions. **Lesions in the cerebral hemispheres do not as a rule cause diplopia.** * Left arm weakness * Somatosensory neglect

Stroke Flashcards

(41 cards)