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Integrative > Stroke > Flashcards

Stroke Flashcards

1
Q

Define a neurovascular unit

A

Relates to the functional and structural interplay between/among neurons, glial cells and endothelial lumens (including the dynamic of the blood brain barrier, a huge part of which is the tight junction of cerebral endothelial cells).

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2
Q

Mechanism of stroke? Reason for its sudden onset?

A

hypoperfusion in the endothelial lumen
reduction in available oxygen and glucose
reduction in ATP synthesis
impairment of all energy dependent cell processes including membrane transport
impairment of AP generation and therefore reduced neuronal transmission

The binary nature of APs and their relationship to the change in neuronal transmission underlies the SUDDEN evolution of stroke symptoms

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3
Q

Anterior cerebral artery stroke associated effects?

A

Contralateral hemiparesis and sensory loss, lower extremity > upper

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4
Q

Middle cerebral artery stroke associated effects?

A

Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia

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5
Q

Posterior cerebral artery stroke associated effects?

A

Contralateral homonymous hemianopia with macular sparing

Visual agnosia

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6
Q

Weber’s Syndrome define? Associated effects?

A

Stroke affecting branches of the posterior cerebral artery that supply the midbrain

Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity

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7
Q

Define wallenberg syndrome? Alternative name? Associated effects?

A

Stroke affecting Posterior inferior cerebellar artery
also called Lateral medullary syndrome

Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
DANVAH - Dysphagia, ataxia (ipsilateral), Nystagmus (ipsilateral), Vertigo, Anaesthesia (ipsilat facial numbness + absent corneal
reflex; Contralateral pain loss)
Horner’s syndrome (ipsilateral)

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8
Q

Lateral pontine syndrome define? Associated effects?

A

Stroke affecting Anterior inferior cerebellar artery

Symptoms are similar to Wallenberg’s , but also:
Ipsilateral: facial paralysis and deafness

Wallenbergs:
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus

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9
Q

Retinal/ophthalmic artery stroke associated effects?

A

Amaurosis fugax

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10
Q

Lacunar stroke presentation? Risk factor? Common sites?

A

• present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
Associated with hypertension
common sites include the basal ganglia, thalamus and internal capsule

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11
Q

List the components of the complete stroke service

A
  • Rapid access TIA clinics
  • Hyperacute stroke unit with access to neurosurgical and interventional radiology services
  • Acute stroke wards
  • Inpatient rehabilitation
  • Outpatient rehabilitation including Early Supported discharge services
  • Outpatient stroke clinics
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12
Q

Differentials, other than stroke, for isolated presentation of dysarthria?

A

Generalised cerebral impairment: alcohol intoxication, sepsis, post-ictal phase
Peripheral neural dysfunction: impaired peripheral vocal apparatus, facial/tongue/throat muscles

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13
Q

Presentations that reduce chance of being a stroke?

A

Isolated presentation of dysarthria, double vision or vertigo

Symptoms that evolve in a sequential fashion are difficult to fit into a vascular territory

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14
Q

Define cryptogenic stroke?

A

when cause of stroke remains unclear after thorough assessment

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15
Q

Features that increase the chance of stroke being the dx?

A

Sudden onset
focal
predominantly negative
Vascular territory hypoperfusion can explain collection of symptoms
Symptoms do not migrate
Episodes do not typically stereotype (symptoms do not recur in an identical fashion

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16
Q

Stroke mimics that involve sensory and visual neurological disturbances that tend to migrate?

A

Migraine, seizures

Slow migration applies to migranous sensory and visual aura

Fairly rapid migration can be a feature of focal seizures – so called “Jacksonian march” - a phenomenon where a simple partial seizure spreads from the distal part of the limb toward the ipsilateral face (on same side of body)

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17
Q

Cases of stroke which do exhibit stereotyping symptoms?

A

Capsular warning syndrome and intracranial stenosis

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18
Q

Capsular warning syndrome define? Mechanism? Presentation? Imaging?

A

a term used to describe recurrent stereotyped lacunar transient ischemic attacks (TIAs)

Intermittent (and critical) hypoperfusion of lentriculostriate arteries

Recurrent events occur over minutes to hours (non vascular stereotyping where recurrence is over days, weeks or even years) - tend to be LACS type stroke

Diffusion weight imaging tends to be positive - confirming infarcted brain tissue

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19
Q

Intracranial stenosis presentation? Imaging?

A

Stroke syndrome episodes are associated with clinical markers of generalised hypoperfusion.
These may include palpitations, dizziness, pallor clamminess, occur on standing in cases of postural hypotension etc.
Targeted imaging with angiography will confirm the stenosis.

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20
Q

What criteria is assessed in the oxford stroke classification?

A
  1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  2. homonymous hemianopia
  3. higher cognitive dysfunction e.g. dysphasia
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21
Q

TACI involvement? Presentation

A

Involves proximal MCA or ICA

Hemiparesis AND higher cortical dysfunction AND homonymous hemianopia

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22
Q

PACI involvement? Presentation?

A

involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery

Isolated higher cortical dysfunction OR Any two of: hemiparesis, higher cortical dysfunction, hemianopia

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23
Q

POCS involvement? features?

A

Occlusion of vertibral, basilar, cerebellar or PCA vessels.

Isolated hemianopia or brainstem or cerebellar syndromes

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24
Q

LACS involvement? Features?

A

Small penetrating artery occlusion - usually in lenticulostriate branches of MCA or supply to brainstem or deep white matter

Pure motor OR pure sensory OR sensorimotor stroke OR ataxic hemiparesis (a combination of cerebellar and pyramidal hemiparesis on the contralateral side of the body) OR Clumsy hand-dysarthria (dysarthria and contralateral ‘clumsiness’ (i.e. weakness) of the hand, which is often most prominent when the patient is writing. )

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25
Q

Signs of spontaneous intracrainial haemorrhage?

A
  • Possible underlying cause
  • Reduced level of consciousness at admission
  • History of headache
  • Seizures
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26
Q

Causes of primary haemorrhage?

A

Primary - caused by spontaneous rupture of small vessels associated with chronic hypertension or amyloid angiopathy.

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27
Q

Causes of secondary haemorrhage?

A

(some other lesion complicated by haemorrhage)

  • Haemorrhagic transformation infarct- Venous sinus thrombosis and venous infarction
  • Tumour –GBM, anaplastic astrocytoma, metastasis
  • Vascular –aneurysm, AVM, vasculitis
  • Coagulopathy, warfarin, aspirin
  • Cocaine, alcohol
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28
Q

Groups of stroke mimics?

A

Group 1 - readily identifiable with standard imaging: subdural heamatomas, space occupying lesions, multiple sclerosis (MS) etc.

Group 2 - syndromically distinguishable from the stroke syndrome on clinical grounds after general medical assessment: syncope syndrome, benign positional vertigo, vestibular neuronitis, transient global amnesia.

Group 3 - conditions where recognition is also clinical but features can be subtle and justify specialist assessment - migraine with aura, focal seizures, functional syndrome, amyloid spells.

29
Q

Define transient global amnesia

A

dysfunction of “episodic” memory with preservation of other kinds of memory e.g. procedural memory (hence patients are able to make a cup of tea or drive during episode), biographical memory etc.

30
Q

Migraine with aura vs stroke?

A

Migraine - Therefore typically gradual onset, migratory and sequential onset of migraine aura symptoms. Also mostly positive symptoms

31
Q

Presentations of migraine affecting different lobes of the brain?

A

Visual aura - occipital lobe
dysphasia and tinnitus - temporal lobe
pins and needles/transient cognitive disturbance (parietal lobe)
unsteadiness/dizziness/ collapse/hemiparesis (cerebellum, brainstem)

32
Q

Amyloid spell presentation? Imaging?

A

Similar to migraine but significantly shorter lived (usually < 10 mins)

typically occur in older people with no previous history of migraine
most importantly the MRI scan here will show features of Cerebral Amyloid Angiopathy

33
Q

Define apparent neurological deficit

A

neurological dysfunction in patients with chronic stroke (but seemingly good recovery) and residual areas of scar tissue (gliosis) at the site of previous brain damage

Symptoms become “apparent” due to underperformance of the gliotic tissue in the context of suboptimal physiology eg. infection, low blood pressure, hypoglycaemia, hypoxia, fatigue etc

34
Q

List stroke chameleons? (ie different presentations of stroke)

A

Venous infarcts – gradual onset, preponderance for seizure activity
Small cortical strokes – peripheral nerve lesions
Limb shaking TIA – ?seizure
Occipital strokes – predominant presentation with confusion ?delirium (visual field examination should still reveal field loss)
Stroke amnestic syndromes
Stroke mimicking vestibular dysfunction

35
Q

1st line radiological Ix for ?stroke?

A

non-contrast CT head scan

36
Q

Hallmarks of early cerebral ischaemia on CT scan?

A
  • Effacement – when CSF is displaced from the sulci due to mass effect pushing adjacent gyri together
  • Loss of grey/white matter distinction
  • Increased density of relevant blood vessel
37
Q

Hallmark of intracerebral haemorrhage on CT?

A

Increased attenuation

38
Q

How to describe cerebral bleeds?

A

location, size, age, presence or absence of mass effect or complications e.g. hydrocephalus.

39
Q

What are the four P’s if stroke imaging?

A

Pipes - refers to exploration of the blood vessels - CT angiography or less usually MR angiography
Parenchyma - refers to exploration of tissue compromise in terms of cell death - non-contrast CT or MRI

Perfusion - CT angiography (measure of collateral circulation)

40
Q

What is the ASPECTS score?

A

a 10-point quantitative topographic CT scan score used in patients with middle cerebral artery (MCA) stroke

2 CT slices used: One at the level of the basal ganglia and the other at the level of body of the lateral ventricles.

Used in revascularisation therapies for patient selection and outcome prediction
ASPECTs score < or equal to 5 - unlikely a patient will be accepted for thrombectomy
Poor ASPECTS - signifies a high likelihood of haemorrhagic complications.

41
Q

What measures are used for perfusion scans?

A

cerebral blood flow - amount of blood perfusing a volume of brain tissue per unit time
mean transit time - the time it takes a volume of blood to traverse a region – increased due to vasodilatation in all hypoperfused/acutely ischaemic regions reflecting cerebral autoregulation.

42
Q

Limitations of perfusion scanning?

A
  • poor availability of the relevant hardware
  • radiographer expertise to generate the images
  • the longer time it takes to get images (eating away your “time to bolus/groin”)
43
Q

List the assessment tools used in stroke

A 
ABCD2
CHA2D2CASc
HASBLED
NIHSS
OCSP classification
ASPECTS
Modified Rankin Scale
ROSIER scale
FAST test
TOAST classification
Barthel index
44
Q

ABCD2 tool use?

A

Estimates the risk of stroke after a suspected transient ischemic attack (TIA).
High risk groups (ABCD2>4, multiple TIAs [>2 in previous 7 days], patients in AF or on anticoagulants) will require urgent review, i.e. within 24 hrs

45
Q

CHA2DS2VASc use?

A

calculates stroke risk for patients with atrial fibrillation
0 -no treatment
1 - Male (consider anticoag). Female (No Tx)
2 or more - (offer anti coag

46
Q

HASBLED tool use?

A

assess 1-year risk of major bleeding in patients taking anticoagulants with atrial fibrillation

score of >= 3 indicates a ‘high risk’ of bleeding, defined as intracranial haemorrhage, hospitalisation, haemoglobin decrease >2 g/L, and/or transfusion.

47
Q

NIHSS use?

A

provides a quantitative measure of stroke-related neurological deficit
Used in assessing stroke severity, patient selection for various acute therapies, estimating prognosis and charting stroke recovery

48
Q

Modified Rankin Scale use?

A

measure of global disability used to assess baseline function and evaluate outcomes and treatment impact after interventions

49
Q

The rosier scale use?

A

Aim is to differentiate between stroke and stroke mimics

Need to exclude hypoglycaemia first

50
Q

TOAST classification use?

A

Describes five sub types of ischaemic stroke.

large-artery atherosclerosis (embolus / thrombosis)*
cardioembolism (high-risk / medium-risk)*
small-vessel occlusion (lacunar)*
stroke of other determined aetiology *
stroke of undetermined aetiology

51
Q

Barthel Index use?

A

used to measure disability

52
Q

When to suspect vasculitis as cause of stroke?

A

the elderly lady
a few months of headache, weight loss, lethargy, pallor
with or without absent temporal pulses (temporal arteritis)

or the patient with past medical history of systemic lupus erythematosus (SLE)

53
Q

When to suspect thrombophilia as cause of stroke?

A

the pregnant stroke patient

or the patient with a history of venous thromboembolism (VTE), multiple miscarriages or active cancer.

54
Q

Causes of deep and lobar bleeds. How to clarify cause?

A

Deep - due to hypertension
Lobar - tend to be secondary - Causes include underlying vascular anomalies, mass lesions, and cerebral amyloid angiopathy

Interval imaging can be required to clarify cause of haemorrhage

55
Q

Clinical and radiological signs of large artery atherosclerosis cause of stroke?

A

Signs of lesion in cortex (Aphasia, apraxia and neglect), subcortex, cerebellum or brainstem

Radiological: CT/MRI - >1.5cm lesion in cortex, subcortex, cerebellum or brainstem compatible with symptoms

CT scan negative when performed shortly after onset

Colour duplex images of precerebral arteries shows stenosis > or equal to in symptomatic major intra/extracranial arteries

56
Q

Clinical and radiological signs of cardioembolic cause of stroke?

A

Signs of lesion in cortex (Aphasia, apraxia and neglect), subcortex, cerebellum or brainstem

Radiological: CT/MRI - >1.5cm lesion in cortex, subcortex, cerebellum or brainstem compatible with symptoms

CT scan negative when performed shortly after onset

ECG/TOE confirm high-medium risk of Cardio-embolic source

57
Q

Clinical and radiological signs of small-vessel disease cause of stroke?

A

Signs of a lacunar syndrome

CT/MRI shows lacunar infarction (lesion <1.5cm)
CT scan negative when performed shortly after onset

58
Q

Rare causes of stroke?

A

Watershed stroke: sudden ↓ in BP (e.g. in sepsis)
Carotid artery dissection
Vasculitis: PAN, HIV
Cerebral vasospasm 2O to SAH
Venous sinus thrombosis
Anti-phospholipid syndrome, thrombophilia

59
Q

Cardiac causes of stroke?

A 
AF: 4.5% /yr
External cardioversion: 1-3%
Prosthetic valves
Acute MI: esp. large anterior
Paradoxical systemic emboli
Cardiac surgery
Valve vegetations
60
Q

Causes of hyperviscosity?

A

Polycythaemia
SCD
Myeloma

61
Q 
Brainstem infarcts presentations?
Hemi- / quadr-paresis 
Conjugate gaze palsy 
Horner’s syndrome 
Facial weakness (LMN) 
Nystagmus, vertigo 
Dysphagia, dysarthria 
Dysarthria, ataxia 
↓ GCS
A

Hemi- / quadr-paresis - Corticospinal tracts
Conjugate gaze palsy Oculomotor system
Horner’s syndrome Sympathetic fibres
Facial weakness (LMN) CN7 nucleus
Nystagmus, vertigo CN8 nucleus
Dysphagia, dysarthria CN9 and CN10 nuclei
Dysarthria, ataxia Cerebellar connections
↓ GCS Reticular activating syndrome

62
Q 
Brainstem infarcts presentations?
Corticospinal tracts
Oculomotor system
Sympathetic fibres
CN7 nucleus
CN8 nucleus
CN9 and CN10 nuclei
 Cerebellar connections
Reticular activating syndrome
A 
Corticospinal tracts
Conjugate gaze palsy Oculomotor system
Horner’s syndrome Sympathetic fibres
Facial weakness (LMN) CN7 nucleus
Nystagmus, vertigo CN8 nucleus
Dysphagia, dysarthria CN9 and CN10 nuclei
Dysarthria, ataxia Cerebellar connections
↓ GCS Reticular activating syndrome
63
Q

Stroke differential’s?

A 
Head injury ± haemorrhage
↑↓ glucose
SOL
Hemiplegic migraine
Todd’s palsy
Infections: encephalitis, abscesses, Toxo, HIV, HTLV
Drugs: e.g. opiate overdose
64
Q

Millard-Gubler Syndrome involvement? Presentation?

A

Pontine infarct

 6th and 7th CN nuclei + corticospinal tracts -  Diplopia  LMN facial palsy + loss of corneal reflex  Contralateral hemiplegia

65
Q

Define locked in syndrome? Causes?

A

Pt. is aware and cognitively intact but completely
paralysed except for the eye muscles.

 Causes: Ventral pons infarction: basilar artery
Central pontine myelinolysis: rapid correction of
hyponatraemia

66
Q

Define TACS features

A

Contralateral hemiparesis/sensory loss AND homonymous hemianopia AND higher cortical dysfunction

67
Q

Define PACS features

A

Contralateral hemiparesis/sensory loss of EITHER face, arm or legs
OR
Contralateral hemiparesis/sensory loss of >1 of face, arm or legs AND homonymous hemianopia OR cortical dysfunction

68
Q

Define LACS features?

A

pure motor (>1 somatic area) OR pure sensory OR sensorimotor OR clumsy hand dysarthria OR ataxic hemiparesis

69
Q

Define POCS features?

A

Isolated hemianopia, cerebellar or brainstem syndrome.

Integrative (17 decks)

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