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gwen - neurology > Stroke - Aetiology, Features and Long-term management > Flashcards

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
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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)
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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
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4
Q

What is the function of the occipital lobe?

A
  • Primary visual cortex
  • Visual perception
  • Involuntary smooth eye movement
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5
Q

What are the main functions of the cerebellum?

A

Balance and coordination

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6
Q

What are the main components of the brainstem?

A
  • Midbrain
  • Pons
  • Medulla
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7
Q

How many of the cranial nerves arise from the brainstem?

A

10 out of 12

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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

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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

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10
Q

How many neurons can you lose per minute in an ischaemic stroke?

A

5 million per minute

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11
Q

What proportion of strokes are ischaemic?

A

85%

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12
Q

What proportion of strokes are haemorrhagic?

A

15%

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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
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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
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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
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16
Q

What are the most common sites for stenosis of the extracerebral arteries?

A
  1. Common carotid
  2. Internal carotid
  3. Vertebral
  4. Subclavian
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17
Q

What is the most common cause of ischaemic stroke?

A

Carotid plaque with arteriogenic emboli - 35%

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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
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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
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20
Q

What are 5 impotant points to detrmine when trying to make the diagnosis of stroke?

A
  1. What is the neuro deficit?
  2. Where is the lesion?
  3. What is the lesion?
  4. Why has it happened?
  5. What are the potential complications?
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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
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22
Q

Are abnormal movements after a stroke normal?

A

No

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23
Q

Are headaches after a stroke normal?

A

No

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24
Q

What are the main stroke syndromes?

A

CLINICALLY CLASSIFIED - OCSP Bamford classification

  • TACS
  • PACS
  • LACS
  • POCS
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25
Q

What are general features which are seen in a stroke?

A
  • 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
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26
Q

What does the anterior cerebral artery supply?

A

Motor cortex - leg, frontal lobe, corpus callosum

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27
Q

What does the middle cerebral artery supply?

A

Motor and sensory cortex
Contraltateral arm and face
Wernikes and brocas in dominant hemisphere

Internal capsule

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28
Q

What is a TACS?

A

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.

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29
Q

What are features of a TACS?

A

3 out of 3 of:

  • Complete hemiparesis/numbness - Face, arm and leg (2/3)
  • Homonymous hemianopia
  • Higher function loss - inattention, dyshasia dominant
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30
Q

What is a PACS?

A

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.

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31
Q

What arteries are most commonly affected in a TACS?

A

Large cortical stroke in middle/anterior cerebral artery area

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32
Q

What arteries are most commonly affected in a PACS?

A

Cortical stroke in middle/anterior cerebral artery areas

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33
Q

What are features of a PACS?

A
  • 2 of 3 TACS criteria

or

  • One higher cortical deficit:
    • Inattention
    • Or dysphasia

or

  • Monoparesis
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34
Q

What are features of a POCS?

A

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
Q

What is a LACS?

A

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
Q

What are the subtypes of LACS strokes?

A
  • Pure motor stroke
  • Pure sensory Stroke
  • Sensory motor stroke
  • Ataxic hemiparesis
  • Dysarthria/clumsy hand
37
Q

What are features of a LACS?

A
  • Weakness/numbness of:
    • Face + arm + leg
    • Or Face + arm
    • Or Arm + leg
  • May have dysarthria
  • Ataxic hemiparesis
38
Q

What structures can be affected in a lacunar stroke?

A
  • Basal ganglia
  • Internal capsule
  • Thalamus
  • Pons
39
Q

What functions of the brain does a lacunar infarct affect?

A

Motor and sensory pathways - THINK HOMUNCULUS

40
Q

What medications would you start if someone had a stroke secondary to AF?

A

Warfarin/DOAC - 10-14 days after stroke onset

41
Q

What is a POCS?

A

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
Q

What are features of a basal artery occlusion?

A
  • Predominantly motor/oculomotor signs/symptoms
  • Bilateral but asymmetrical
  • Alteration in level of consciousness common
  • May present as reduced responsiveness
43
Q

If someone presenting with a brainstem stroke had sensory loss, what spinal tracts might be affected?

A
  • Medial lemniscus/Dorsal columns
  • Spinathalamic tracts
44
Q

What does occlusion of the anterior cerebral artery cause in terms of clinical signs?

A
  • Contralateral leg +/- similar/milder arm features
  • Spared face
45
Q

Symptoms/signs in a middle artery occlusion

A
  • 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
Q

Symptoms/signs in an anterior cerebral occlusion

A

Lower limb sensory loss (foot and leg)

Contralateral hemiplegia (lower limb)

Gait apraxia (impaired gait and stance)

Confusion

47
Q

Sings/symptoms in a lacunar stroke

A
  • 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
Q

Signs and symptoms in posterior cerebral artery occlusion

A
  • Supplies brainstem, cerebellum, front of occipital and temporal lobes
  • Homonymous hemianopia
  • Contralateral Hemiplegia
  • Ataxia
  • Visual agnosia
  • Cortical blindness (occipital lobe)
49
Q

Signs and symptoms of posterior inferior cerebellar artery

A

AKA lateral medullary syndrome

  • Vertigo (+vomiting)
  • Ipsilateral Horner’s syndrome
  • Facial numbness (ipsilateral sensory)
  • Dysarthria
  • Contralateral spinothalamic loss
50
Q

Signs and symptoms of basilar artery

A
  • CN palsies (combination)
    • Vertigo
    • Diplopia
    • Dysarthria
  • Altered consciousness
51
Q

Signs and symptoms of brainstem dysfunction

A
  • Coma, vertigo, CN palsies
  • Hemiparesis, hemi sensory loss
  • Visual defects
  • Locked-in-syndrome
52
Q

What spinal tracts would be affected if someone with a brainstem infarct had hemi/tetraparesis?

A

Corticospinal tracts

53
Q

What artery is implicated in lateral medullary syndrome?

A

Thrombosis of posterior inferior cerebellar artery (PICA)

54
Q

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?

A

Left middle cerebral artery

55
Q

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?

A

Right middle cerebral artery

56
Q

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?

A

Lateral medullary syndrome

57
Q

What structure would be affected if someone with a brainstem infarct had diplopia?

A

Occulomotor nuclei

58
Q

What structure would be affected if someone with a brainstem infarct had nystagmus/vertigo?

A

Vestibular connections

59
Q

What structure would be affected if someone with a brainstem infarct had facial weakness?

A

Facial nerve nuclei

60
Q

What structure would be affected if someone with a brainstem infarct had facial numbness?

A

Trigeminal nerve nuclei

61
Q

What structure would be affected if someone with a brainstem infarct had dyphagia or dysarthria?

A

CNIX and CNX nuclei

62
Q

What structure would be affected if someone with a brainstem infarct had altered consciousness?

A

Reticular formation

63
Q

What can occlusion of the middle cerebral artery cause in terms of clinical signs?

A
  • 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
Q

What can occlusion of the posterior cerebral artery cause in terms of clinical signs?

A
  • Contralateral homonymous hemianopia
65
Q

If someone was presenting with features of a stroke, what would be part of your differential diagnosis?

A
  • 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
Q

What features of a stroke may point to an intracranial haemorrhage as the cause?

A

These may give an indication, but are very unreliable

  • Features of meningism
  • Severe headache
  • Coma
67
Q

What features in history and examination may point towards an ischaemic cause for a stroke?

A
  • Carotid bruit
  • AF
  • Past TIA
  • IHD
68
Q

What investigations would you always perform in someone with a stroke?

A
  • Bloods - FBC, ESR, U+E, Glucose, TSH, Cholesterol
  • ECG
  • CXR
  • Non-contrast CT Scan
69
Q

What investigations would you consider doing in someone with a stroke on top of the standard investigations?

A
  • Coag studies
  • Auto-antibodies
  • Thrombophilia screening
  • Lupus anticoagulant
  • Anticardiolipin antibodies
  • ECHO
  • 24 hr holter
  • Carotid US
70
Q

How might the following stroke present clinically (i.e. clinical stroke syndrome)?

A

PACS

71
Q

How might the following stroke present clinically (i.e. clinical stroke syndrome)?

A

TACS

72
Q

How might the following present clinically (i.e. clinical stroke syndrome)?

A

LACS

73
Q

How might the following present clinically (i.e. clinical stroke syndrome)?

A

POCS

74
Q

What are CTs good at looking for?

A

Haemorrhagic stroke - can help distinguish from ischaemic stroke

75
Q

What medications would you give to reduce the risk of strokes recurring in someone who has had an ischaemic stroke?

A
  • Aspirin 300mg - acutely up to 2 weeks
  • Clopidogrel monotherapy - long term
  • Warfarin/DOAC - if underlying AF
  • Statin - artovastatin
  • ACEi - BP management
76
Q

What are important aspects of long-term stroke management to consider?

A
  • Swallowing and fluids
  • Temperature
  • Primary/Secondary prevention
  • Urinary incontinaence
  • DVT prophylaxis
  • Skin Care
  • Positioning
  • Feeding
  • Depression
  • Pain
  • Rehabilitation
77
Q

What are primary prevention measures that can be taken to prevent high risk individuals from having a stroke?

A
  • Control Risk factors - hypertension, obesity, lipids, cholesterol, diabetes smoking
  • Anticoagulation – lifelong therapy for those with rheumatic heart disease or prosthetic valves, or AF
78
Q

What are secondary prevention measures for prevention of further strokes?

A
  • Control risk factors – controlling BP and cholesterol greatly reduces the risk
  • Anticoagulation– if embolic stroke, then aspirin (2 weeks), followed by clopidogrel
79
Q

What investigations might you do to identify risk factors that may need intervention as part of your long term management following a stroke?

A
  • 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
Q

What is the role of the occupational therapists in stroke rehabilitation?

A

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
Q

What is the role the the speech therapist in stroke rehabilitation?

A

Help with:

  • Dysphasia
  • Dysphagia
82
Q

What is the role of the physiotherapist in stroke rehabilitation?

A

Helps to prevent spasticity and contractures. Also teaches patients how to cope with their current level of function

83
Q

What antiplatelet therapy would you use as secondary prevention following a stroke?

A

Aspirin - 300mg, followed by Clopidogrel long-term

gwen - neurology (38 decks)

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