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Neurology > Stroke > Flashcards

Stroke Flashcards

1
Q

Define stroke

A

A clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin

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2
Q

Define TIA

A

Duration less than 24 hours

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3
Q

Define ischemia

A

Interruption of blood supply

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4
Q

Define haemorrhage

A

Bleeding into brain

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5
Q

Symptoms of a stroke of the carotid artery

A

Weakness of:

  • face
  • leg
  • arm
  • impaired language
  • amaurosis fugax
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6
Q

Symptoms of a stroke of the posterior circulation

A
  • dysarthria (impaired speech)
  • dysphagia
  • diplopia
  • dizziness
  • ataxia
  • diplegia (paralysis)
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7
Q

Treatment for a TIA

A

A: aspirin (300mg stat, 75mg daily (give with PPI if hx of dyspepsia)
B: Admit to acute stroke unit
C: Treat BP
D: Order CT

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8
Q

What score is used to identify risk of stroke after TIA?

A

ABCD2

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9
Q

What is the ABCD2 risk score?

A 
Age: over 60 =1
BP SBP>140 or DBP>90 = 1
Clinical features:
unilateral weakness = 2
Speech disturbance alone = 1
Duration of sx:
>60 mins = 2
10-60 mins = 1
<10 mins = 0
Diabetes =1
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10
Q

what do the scores mean?

A

1-3 risk is 0.4%
4-5 risk is 12%
6 risk is 31%

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11
Q

When are you at a high risk of a TIA?

A
  • ABCD2>/=4
  • more than one TIA in last 7 days
  • new arrhytmia
  • known high grade ipsilateral carotid stenosis
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12
Q

If at high risk of TIA

A

300mg aspirin for 2 weeks then clopidogrel

- specialise assessment and ix within 24hrs of sx

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13
Q

Imaging after a TIA

A

MRI
Carotid doppler (look for significant stenosis of internal carotid)
24 hour ECG

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14
Q

Surgery for TIA

A

Carotid endarterectomy and carotid stenting when symptomatic carotid stenosis

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15
Q

Are ischaemic or haemorrhagic more common?

A

Ischaemic (85%)

Haemorrhagic (15%)

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16
Q

Acute iscaemic stroke has 3 main blood supplies

A
  1. Anterior circulation infarction (partial/total)
  2. Posterior circulation infarction
  3. Lacunar infarction
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17
Q

Sx of an anterior circulation infarction?

A

ANTERIOR AND MIDDLE ARTERIES

Contralateral weakness 
Contralateral sensory loss/sensory inattention 
Dysarthria
Dysphasia (receptive, expressive) 
Homonymous Hemianopia/visual inattention
Higher cortical dysfunction
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18
Q

Sx of a posterior circulation infarction?

A

Cranial nerve palsy and a contralateral motor/sensory deficit (‘crossed signs’)

Conjugate eye movement disorder (e.g. horizontal gaze palsy)

Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia, dysarthria)

Isolated homonymous hemianopia
Bilateral events can cause reduced GCS

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19
Q

Sx of a lacunar circulation infarction?

A

Occlusion of deep penetrating arteries

Only affects a small volume of subcortical white matter (therefore do not present with cortical features e.g. dysphasia, apraxia, neglect, visual field loss)

Underlying process is often referred to as small vessel disease (arterial wall disorganisation, microatheroma, lipohyalinosis)

Lacunar syndromes:
Pure motor hemiparesis 
Ataxic hemiparesis
‘Clumsy hand’ and dysarthria
Pure hemisensory 
Mixed sensorimotor
20
Q

If a ptx comes in with a stroke what is the pathway?

A
  1. ABCDE + bloods
  2. brief hx and ex
  3. BP
  4. Grade severity of stroke
  5. urgent CT head (+/- CT angiography)
  6. Thrombolysis (4 and a half hours) +/- mechanical thombectomy if indicated or aspirin 300mg
  7. Ix cause
  8. Screen and prevent complications (dehydration, aspirin, VTEs. pressure sores, infection)
  9. Establish 2ndry prevention
  10. rehab - physios, OT, SALTs
21
Q

Example of thrombolyssis

A

Alteplase (tissue plasminogen activator)

22
Q

Time limit for thrombolysis

A

4.5 hours

23
Q

CIs for thrombolysis

A
  • haemorrhagic stroke
  • Suspected SAH
  • recent GI/UT haemorrhafe in 3 weeks
  • recent treatment with warfarin
  • 14days post major surgery
  • abnormal blood glucose
  • pregnancy
  • acute pancreatitis
24
Q

3 post thrombolysis care

A
  1. More aggressive BP monitoring
  2. Vigilance for complications (bleeding)
  3. 24 hour CT to check for haemorhagic transformation
25
Q

When would a mechanical thrombectomy be used?

A
  • proximal stenosis
  • 6 hour time frame
  • limited resource
26
Q

What ix would you do for a ?stroke?

A 
Blood tests 
ECG
Carotid doppler USS
Echocardiogram 
MRI
27
Q

Which blood tests would you do?

A

FBC – Hb and HCt (PRV/anaemia and hypo-oxygenation), MCV (haemoglobinopathies), WCC (intracranial infection, endocarditis), platelet count (high/low)

ESR (vasculitis/autoimmune disease)

U&Es (hydration status, guide drug treatment)

Lipid profile (hypercholesterolaemia/triglyceridaemia)

LFTs (can affect clotting, guides drug treatment)

CRP (infection – causative/associated)

Clotting screen (APTT, PT, Fibrinogen)

Glucose and HbA1C (hyper/hypoglycaemia – mimic/risk factor)

28
Q

Why would you do an ECG?

A

MI, atrial fibrillation/flutter

29
Q

When would you add a 72 hour tape to the ECG?

A

paroxysmal AF

30
Q

Why would you do a cortid doppler USS

A

carotid stenosis

31
Q

Why would you do a echocardiogram?

A

endocarditis/thrombus

32
Q

Why would you do an MRI

A

confirm diagnosis, look for multiterritory infarcts – delayed CT head if MRI contra-indicated

33
Q

In a young patient/atypical stroke what ix should you consider?

A 
Bloods:
- HIV and vasculitic screen
- Thrombophilia screen 
- Homocysteine 
Cardiac investigations:
- 7 day Holter recorder/implantable loop recorder
- Transcranial dopplers
- Transoesophageal echo
Vascular imaging:
- CT angiography 
- MR anigography
34
Q

Role of nurses in stroke recovery

A

Analysing clinical status and progress; blood pressure management

Administration of medications

Nasogastric feeding

Preventing pressure sores

35
Q

Role of physios in stroke recovery

A

Strength, balance, function

Preventing spasticity

Chest physiotherapy in infections and sputum clearance

36
Q

Role of OTs in stroke recovery

A

Functional assessments and future needs planning

Cognitive and mood screening

37
Q

Role of SALTs in stroke recovery

A

Swallowing impairment and prognosis

Communication rehabilitation in dysphasias

38
Q

Other members of MDT for stroke

A
  • dietician

- orthoptics

39
Q

Lifestyle management after a stroke?

A

Smoking cessation

Drug and alcohol cessation

Dietary modifications

Exercise

Driving advice (one month after stroke/TIA)

40
Q

Medical management to prevent complications

A

VTE assessment
- Intermittent pneumatic
compression devices

Hydration

NG feeding +/- PEG feeding

Spasticity

  • Physiotherapy
  • Botox

Monitoring for infection

41
Q

Medical secondary prevention

A

Antiplatelets:
- Aspirin 300mg PO/PR for 2 weeks (small ARR) and clopidogrel lifelong

Anticoagulation:

  • If in AF or evidence of pAF – may need to wait up to 2 weeks
  • HASBLED and CHADSVASC scores

Hypertension:

  • Acute: risk of hypoperfusion
  • Chronic: long term blood pressure target of < 130/80 (higher if severe bilateral carotid stenosis)

Cholesterol:
- Statin therapy – aim 40% reduction in non-HDL cholesterol

42
Q

Surgical management

A

Extracranial Carotid Stenosis:
- USS carotid dopplers +/- CTA/MRA
- Ipsilateral (symptomatic) carotid stenosis
Alternative: carotid artery stenting

Malignant MCA syndrome
- Decompressive hemicraniectomy

Posterior circulation infarct

  • Risk of hydrocephalus
  • EVD/posterior fossa decompression
43
Q

Management of a haemorrhagic stroke

A
  1. ABCDE - monitored environment, regular neuro-observations (inc GCS and pupils)
  2. Blood pressure? (140-160 systolic acutely, <130/80 long term)
  3. Bleeding tendency? (coagulopathy/low platelets/medication-related)
  4. Underlying malformation? (tumour aneurysm, amyloid angiopathy, AV malformation, cavernoma)
  5. Need for neurosurgery? (useful for superficial clots, CSF obstruction causes hydrocephalus, posterior fossa decompression)
44
Q

Anticoagulation options and their reversers

A

DOACs are LESS reversible*

Warfarin (Beriplex and Vitamin K)
Heparin (Protamine)
LMWH (partially reversed with protamine)
Apixaban/Rivaroxaban/Edoxaban (Beriplex is possibly effective)
Dabigatran (Idarucizumab)

45
Q

Differentials for a stroke

A

Seizures
Tumours /Abscess
Migraine
Metabolic (e.g. hypoglycaemia, hyponatraemia)
Functional
Spinal cord/peripheral nerve/cranial nerve

Neurology (4 decks)

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