Stroke Flashcards
List the publicity campaign’s Signs of Stroke using the Acronym.
FAST
Face: Face fallen on one side/cannot smile
Arms: cannot raise both arms and maintain them there
Speech: Speak clearly and coherently
Time: Call 999
Outline the Local (Fife) Protocol regarding Strokes.
Hospital admission for immediate assessment, investigation and treatment.
CT scanned on day of admission
Water swallow screening test on day of admission
Admit to stroke unit (90% target)
Suspected TIAs refer to TIA clinic - 4 per week in NHS Fife.
- Electronic referrals to TIA clinics screened daily by stroke consultant
What is a TIA?
Sudden loss of focal or monocular function due to ischaemia from micro emboli or microthrombi associated with arterial, cardiac or haematolgical disease with symptoms lasting less than 24 hours
Suggest 5 focal neurological categories of symptoms. For each category, give an example of a symptom.
Motor:
- Hemiparesis
- Bilateral weakness
- Dysphagia
- Ataxia
Speech/Language:
- Dysphagia
- Dysgraphia
- Dyscalculia
- Dysarthria
Sensory:
- Somatosensory (hemisensory disturbance)
- Sensory inattention
Visual:
- Amaurosis fugax
- Homonomous hemianopia
- Quadrantanopia
- Diplopia
Vestibular:
- Vertigo
Behavioural/Cognitive: - Difficulty dressing - Combing hair - Cleaning hair Cleaning teeth Visualspatial-perception dysfunction
List 5 symptoms which are non-focal neurological symptoms. What might these suggest?
- Generalised weakness ± sensory disturbance
- Light headedness/faintness
- Blackouts with altered/loss of consciousness fainting ± impaired vision in both eyes
- Incontinence of urine or faeces
- Confusion
- Intermittent diplopia
Any if isolated:
- Vertigo
- Tinnitus
- Dysphagia
- Dysarthria
- Diplopia
- Ataxia
Consider:
- Hypoglycaemia
- Migraines
- Focal epilepsy
- Syncope
- Cerebral hypoperfusion
What arteries supply the anteriomedial area of the cerebrum?
Anterior cerebral arteries
What arteries supply the lateral area of the cerebrum?
Middle cerebral arteries
What arteries supply the posterior area of the cerebrum?
Posterior cerebral arteries
Give the criteria for a TACS Ischaemic Stroke.
What does this stand for?
- Unilateral weakness
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphagia, visuospatial disorder)
TACS = Total Anterior Cerebral Stroke
Give the criteria for a PACS.
What does this stand for?
2/3
- Unilateral weakness
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphagia, visuospatial disorder)
PACS = Partial Anterior Circulation Stroke
Give the criteria for a LACS.
What does this stand for?
One of the following:
- Sensory stroke
- Motor stroke
- Sensori-motor stroke
- Ataxic hemiparesis
Give the criteria for a POCS.
What does this stand for?
One of the following:
- Cerebellar syndrome: DANISH
- Cranial nerve palsy and a contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement (e.g. gaze palsy)
- Isolated homonymous hemianopia or cortical blindness
BICCC
A patient presents following a sudden bilateral motor deficit. O/E everything else is fine however he cannot move both arms.
A CT scan shows occlusion of a blood vessel in the brain.
Where is this occlusion most likely to be?
What type of stroke would this be?
Using the Bamford Classification of Stroke, what type of stroke is this?
Posterior Cerebral Artery
Ischaemic
POCS:
- Bilateral motor/sensory deficit
- Isolated homonymous hemianopia
- Cranial nerve palsy and contralateral motor/sensory deficit
- Cerebellar Syndrome: DANISH
- Conjugate eye movement
A patient presents following a sudden cranial nerve palsy and contralateral sensory deficit. O/E everything else is fine however he cannot move both arms.
A CT scan shows occlusion of a blood vessel in the brain.
Where is this occlusion most likely to be?
What type of stroke would this be?
Using the Bamford Classification of Stroke, what type of stroke is this?
Posterior Cerebral Artery
Ischaemic
POCS:
- Bilateral motor/sensory deficit
- Isolated homonymous hemianopia
- Cranial nerve palsy and contralateral motor/sensory deficit
- Cerebellar Syndrome: DANISH
- Conjugate eye movement
A patient presents following a sudden nystagmus, ataxia, intention tremor and dysdiadochokinesia. O/E everything else is fine however he cannot move both arms.
A CT scan shows occlusion of a blood vessel in the brain.
Where is this occlusion most likely to be?
What type of stroke would this be?
Using the Bamford Classification of Stroke, what type of stroke is this?
Posterior Cerebral Artery
Ischaemic
POCS:
- Bilateral motor/sensory deficit
- Isolated homonymous hemianopia
- Cranial nerve palsy and contralateral motor/sensory deficit
- Cerebellar Syndrome: DANISH
- Conjugate eye movement
A patient presents following a sudden change in eye movement identified to be a conjugate eye movement. O/E everything else is fine however he cannot move both arms.
A CT scan shows occlusion of a blood vessel in the brain.
Where is this occlusion most likely to be?
What type of stroke would this be?
Using the Bamford Classification of Stroke, what type of stroke is this?
Posterior Cerebral Artery
Ischaemic
POCS:
- Bilateral motor/sensory deficit
- Isolated homonymous hemianopia
- Cranial nerve palsy and contralateral motor/sensory deficit
- Cerebellar Syndrome: DANISH
- Conjugate eye movement
a 67 year old patient presents with a feeling of complete weakness on one half of their body, visual disturbances and has said they no longer recognise space as well.
O/E you identify they have weak swallowing, confirmed by their recent anorexia due to difficulty swallowing, you identify vision loss on the L side in both eyes and confirm the hemiparesis.
What are these signs and symptoms and what are they suggestive of?
Where would the stroke most likely be and what area of brain would this affect?
What type of Stroke is this and give the Bamford classification.
- Hemiparesis
- Dysphagia
- Homonymous hemiparesis
Ischaemic stroke
Anterior cerebral arteries
Anteromedial brain
TACS
A 54 year old patient presents with a pure sensory stroke. What type of stroke is this using the Bamford classification of strokes?
Lacunar Syndrome (LACS)
Which is the largest branch of the Internal Carotid Artery?
Middle Cerebral Artery
Which artery is the most common cerebral occlusion site?
Middle Cerebral Artery
List 3 key areas secondary stroke prevention is focused on. For each, give details.
BP: ACEi + Diuretics; < 140/90 or 130/90mmHg if diabetic
Lipids: Statins - Simvastatin 40mg or Atorvastatin 40mg-80mg
Antiplatelets: 300mg aspirin ASAP and for 14 days - Clopidogrel 75mg \+ Lansoprazole OR - Aspirin + Dipyridamole
Lifestyle:
- Smoking cessation
- CME 150 mins + x2 resistance exercises
- Reduce alcohol
- Healthy diet: low salt, low fat, increased fruit and vegetables
- Good diabetes control HbA1c < 7%
Why should you not co-prescribe Omeprazole or Esomeprazole with Clopidogrel for secondary prevention of a stroke?
Potential antagonism of anti platelet effect
List 3 lifestyle changes that can be made as part of secondary prevention of stroke.
Lifestyle:
- Smoking cessation
- CME 150 mins + x2 resistance exercises
- Reduce alcohol
- Healthy diet: low salt, low fat, increased fruit and vegetables
- Good diabetes control HbA1c < 7%
What is amaurosis fugax?
Temporary loss or partial loss of vision in one eye secondary to TIA
What is the likely cause of amaurosis fugax?
Embolus from carotid artery distribution
Define a Lacunar Stroke.
Small infarct (2-20mm diameter) in deep cerebral white matter basal ganglia, Pons, presumed to result from occlusion of a single small perforating artery supplying the subcortical areas o the brain - e.g. caused by small vessel disease
What is the most important initial investigation in someone presenting with stroke.
What is the main purpose of this investigation?
CT-head
Rule out haemorrhage
Define a TIA.
Transient episode
What is more common, ischaemic or haemorrhagic stroke?
Ischaemic Stroke
How would you diagnose carotid artery stenosis using an investigation?
O/E suspicion from carotid artery bruit (turbulent flow)
Investigation: Doppler US
Name 3 conditions that could be mistaken for a stroke.
5S’s Mistaken for a Stroke
- Somatisation
- Sepsis
- Seizures
- Syncope
- SOL
What is the 1st line treatment for ischaemic stroke within the primary given window of opportunity.
Give the window of opportunity for the medical treatment of ischaemic stroke.
4.5 hours from symptom onset
Alteplase (r-tPA) 0.9mg/kg as 10% dose as bolus with remaining 90% infused over 1 hour
Maximum 90mg total dose
What is the 1st line treatment for ischaemic stroke presenting after 4.5 hours?
Aspirin 300mg daily for 2 weeks
What is the window of opportunity for surgical treatment of ischaemic stroke?
6 hours
Outline the difference in UMN and LMN lesions using the following categories:
- Inspection
- Pronator drift
- Tone
- Power
- Reflexes
- Plantar reflexes
UMN: No fasciculation/wasting --> Possible disuse atrophy/contractures Maybe present Increased (spasticity) ± ankle clonus Pyramidal pattern of weakness - Arm flexors > - Leg extensors > Hyperreflexia: Exaggerated or brisk Babinski positive (Upgoing/extensor)
LMN:
Wasting and fasciculation
May be some drift movement of arm(s) or be de-afferented but not pronator
Decreased (hypotonia) or normal
Different patterns of weakness depending on cause
- E.g. proximal weakness in muscle disease
- E.g. distal weakness in peripheral neuropathy
Hyporeflexia/Areflexia: Reduced or absent
Normal (downgoing/flexor)
What is the recommended for the management of a patient who presents in primary care with a diagnosis of TIA?
To be seen in specialist clinic within 24 hours
Name 3 allied health professional roles that are important in the management of stroke patients and why?
SALT, dietician, physiotherapist, OT –discuss role
Name 4 important lifestyle measures in primary stroke prevention
Stop smoking, increase exercise, lose weight/diet, reduce alcohol intake (illicit drugs)
Name 4 medical (non lifestyle) interventions that could reduce the risk of a second ischaemic stroke (secondary prevention)
Reduce BP, treat diabetes, statin, anti-platelet treatment, (treat sleep apnoea)
What is the preferred medical treatment for secondary prevention of ischaemic stroke?
Clopidogrel 75mg daily
Name 2 risk factors for haemorrhagic stroke
Hypertension, anticoagulant treatment (high alcohol intake, use of sympathomimetic drugs); age
Name 2 causes of embolic stroke
Atrial fibrillation
Valvular heart disease
What is the most common cause of embolic stroke?
Atrial fibrillation
Give 2 medical treatments that could prevent embolic stroke.
Warfarin
DOAC
What is the criteria for considering carotid endarterectomy in a patient with a history of TIA?
Greater than 50% occlusion
Rate control is the most important measure that can be taken to prevent strokes in AF patients: T or F?
False – it’s anticoagulation
Stopping anti-coagulation long term is mandatory in AF patients after a haemorrhagic stroke: T or F?
False – risks need weighing up
Name two possible medical treatments for a non-AF patient with a history of TIA
clopidogrel
Aspirin/MR dipyridamole
Blood pressure most be lowered as quickly as possible in a hypertensive patient presenting with acute stroke – T or F?
False – could make matters worse
Describe the blood supply to the brain.
Circle of Willis
- Internal Carotid Artery
- Anterior choroidal artery
- Ophthalmic Artery
- Anterior Cerebral Artery
- Posterior Cerebral Artery
- Middle Cerebral Artery - Vertebral Artery
- Basilar artery
- Pontine arteries
- Posterior Cerebral Artery
Outline the route of the Internal Carotid Artery from beginning to end.
Common Carotid Arteries bifurcate @ C4 -> superior in carotid sheath -> enter brain via carotid canal of temporal bone -> pass anteriorly through cavernous sinus -> Give rise to: -> Continues as middle cerebral artery
Outline the route of the Vertebral Arteries, from start to finish.
Subclavian arteries @ medial to anterior scalene muscle -> Vertebral arteries -> Posterior aspect of neck -> Transverse process of cervical vertebrae (foramen transversarium) -> Foramen magnum -> Gives rise to: -> Converge to Basilar artery -> Branches to cerebellum and pons -> Bifurcates into posterior cerebral arteries
What vessel predominantly supplies the medial brain?
Middle Cerebral Artery
What vessel predominantly supplies the lateral brain?
Lateral Cerebral Artery
What vessel predominantly supplies the anterior brain?
Anterior Cerebral Artery
Outline the venous drainage of the brain.
Cerebral veins drain to venous sinuses of dura mater
Superior cerebral veins drain to Superior Sagittal sinus
Middle cerebral vein drains to cavernous sinus
Superior anastomotic vein drains to Superior sagittal sinus
What are the three watershed areas of the brain?
- Cortical Border Zone: ACA + MCA
- Internal Border Zone: LCA + MCA
- Cortical Border Zone: MCA + PCA
List the red flags of headache.
- No history
- No risk factor
- No imaging abnormality
- Young age
- Seizures
- Unusual headache
Give 3 differentials which mimic stroke.
- Seizures
- Sepsis
- Syncope
- SOL (tumour, subdural)
- Somatisation
A patient presents with hemiparesis, homonymous hemianopia and dysphagia and visuospatial disorder.
What type of stroke is this likely to be?
TACS
A patient presents with hemiparesis and a homonymous hemianopia.
What type of stroke is this likely to be?
PACS
A patient presents with sensory deficit alone following a stroke.
What type of stroke is this likely to be?
LACS
A patient presents with dysdiadochokinesis, ataxia, apraxia, intention tremor and nystagmus following a stroke.
What type of stroke is this likely to be?
POCS
What is a cerebral infarction?
Thromboembolic cerebral infarctions causing a stroke due to vessel occlusion with subsequent cerebral hypoperfusion and resultant brain ischaemia and infarction. The infarcted area is surrounded by a swollen area which may regain function with neurological recovery.
What is an Intracerebral Haemorrhage?
Interruption of blood supply to focal part of brain due to haemorrhage causing a loss of neurological function with symptoms lasting > 24 hours or leading to death with no apparent cause other than vascular origin
Outline the pathophysiology of an intracerebral haemorrhage.
• Hypertension/Tumour/SOL/Bleeding disorder/Vascular malformation/Cerebral venous sinus thrombosis -> intracranial/subarachnoid haemorrhage = infarction -> symptoms and signs
List 7 potential clinical features
- Sudden loss of consciousness
- Severe headache: Thunderclap headache
- Neck stiffness
- Homonymous hemianopia
- Diplopia
- Sensory loss: Cortical sensory loss fine sensory processing e.g. 2-point discrimination/stereognosis/ graphaesthesia
- Gaze paresis
- Aphasia
- Dysarthria
- Ataxia
List the treatment for an intracranial haemorrhage,
• STOP anticoagulants
–> Restart on case-by-case bases 7-10 days later
• Hypertension: ACEi + ARBs/CCBs/Diuretics
–> Target: BP < 140-150/90mmHg
- Reduce ICP: Mechanical ventilation or Mannitol
- Trepanning: Burr holes in skull Relieve ICP
- Supportive care: Stroke unit/Swallowing test +Feeding/Hydration/DVT prevention - stockings
Outline the treatment for a subarachnoid haemorrhage.
- Supportive: Bed rest + Supportive measures
- CCB: Nimodipine (CCB): 60mg 4 hourly or IV 1-2mg per hour
- IV saline (0.9%): Salt replenishment –> normal salt levels
• Endovascular coiling
OR
• Surgical clipping
• Lifestyle change: Hypertension control + Smoking cessation
Outline the treatment for an Extradural haematoma.
• ABCDE
• Trepanning: Decompression via Burr holes
or/ ±
• Craniectomy + cauterise: Bone flap removed Access to vasculature + cauterise
- Diuretics: Mannitol
- Anti-convulsants:
- Prophylactic ABX
- Barbiturates
Outline the treatment for an Subdural haematoma.
• ABCDE
Bleed < 10mm
• Observe + Follow-up CT in 2-3 weeks
• Anti-epileptic prophylaxis: IV Phenytoin
• Correct coagulopathies
• Lower ICP: Diuretics (mannitol) + Repeated LP
• Surgery: Trepanning or Craniotomy
