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Y3 MedEd > Stroke > Flashcards

Stroke Flashcards

1
Q

Which acute neurological conditions can result in collapse? (7)

A 
Stroke/TIA*
Epilepsy*
Guillain-Barré Syndrome
Hydrocephalus
Cord compression
Radiculopathy/spondylopathy
GCS
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2
Q

A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. On examination, power is 2/5 in his right arm, 4/5 in his right leg and 5/5 in his left arm and leg. A CT head scan is performed and an ischaemic stroke is diagnosed.
What type of stroke is it?

Left total anterior circulation stroke
Right anterior cerebral artery stroke
Left middle cerebral artery stroke
Right middle cerebral artery stroke
Left brainstem stroke
A

MCA

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3
Q

Mrs Smith, an 85-year-old woman, is brought to A & E by her husband. When she woke up this morning her husband noticed that Mrs Smith’s smile looked strange and that she was unable to move her right arm. She seemed fine last
night going to bed after watching the news as normal. On examination she had right sided hemiparesis and a positive Babinski sign. A CT-head done at the A & E excluded a haemorrhage. What is the next most appropriate step in her
management?

Carotid doppler
300mg aspirin, orally
75 mg clopidogrel, orally
ECG
IV alteplase
A

Aspirin 300 mg orally

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4
Q

Difference between stroke and TIA?

A

Stroke: A sudden onset focal neurological deficit of
presumed vascular origin lasting more than 24 hours.

Transient Ischaemic Attack (TIA): Same thing but
symptoms resolve in < 24 hours.

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5
Q

How common is stroke?

A

Third leading cause of death in the UK

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6
Q

Three pathological mechanisms of ischaemic stroke

A

Thrombosis
Emboli
Hypotension

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7
Q

What does brain ischaemia due to atherosclerosis affecting mainly smaller cerebral vessels result in?

A

Lacunar infarcts

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8
Q

What three mechanisms can lead to stroke from thrombosis?

A

Atherosclerosis
And prothrombotic states:
Dehydration
Thrombophilia

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9
Q

What four mechanisms can lead to ischaemic stroke from emboli?

A

from intimal flap of carotid dissection
atheromatous plaques in the carotid arteries
from the heart (e.g. atrial fibrillation)
Rarely they can arise fomr venous circulation and pass through a right-left heart defect (VSD)

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10
Q

Which larger cerebral artery is commonly affected by thrombosis?

A

Middle cerebral artery

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11
Q

What is a watershed stroke

A

Defined as abrain ischemiathat is localized to the vulnerable border zones between the tissues supplied by theanterior,posteriorandmiddlecerebral arteries

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12
Q

Pathologies that can lead to intracerebral haemorrhage: (7, 4 common 3 less common)

A

Hypertension, Charcot-Bouchard microaneurysm rupture, amyloid angiopathy, arteriovenous malformation. Less commonly: trauma, tumours, vasculitis

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13
Q

What scoring system is used to assess the risk of stroke in patients with AF

A

CHADSVASC

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14
Q

What scoring system is used to assess the risk of bleeding from anti-coagulation

A

HAS-BLED

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15
Q

Stroke/TIA risk factors (6)

A 
Hypertension
Diabetes
Obesity
Old age
Hypercholesterolaemia
Smoking
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16
Q

Stroke presentation: (5)

A 
SUDDEN onset
Weakness/numbness in the face, arm or leg
Change in vision
Dizziness, loss of coordination/balance
Problems with speech
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17
Q

Pointers to ischaemic stroke (4)

A

carotid bruit, AF, past TIA, IHD

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18
Q

Pointers to haemorrhagic stroke (2)

A

meningism, severe headache

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19
Q

Which artery supplies the medial aspect of the frontal and parietal lobes

A

ACA

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20
Q

What part of the brain does the ACA supply

A

The medial aspect of the frontal and parietal lobes

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21
Q

Which artery supplies the lateral surface of the hemispheres

A

MCA

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22
Q

Which artery supplies subcortical structures

A

MCA

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23
Q

What does the MCA supply

A

The lateral surface of the frontal and parietal lobe, the superior-lateral part of the temporal lobe and also subcortical structures

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24
Q

Which artery does the ACA arise from

A

Terminal branch of the internal carotid artery

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25
Q

Which artery does the MCA arise from

A

Branch of the internal carotid artery

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26
Q

Which artery does the PCA arise from

A

Basilar artery

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27
Q

What does the PCA supply

A

The occipital lobe and the inferomedial part of the temporal lobe.

28
Q

What artery supplies the occipital lobe

A

PCA

29
Q

What are the distinguishing features of an anterior cerebral artery stroke (2)

A

Contralateral hemiparesis affecting the lower limb more than the upper limb

Behavioural changes

30
Q

What are the distinguishing features of a middle cerebral artery stroke (5)

A 
Contralateral hemiparesis affecting the upper limb/face more than the lower limb
Contralateral hemisensory loss
Apraxia
Aphasia
Quadrantopias
31
Q

Which cerebral artery stroke causes apraxia and why

A

MCA. Apraxia is a disorder of skilled movement. If you think about it it makes sense to have this in lesions where the parietal lobe is affected, bc the parietal lobe is involved in bringing together and combining information needed to perform skillfull actions.

32
Q

Which cerebral artery stroke causes contralateral hemisensory loss and why

A

MCA bc somatosensory cortex (parietal lobe) is affected

33
Q

Which cerebral artery stroke causes aphasia and why

A

Left MCA as language centres there

34
Q

What are the 2 types of aphasia and which area is responsible for is which

A

Broca’s area: responsible for speech production (expressive aphasia)
Wernicke’s area: responsible for language comprehension (receptive aphasia)

35
Q

Which cerebral artery stroke causes contralateral visual loss and why

A

With an MCA stroke you might get visual problems manifesting as quadranopias if the optic radiations are affected. (look again at Dan’s CNS lecture for details of visual pathway)
Optic radiation: contain tracts that carry information from lateral geniculate nucleus to the primary visual cortex in 2 loops:

Meyer’s = inferior optic radiation. They pass through the temporal lobe. If cut causes superior quadrantopia.
Baum’s = superior optic radiation. They pass through the parietal lobe. If cut causes inferior quadrantopia
36
Q

What are the distinguishing features of a posterior cerebral artery stroke (2)

A

Homonymous contralateral hemianopia

Visual agnosia

37
Q

Why can PCA stroke be macular sparing (2)

A

macular representation, found at the posterior pole of the occipital lobe, is disproportionately large. Because of the large macular representation, as well as the dual blood supply to the posterior occipital lobe (both PCA and MCA), sparing of the centre of the visual field is commonly found with occipital lobe lesions

38
Q

What are the 6 signs of cerebellar damage?

A 
Dysdiadochokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/Heel-shin test
39
Q

A lesion in one cerebellar hemisphere will cause motor deficits on which side of the body and why

A

Ipsilateral bc pathways from the cerebellum to the lateral motor systems and then to the periphery are“double crossed”

40
Q

What signifies brainstem stroke damage

A

↓ consciousness

CN pathology

41
Q

What is the internal capsule

A

is the white matter tract where the pyramidal UMN axons from the primary motor cortex travel through before reaching the brain stem.

42
Q

What can internal capsule lacunar infarcts present with

A

Pure motor deficit

43
Q

What can pontine lacunar infarcts present with

A

Dizziness/vertigo, bilateral affected

44
Q

What can thalamic lacunar infarcts present with

A

Affected consciousness

45
Q

What can basal ganglia lacunar infarcts present with

A

Dyskinesias

46
Q

What causes amaurosis fugax

A

to occlusion of the retinal artery which is a branch of the ophthalmic artery which is a branch of the ICA

47
Q

Where do lacunar infarcts occur (4)

A

the deep cerebral white matter of the internal capsule, basal ganglia, thalamus or pons

48
Q

What defines a total anterior circulation stroke

A

All 3 of:
Contralateral motor or sensory deficit
Homonymous hemianopia
Higher cortical dysfunction

49
Q

What defines a partial anterior circulation stroke

A

2 of:
Contralateral motor or sensory deficit
Homonymous hemianopia
Higher cortical dysfunction

50
Q

What defines a posterior circulation stroke

A

Any of:
Isolated homonymous hemianopia
Brainstem signs
Cerebellar ataxia

51
Q

What defines a lacunar circulation stroke

A

Any of:
Pure motor deficit
Pure sensory deficit
Sensorimotor deficit

52
Q

Ix for a suspected stroke (4)

A

Urgent within 1 hour non-contrast CT head
Bloods
ECG
Vital signs

53
Q

What bloods do you request in someone with a stroke and why (6)

A

Serum glucose (exclude hypoglycaemia as a cause for focal neurological signs)

FBC (excludes anaemia or thrombocytopaenia prior to possible initiation of thrombolytics, anticoagulants, antithrombotics)

Electrolytes (to exclude electrolyte disturbance as a cause for focal neurological signs)

Urea and creatinine (to exclude renal failure – renal failure might be a potential contraindication to some interventions)

Partial thromboplastin and prothrombin times (with international normalised ratio)

Cardiac enzymes (stroke may be associated with concomitant MI

54
Q

Why do we do an ECG in suspected stroke

A

An ECG should be performed to exclude cardiac arrhythmia or ischaemia, which are relatively common in ischaemic stroke.

55
Q

When should you delay the administration of rTPA

A

the presence of hypoglycaemia has been associated with autonomic and neurological symptoms, including stroke mimics and seizures, and hyperglycaemia has been associated with intracerebral bleeding and worse clinical outcomes in patients treated with r-tPA

56
Q

Why is lowering blood pressure bad in strokes

A

Lowering BP could reduce cerebral perfusion pressure and promote stroke extension

57
Q

Mx of stroke (think about time)

A

< 4.5 hours
↓
IV alteplase
(recombinant tissue plasminogen activator, r-tPA)
Then give aspirin 24 hours later and ONLY after CT head shows lack of haemorrhage (300 mg, oral)

> 4.5 hours
OR thrombolysis is contraindicated*:
↓
Aspirin (300 mg, oral)

58
Q

Contraindications for thrombolysis (7)

A

onset of symptoms >4.5 hrs, CT reveals acute trauma or haemorrhage, symptoms suggestive of SAH, high INR, APPT, PT

59
Q

What is alteplase

A

recombinant tissue plasminogen activator, r-tPA

60
Q

What further management is involved in a stroke patient (3)

A

Swallowing assessment
VTE prophylaxis
GCS monitoring

61
Q

What is used to identify patients who are eligible and what is the criteria for carotid endarterectomy

A

Carotid doppler showing stenosis over 70% or

50-69% and symptomatic

62
Q

Secondary prevention of stroke in AF patients

A

Warfarin prophylaxis

63
Q

Secondary prevention of stroke in non-AF patients

A

Continue aspirin for 2 weeks then switch to lifelong clopidogrel

64
Q

Mx of haemorrhagic stroke

A

Neurosurgical evaluation
leading to either:
Surgery
ICU/stroke unit for monitoring and support

65
Q

Complications of stroke (7)

A 
Aspiration pneumonia
Cerebral oedema (↑ ICP)
Immobility
Depression
DVT
Seizures
Death
66
Q

Prognosis for strokes

A

10% mortality in the first month
Up to 50% that survive will be dependent on others
10% recurrence within 1 year
Prognosis for haemorrhagic is WORSE than ischaemic
For patients with TIA, 8% will have a stroke during hospitalization and >10% in the next 3 months
ABCD2 score estimates the risk of stroke after TIA

Y3 MedEd (34 decks)

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