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Neuro > Stroke > Flashcards

Stroke Flashcards

1
Q

On average how many strokes occur in one year in the UK?

A

120,000-150,000

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2
Q

Define a stroke

A

Sudden onset of focal or global neurological symptoms caused by ischaemia or haemmorhage lasting more than 24 hours

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3
Q

How is a Transient Ischaemic Attack different to stroke?

A

Symptoms resolve within 24 hours

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4
Q

2 Main causes of stroke

A

Ischaemic

Haemorrhagic

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5
Q

Causes of ischaemic stroke?

A 
Large artery atherosclerosis
Cardioembolic (infective endocarditis)
Small artery occlusion (Lacunar)
Undetermined
Rare causes - arterial dissection, venous sinus thrombosis
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6
Q

Causes of haemorrhagic stroke

A

Intracerebral haemorrhage

Secondary haemorrhage- SAH, Arteriovenous malformation

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7
Q

Define ischaemia

A

failure of cerebral blood flow; interrruption in blood supply

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8
Q

Ischaemia leads to…

A

Hypoxia

Prolonged –> anoxia –> infarction –> necrosis: STROKE

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9
Q

Further damage following prolonged hypoxia

A

Oedema

Secondary haemorrhage into stroke

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10
Q

Pathogenesis of ischaemic stroke (4)

A

Disruption or injury to plaque surface
Platelet ahdesion/aggregation and fibrin formation
Thrombus formation
Total arterial occlusion

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11
Q

Non-modifiable risk factors of stroke

A

Previous stroke
Family history
Age
Male

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12
Q

Modifiable risk factors

A 
Hypertension
Diabetes
Smoking
Lipids
Alcohol
Obesity (abdominal)
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13
Q

Other risk factors

A 
Hypercoagulable states (pregnancy, cancer, sickle cell disease)
Impaired cardiac function (Atrial fibrillation)
OC & HRT - high estrogen content
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14
Q

Arterial supply to anterior brain

A

Internal carotid artery

Divides into Anterior Cerebral artery and Middle Cerebral Artery

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15
Q

Arterial supply to posterior brain

A

Vertebral to Basilar
3 pairs of cerebellar arteries - Superior, Anterior inferior, Posterior inferior
2 Posterior cerebral arteries PCA

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16
Q

Name the anastomoses of the arterial blood supply to the brain

A

CIRCLE OF WILLIS

Anterior and posterior communicating arteries

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17
Q

Branches of the ACA

A 
Medial orbitofrontal
Frontopolar
Callosomarginal
Pericallosal
Paracenral
Precuneal artery
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18
Q

ACA occlusion symptoms

A

Contralateral paralysis of foot and leg, sensory loss over foot and leg, impaired gait and stance

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19
Q

Branches of the MCA

A 
Anterior/Middle/Posterior Temporal
Lateral orbitofrontal
Ascending frontal
Precentral
Central
Anterior/Posterior Parietal
Angular artery
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20
Q

Symptoms of MCA occlusion

A

Contralateral paralysis of face/arm/leg, sensory loss,
Homonymous hemianopia
Gaze paralysis to opposite side
Aphasia if stroke on dominant side
Unilateral neglect and agnosia for 1/2 external space if non-dominant (usually RHS)

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21
Q

Left hemisphere MCA territory contains which functional areas

A

Broca’s
Wernicke’s
Auditory complex

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22
Q

Symptoms if left hemisphere affected

A

Hemiplegia, homonymous hemianopia, dysphasia

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23
Q

Right hemisphere symptoms

A

Left hemiplegia, homonymous hemianopia, neglect syndromes (Agnosias)

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24
Q

4 Types of Agnosia

A

Visual agnosia
Sensory agnosia
Anosagnosia (denial of hemiplegia)
Prosopagnosia (failure to recognise faces)

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25
Q

Which arteries are occluded when stroke occurs in area of basal ganglia and name the type of stroke

A

MCA –> Medial and Lateral Lenticulostriate arteries

Lacunar stroke

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26
Q

Name the 4 Lacunar Stroke Syndromes

A

Pure motor stroke
Pure sensory stroke
Dysarthria (clumsy hand syndrome)
Ataxic hemiparesis

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27
Q

What signs are devoid in Lacunar stroke?

A

Cortical

No dysphasia, neglect or hemianopia experienced

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28
Q

Name the arteries within the posterior circulation to the brain

A 
Basilar artery
Superior cerebellar
Anterior inferior cerebellar
Posterior temporal
Calcarine artery
Parietooccipital
Posterior pericallosal artery
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29
Q

Think of the anatomy involved in a stroke within the posterior circulation

A

Brainstem, thalamus, Cerebellum, Occipital and medial temporal

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30
Q

Symptoms of posterior stroke

A 
Brainstem dysfunction
Coma, vertigo, nausea, vomiting, cranial nerve palsie, ataxia
Hemiparesis, hemisensory loss
Cossed sensori-motor deficit
Visual field deficits
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31
Q

3 Goals of Acute Ischaemic Stroke treatment

A

Restore blood supply
Limit ischaemic damage
Protect vulnerable brain tissue

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32
Q

Treatments for acute ischaemic stroke

A

Thrombolysis - alteplase
Aspirin 300mg
Thrombectomy
Stroke Unit

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33
Q

Classification system for stroke

A

Bamford/ Oxfordshire Community Stroke Project (OCSP) classification

Lacunar Stroke (LACS)
Partial Anterior Circulation Stroke (PACS)
Total Anterior Circulation Stroke (TACS)
Posterior Circulation Stroke (POCS)

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34
Q

What system is used to differentiate from stroke mimics?

A

ROSIER
Recognition of Stroke in the Emergency Room

-Seizures, loss of consciousness - not typically stroke

Assymetric facial, leg and arm weakness
Speech disturbance
Visual defect
All score 1 point

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35
Q

Bamford classification of Lacunar Stroke (LACS)

A

Motor +/- sensory loss

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36
Q

Bamford classification of Partial Anterior Circulation Stroke

A 
Motor +/- sensory loss
1 from
Hemianopia
Dysphasia
Neglect
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37
Q

Bamford classficiation of Total Anterior Circulation Stroke

A

Motor +/- sensory loss
2 from
Hemianopia +
Neglect or Dysphasia

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38
Q

Bamford classficiation of Posterior Circulation Stroke (POCS)

A

Motor +/- sensory loss
Hemianopia/dysphasia/neglect
Brainstem and or cerebellar signs

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39
Q

Highest death rates in which type of stroke from Bamford Classification

A

Total Anterior Circulation Stroke (TACS) - 96%- includes dependence in 6 months

40
Q

What is thrombolysis?

A

Tissue Plasminogen Activator (TPA)- Alteplase

Breaks down the clot

41
Q

Criteria for TPA

A

Less than 4.5 hours since symptom onset
Disabling neurological deficit
Symptoms present > 60 minutes
Consent

42
Q

Exclusion criteria for TPA

A 
Evidence of haemorrhage
- blood on CT
- Surgery
- Bleeding
- Coagulation problems
BP > 185 systolic or 110 diastolic
Glucose less than 2.8 or > 28mmol/L
43
Q

What is supplied by the carotid system?

A

Anterior cerebral and middle cerebral hemispheres and cortical deep white matter

44
Q

What is supplied by the vertebro-basilar system?

A

Brainstem, cerebellum and occipital lobe

45
Q

What function is determined by the motor cortex?

A

Movement

46
Q

What is determined by the sensory cortex?

A

Pain, heat and other sensations

47
Q

What function is determined by the parietal lobe?

A

Comprehension of language

48
Q

What functions are determined by the temporal lobe?

A

Hearing
Intellect
Emotion

49
Q

What area does the occipital lobe belong to?

A

Primary visual area

50
Q

What function is determined by Wernicke’s area?

A

Speech comprehension

51
Q

What function is determined by the cerebellum?

A

Coordination

52
Q

What functions are determined by the brainstem?

A

Swallowing, breathing, heartbeat, wakefulness center and involuntary functions

53
Q

What functions are related to the frontal lobe?

A

Smell
Judgement
Foresight
Voluntary movement

54
Q

What area is related to speech?

A

Broca’s

Wernicke’s for comprehension

55
Q

What key areas need to be explored in the nuerological history and examination for stroke?

A 
Motor
Sensory - loss of feeling
Speech - dysarthria, dysphasia (weakened muscles of face and mouth)
Neglect/visuospatial problems
Vision
Gaze palsy
Ataxia/vertigo.incoordination, nystagmus
56
Q

Which areas are most commonly unaffected or recover well in smaller strokes?

A

Frontal and speech cortex

57
Q

Damage to which area due to stroke results in locked in syndrome/locked-in like states?

A

Pons

58
Q

Why would damage to the pons cause a locked in syndrome?

A

Catches all of the motor and sensory fibres in cortex

59
Q

Why are cancer patients more vulnerable to stroke?

A

Prothrombotic state

60
Q

Causes of stroke

A

Blockage of vessel with thombus/embolus
Disease of vessel wall
Disturbance of normal properties of blood
Rupture of vessel wall (haemorrhage)

61
Q

Symptoms of carotid stenosis

A 
Sudden severe headache
Dizziness
Loss of balance
Unable to move limbs
Sight
Weakness, numbness on one side
62
Q

Most common cause of cardioembolic stroke?

A

Atrial fibrillation

63
Q

What arteries are branches of the middle cerebral artery?

A

Medial and lateral lenticulostriate arteries

64
Q

Which stroke occurs after HT and hypertrophy of the lenticulostriate arteries?

A

Small lacunar stroke

Motor +/- sensory

65
Q

What rare cause of stroke is the commonest cause of painful Horner’s syndrome?

A

Carotid dissection

Drooping eye, can’t perspire

66
Q

What vessels are usually occluded in a Total anterior circulation stroke?

A

Proximal middle cerebral artery or internal carotid

67
Q

Which vessels are more commonly occluded in a partial anterior circulation stroke?

A

Branches of MCA

68
Q

Which type of stroke is often silent or misdiagnosed?

A

Lacunar Stroke

69
Q

What type of presentation of lacunar stroke is most common?

A

Pure motor symptoms - complete/incomplete weakness of 1 side, 2 or 3 areas

70
Q

Which investigations should be carried out when someone presents with stroke like symptoms?

A 
Bloods
ECG
CT
MRI
Carotid doppler - examine vessels
Echocardiogram - clots in heart
71
Q

What is a priority to optimise recovery and discharge after a stroke?

A

Get the patient mobilising

72
Q

What treatment alongside intravenous thrombolysis improves outcomes?

A

Clot retrieval/thrombectomy

73
Q

When is hemicraniectomy indicated?

A

Acute MCA territory ischaemic stroke complicated by massive cerebral oedema
Individuals up to 60 years of age

74
Q

In what time frame should thrombolysis be considered for acute stroke treatment?

A

Within 4.5 hours onset of symptoms

75
Q

Is CT offered for a suspected TIA?

A

No, unless suspicion of other condition that could be picked up by CT

76
Q

Treatment for stroke prevention in TIA or otherwise

A

Clopidogrel 75mg or Aspirin
Dipyridamole MR 200mg bd
Statin
BP drugs - even if BP normal

77
Q

What are patients at risk of if swallow affected after stroke?

A

Aspiration pneumonia

78
Q

Mechanism of aspirin

A

Inhibits thromboxane production
Prevents platelet aggregation and vasoconstriction
ANTIPLATELET

79
Q

Mechanism of clopidogrel

A

Inhibits ADP receptor activated platelet aggregation

80
Q

Newer agents to clopidogrel

A

Ticagrelor and prosugrel

81
Q

Mechanism of statins (simvastatin,pravastatin, atorvastatin)

A

HMG CoA Reductase inhibitors

Stabilise atheromatous plaques and reduce inflammatory properties

82
Q

Risk associated with aspirin and clopidogrel (antiplatelets)

A

GI bleeding

83
Q

Treatment for carotid stenosis

A

Best Medical therapy - smoking cessation, BP control, antiplatelet, statin, diabetic control

Confirmed TIA - carotid doppler
Carotid endarterectomy

84
Q

Complications of carotid endarterectomy

A 
Wound infection
Bleeding
Scar
Anaesthetic risk
Nerve damage
Perioperative stroke
85
Q

Which nerves are at risk of damage during a carotid endarterectomy?

A

Glossopharyngeal
Hypoglossal
Vagus

86
Q

Symptoms of nerve damage from carotid endarterectomy

A

Numbness along jaw

Issues swallowing and with speech

87
Q

When is stenting considered in a carotid endarterectomy?

A

Inaccessible disease
Scarring
Previous surgery
Area too high up for open surgery

88
Q

Categories of ischaemic stroke

A

Thrombotic
Embolic
Hypoperfusion
Lacunar

89
Q

Causes of thrombotic stroke

A

Atherosclerosis

Prothrombotic state

90
Q

Which group of patients are in a prothrombotic state?

A

Pregnant
Cancer patients
Antiphospholipid syndrome
Sickle cell anaemia

91
Q

3 examples of embolic stroke causes

A

Atrial fibrillation
Paradoxical embolus
Infective endocarditis

92
Q

What is meant by a paradoxical embolus?

A

Clot occurs within venous system, embolises through right side of heart to the left via default in ventricular septum
Travels to brain

93
Q

What is the pathophysiology of lacunar strokes?

A

Hypertension

Occurs in basal ganglia

94
Q

Categories of haemorrhagic stroke

A

Intracerebral haemorrhage

Subarachnoid haemorrage

95
Q

Causes of intracerebral haemorrhage

A

Trauma
Hypertension
Cerebral amyloid

96
Q

Causes of Subarachnoid haemorrhage

A

Trauma
Berry aneurysm
Arteriovenous malformation

97
Q

What is Todd’s paresis and what does this condition score on the ROSIER scale?

A

Hemiplegia following tonic clonic seizure

-1 - seizure; unlikely to be a stroke

Neuro (9 decks)

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