Stroke - Aetiology, Features and Long-term management Flashcards
1
Q
F
What is the frontal lobe involved in?
A
- High level cognitive functions - abstraction, concentration, reasoning
- Memory
- Control of voluntary eye movement
- Motor control of speech (dominant hemisphere)
- Motor cortex
- Urinary continence
- Emotion and personality
2
Q
What are the functions of the parietal lobe?
A
- Sensory cortex
- Sensation - touch, pressure, position
- Awareness of parts of the body
- Spatial orientation and visuospatial information - non dominant hemisphere
- Ability to perform learned motor tasks (dominant)
3
Q
What are the functions of the temporal lobe?
A
- Primary auditory receptive area
- Comprehension of speech (dominant) – Wernicke’s
- Visual, auditory and olfactory perception
- Important role in learning, memory and emotional affect
4
Q
What is the function of the occipital lobe?
A
- Primary visual cortex
- Visual perception
- Involuntary smooth eye movement
5
Q
What are the main functions of the cerebellum?
A
Balance and coordination
6
Q
What are the main components of the brainstem?
A
- Midbrain
- Pons
- Medulla
7
Q
How many of the cranial nerves arise from the brainstem?
A
10 out of 12
8
Q
What is the definition of a stroke?
A
Rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting >/= 24 hrs, or leading to death with no apparent cause other than vascular
9
Q
What is the definition of a TIA?
A
A brief episode of neurological dysfunction caused by focal brain or retinal ischemia with clinical symptoms typically lasting less than one hour and without evidence of acute brain infarction
10
Q
How many neurons can you lose per minute in an ischaemic stroke?
A
5 million per minute
11
Q
What proportion of strokes are ischaemic?
A
85%
12
Q
What proportion of strokes are haemorrhagic?
A
15%
13
Q
What are causes of ischaemic stroke?
A
-
Atherosclerosis
- Carotid plaques (commonly at junctions - carotid bifurcation, vertebral arteries (basilar))
- Aortic arch plaque
- Flow reducing carotid stenosis
-
Thrombolysis/embolism
- Cardiac emboli - AF, endocarditis, MI (mural thrombus), valve disease, LV thrombi
- Idiopathic
-
Rarer causes
- Arterial dissection
- Venous sinus dissection
- Penetrating artery disease
14
Q
What are the causes of a haemorrhagic stroke?
A
- Primary intra-cerebral haemorrhage (hypertension)
- Most commonly in basal ganglia (50%), lobar white matter (20%), pons (10%) and cerebellum 10%
- Secondary haemorrhage
- SAH
- Aterio-venous malformation
15
Q
What are risk factors for having a stroke?
A
-
Non modifiable
- Age
- Gender - male
- FH
- Previous stroke
- Deletion polymorphism in ACE gene
- Ethnicity - black/asian
-
Modifiable
- Smoking
- Alcohol
- Diet
- Obesity
- Phyiscal inactivity
- Hyperlipidaemia
- HYPERTENSION
- DM
- Blood ocagulation factors - high fibrinogen, factor 7
-
Other RF
- Atrial fibrillation
- Hypercoaguable states
16
Q
What are the most common sites for stenosis of the extracerebral arteries?
A
- Common carotid
- Internal carotid
- Vertebral
- Subclavian
17
Q
What is the most common cause of ischaemic stroke?
A
Carotid plaque with arteriogenic emboli - 35%
18
Q
What are cardioembolic causes of stroke?
A
- AF
- Cardioversion
- Acute MI + akintic LV - Mural thrombosis
- Infective endocarditis
- Cardiac surgery
- Valvular disease
- Patent foramen ovale/septal defect - DVT can pass through
19
Q
If someone below the age of 40 presented with a stroke, what might you consider investigating for as a cause?
A
- Sudden drop in BP >/= 40mmHg
- Carotid artery dissection
- Vasculitis
- SAH
- Venous sinus thrombosis
- Antiphospholipid syndrome
- Thrombophilia
20
Q
What are 5 impotant points to detrmine when trying to make the diagnosis of stroke?
A
- What is the neuro deficit?
- Where is the lesion?
- What is the lesion?
- Why has it happened?
- What are the potential complications?
21
Q
If you had a stroke in the brainstem, where would you see neruological signs?
A
- Ipsilateral cranial nerve signs
- Contralateral motor signs/Quadraplegia
- Disturbances of gaze and vision
- Locked in syndrome
22
Q
Are abnormal movements after a stroke normal?
A
No
23
Q
Are headaches after a stroke normal?
A
No
24
Q
What are the main stroke syndromes?
A
CLINICALLY CLASSIFIED - OCSP Bamford classification
- TACS
- PACS
- LACS
- POCS
25
What are general features which are seen in a stroke?
* **Motor -** clumsy or weak limb
* **Sensory** **loss**
* **Speech** - Dysarthria/Dysphasia
* **Neglect / visuospatial problems**
* **Vision** - loss in one eye (amaurosis fugax) or hemianopia
* **Gaze palsy**
* **Ataxia/ vertigo / incoordination / nystagmus**
26
What does the anterior cerebral artery supply?
Motor cortex - leg, frontal lobe, corpus callosum
27
What does the middle cerebral artery supply?
Motor and sensory cortex
Contraltateral arm and face
Wernikes and brocas in dominant hemisphere
Internal capsule
28
What is a TACS?
**Total anterior circulation stroke**
Constellation of symptoms of a patient who clinically appears to have suffered from a total anterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to confirm the diagnosis.
29
What are features of a TACS?
3 out of 3 of:
* **Complete hemiparesis/numbness** - Face, arm and leg (2/3)
* **Homonymous hemianopia**
* **Higher function loss** - inattention, dyshasia dominant
30
What is a PACS?
**Partial anterior circulation syndrome**
Constellation of symptoms of a patient who clinically appears to have suffered from a partial anterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to confirm the diagnosis.
31
What arteries are most commonly affected in a TACS?
Large cortical stroke in middle/anterior cerebral artery area
32
What arteries are most commonly affected in a PACS?
Cortical stroke in middle/anterior cerebral artery areas
33
What are features of a PACS?
* **2 of 3 TACS criteria**
or
* **One higher cortical deficit:**
* Inattention
* Or dysphasia
or
* **Monoparesis**
34
What are features of a POCS?
One of the following:
1. **Cerebellar/brainstem syndromes** - Loss of balance/coordination (cerebellar dysfunction), Ipsilateral CNIII-XII nerve motor/sensory loss, Vertigo, Dysarthria
2. **Isolated Homonymous hemianopia/Cortical blindness**
3. **Loss of consciousness**
35
What is a LACS?
**Lacunar syndrome**
Constellation of symptoms that result from the occlusion of small penetrating arteries that provide blood to the brain's deep structures. Small infarcts called are called ‘lacunes’
36
What are the subtypes of LACS strokes?
* **Pure motor stroke**
* **Pure sensory Stroke**
* **Sensory motor stroke**
* **Ataxic hemiparesis**
* **Dysarthria/clumsy hand**
37
What are features of a LACS?
* **Weakness/numbness of:**
* Face + arm + leg
* Or Face + arm
* Or Arm + leg
* **May have dysarthria**
* **Ataxic hemiparesis**
38
What structures can be affected in a lacunar stroke?
* Basal ganglia
* Internal capsule
* Thalamus
* Pons
39
What functions of the brain does a lacunar infarct affect?
Motor and sensory pathways - THINK HOMUNCULUS
40
What medications would you start if someone had a stroke secondary to AF?
Warfarin/DOAC - 10-14 days after stroke onset
41
What is a POCS?
**Posterior Circulation Syndrome**
Symptoms of a patient who clinically appears to have had a posterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to confirm the diagnosis.
42
What are features of a basal artery occlusion?
* **Predominantly motor/oculomotor signs/symptoms**
* **Bilateral but asymmetrical**
* **Alteration in level of consciousness common**
* **May present as reduced responsiveness**
43
If someone presenting with a brainstem stroke had sensory loss, what spinal tracts might be affected?
* **Medial lemniscus/Dorsal columns**
* **Spinathalamic tracts**
44
What does occlusion of the anterior cerebral artery cause in terms of clinical signs?
* **Contralateral leg +/- similar/milder arm features**
* **Spared face**
45
Symptoms/signs in a middle artery occlusion
* Limb initially flaccid with reduced reflexes then develops into spastic hemiplegia (UMN)- increased reflexes, upgoing plantars
* Contralateral sensory loss (hemi sensory loss)
* Contralateral hemiplegia (face, arm + leg)
* Homonymous Hemianopia- gaze paralysis to opposite side
* Dysphasia (receptive or expressive)
* Non-dominant hemisphere symptoms:
* Agnosia (neglect)
* Visual sensory agnosia
* Anosagnosia
* Prosopagnosia
* Apraxia
* Inability or difficulty to build, assemble or draw objects
46
Symptoms/signs in an anterior cerebral occlusion
Lower limb sensory loss (foot and leg)
Contralateral hemiplegia (lower limb)
Gait apraxia (impaired gait and stance)
Confusion
47
Sings/symptoms in a lacunar stroke
* Small infarcts around basal ganglia, internal capsule, thalamus + pons
* Devoid of cortical signs (no dysphasia, neglect, hemianopia)
* Intact consciousness/cognition
* Types:
* Pure Motor Stroke
* Pure Sensory Stroke
* Sensory-motor Stroke
* Ataxic Hemiparesis
* Dysarthria/clumsy hand syndrome
48
Signs and symptoms in posterior cerebral artery occlusion
* Supplies brainstem, cerebellum, front of occipital and temporal lobes
* Homonymous hemianopia
* Contralateral Hemiplegia
* Ataxia
* Visual agnosia
* Cortical blindness (occipital lobe)
49
Signs and symptoms of posterior inferior cerebellar artery
AKA lateral medullary syndrome
* Vertigo (+vomiting)
* Ipsilateral Horner’s syndrome
* Facial numbness (ipsilateral sensory)
* Dysarthria
* Contralateral spinothalamic loss
50
Signs and symptoms of basilar artery
* CN palsies (combination)
* Vertigo
* Diplopia
* Dysarthria
* Altered consciousness
51
Signs and symptoms of brainstem dysfunction
* Coma, vertigo, CN palsies
* Hemiparesis, hemi sensory loss
* Visual defects
* Locked-in-syndrome
52
What spinal tracts would be affected if someone with a brainstem infarct had hemi/tetraparesis?
Corticospinal tracts
53
What artery is implicated in lateral medullary syndrome?
Thrombosis of posterior inferior cerebellar artery (PICA)
54
If someone having a stroke presented with right-sided weakness involving face and arms more than the leg, and dysphasia, what artery might be the culprit?
Left middle cerebral artery
55
If someone having a stroke presented with left-sided weakness involving face and arms more than the leg, and visual and/or sensory neglect, what artery might be the culprit?
Right middle cerebral artery
56
If someone having a stroke presented with ipsilateral horner's syndrome, CNX palsy, Facial sensory loss, limb ataxia with contralateral spinothalamic sensory loss, and vertigo, what might be the diagnosis?
Lateral medullary syndrome
57
What structure would be affected if someone with a brainstem infarct had diplopia?
Occulomotor nuclei
58
What structure would be affected if someone with a brainstem infarct had nystagmus/vertigo?
Vestibular connections
59
What structure would be affected if someone with a brainstem infarct had facial weakness?
Facial nerve nuclei
60
What structure would be affected if someone with a brainstem infarct had facial numbness?
Trigeminal nerve nuclei
61
What structure would be affected if someone with a brainstem infarct had dyphagia or dysarthria?
**CNIX and CNX nuclei**
62
What structure would be affected if someone with a brainstem infarct had altered consciousness?
## Footnote
**Reticular formation**
63
What can occlusion of the middle cerebral artery cause in terms of clinical signs?
* **Contralateral hemiparesis**
* **Hemisensory loss** - esp face and arm (look at homunculus)
* **Contralateral homonymous hemianopia** - optic radiation involvement
* **Dysphasia** - dominant hemisphere
* **Visuospatial disturbance** - non-dominant hemisphere
64
What can occlusion of the posterior cerebral artery cause in terms of clinical signs?
* **Contralateral homonymous hemianopia**
65
If someone was presenting with features of a stroke, what would be part of your differential diagnosis?
* **Head injury**
* **Hypo/hyperglycaemia**
* **Subdural haemorrhage**
* **Intracranial tumours**
* **Hemiplegic migraine**
* **Post-ictal features - e.g. Todd's paralysis**
* **CNS lymphoma**
* **Wernicke's/hepatic encephalopthy**
* **Encephalitis**
* **Toxoplasmosis**
* **Cerebral abscesses**
* **Mycotic aneurysm**
* **Drug overdose**
66
What features of a stroke may point to an intracranial haemorrhage as the cause?
These may give an indication, but are very unreliable
* **Features of meningism**
* **Severe headache**
* **Coma**
67
What features in history and examination may point towards an ischaemic cause for a stroke?
* **Carotid bruit**
* **AF**
* **Past TIA**
* **IHD**
68
What investigations would you ***_always_*** perform in someone with a stroke?
* **Bloods** - FBC, ESR, U+E, Glucose, TSH, Cholesterol
* **ECG**
* **CXR**
* **Non-contrast CT Scan**
69
What investigations would you consider doing in someone with a stroke on top of the standard investigations?
* **Coag studies**
* **Auto-antibodies**
* **Thrombophilia screening**
* **Lupus anticoagulant**
* **Anticardiolipin antibodies**
* **ECHO**
* **24 hr holter**
* **Carotid US**
70
How might the following stroke present clinically (i.e. clinical stroke syndrome)?
PACS
71
How might the following stroke present clinically (i.e. clinical stroke syndrome)?
TACS
72
How might the following present clinically (i.e. clinical stroke syndrome)?
LACS
73
How might the following present clinically (i.e. clinical stroke syndrome)?
POCS
74
What are CTs good at looking for?
**Haemorrhagic stroke** - can help distinguish from ischaemic stroke
75
What medications would you give to reduce the risk of strokes recurring in someone who has had an ischaemic stroke?
* **Aspirin 300mg** - acutely up to 2 weeks
* **Clopidogrel monotherapy** - long term
* **Warfarin/DOAC** - if underlying AF
* **Statin** - artovastatin
* **ACEi** - BP management
76
What are important aspects of long-term stroke management to consider?
* **Swallowing and fluids**
* **Temperature**
* **Primary/Secondary prevention**
* **Urinary incontinaence**
* **DVT prophylaxis**
* **Skin Care**
* **Positioning**
* **Feeding**
* **Depression**
* **Pain**
* **Rehabilitation**
77
What are primary prevention measures that can be taken to prevent high risk individuals from having a stroke?
* **Control Risk factors** - hypertension, obesity, lipids, cholesterol, diabetes smoking
* **Anticoagulation** – lifelong therapy for those with rheumatic heart disease or prosthetic valves, or AF
78
What are secondary prevention measures for prevention of further strokes?
* **Control risk factors** – controlling BP and cholesterol greatly reduces the risk
* **Anticoagulation**– if embolic stroke, then aspirin (2 weeks), followed by clopidogrel
79
What investigations might you do to identify risk factors that may need intervention as part of your long term management following a stroke?
* **Hypertension** - Eyes, kidneys, CXR
* **Cardiac source** - ECG, CXR, ECHO
* **Cortid artery stenosis** - doppler, CT/MRI
* **Vasculitis** - ESR, ANCA
* **Hypervisciocity** - FBC
* **Thrombocytopenia** - FBC
* **Diabetes** - fasting glucose
80
What is the role of the occupational therapists in stroke rehabilitation?
Looks at levels of function, and teaches patient how to cope. Also arranges home alterations (stair lifts, hand rails etc) to help the patient stay living at home.
81
What is the role the the speech therapist in stroke rehabilitation?
Help with:
* **Dysphasia**
* **Dysphagia**
82
What is the role of the physiotherapist in stroke rehabilitation?
Helps to prevent spasticity and contractures. Also teaches patients how to cope with their current level of function
83
What antiplatelet therapy would you use as secondary prevention following a stroke?
Aspirin - 300mg, followed by Clopidogrel long-term
