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Neuro > Stroke and Brain Haemorrhage > Flashcards

Stroke and Brain Haemorrhage Flashcards

1
Q

Define stroke

A

Sudden onset of focal or global neurological symptoms due to disruption of blood supply (ischaemia or haemorrhage) and lasting more than 24 hours

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2
Q

List the causes of ischaemic stroke

A

Unexplained
Large artery athersclerosis (plaque/thrombus embolises to brain)
Cardioembolic (e.g. atrial fibrillation)
Small artery occlusion (lacune)
Rare causes e.g. arterial dissection or venous sinous thrombosis

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3
Q

What type of imaging can be used to prove a stroke?

A

Diffusion-weighted MRI

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4
Q

Stroke pathophysiology; describe the ischaemic cascade

A

Interruption of the blood supply to the brain
Ischaemia - failure of cerebral blood flow to part of the brain
Hypoxia
Anoxia
Infarction - stroke
Oedema and/or secondary haemorrhage

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5
Q

List the non-modifiable risk factors for stroke

A

Previous stroke
Old age
Male
Family history of stroke

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6
Q

List the modifiable risk factors fro stroke

A 
Hypertension
Smoking
High cholesterol
Poor diet
Obesity
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7
Q

Describe how chronic hypertension and smoking increase the risk of stroke

A

Chronic hypertension worsens atheroma and affects small distal arteries
Smoking increases risk of cardiac problems which in turn increases risk of stroke

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8
Q

What is the main function of Broca’s area in the brain?

A

Speech (initiation)

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9
Q

What is the main function of Wernicke’s area in the brain?

A

Speech comprehension

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10
Q

Which part of the brain is responsible for general comprehension of language

A

Parietal lobe

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11
Q

Which arteries give rise to anterior circulation in the brain? What are the two major branches of these arteries?

A

Internal carotid arteries

Branch into anterior cerebral and middle cerebral arteries

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12
Q

Describe the anatomy of the arteries that for the posterior circulation in the brain

A

Vertebral arteries, become basilar artery, branches into cerebellar/pontine arteries and posterior cerebral artery

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13
Q

What symptoms might present if the anterior cerebral artery is occluded?

A

Contralateral:
paralysis of foot and leg
sensory loss over foot and leg
impairment of gait and stance

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14
Q

What is agnosia?

A

neglect syndromes, e.g.

  • visual
  • sensory
  • anosagnosia
  • prosopagnosia
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15
Q

Occlusion of which artery is most likely to cause agnosia?

A

Middle cerebral artery of the right (non-dominant) hemisphere

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16
Q

What symptoms might present if the middle cerebral artery is occluded on the left (dominant) side?

A

paralysis/sensory loss of right (contralateral)
homonymous hemianopia
dysphasia/aphasia

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17
Q

What type of stroke tends to occur in the basal ganglia?

A

Small vessel lacunar strokes

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18
Q

What happens over time to lacunar strokes?

A

Infarcts are replaced by CSF forming little “lakes”

19
Q

What are the symptoms of lacunar strokes?

A

No cortical signs (dysphasia, neglect, hemianopia)
May be purely motor or purely sensory
Dysarthria - “clumsy hand syndrome”
Ataxic hemiparesis

20
Q

Which parts of the brain would be affected by a posterior circulation stroke?

A 
brainstem, 
cerebellum, 
thalamus, 
occipital lobe, 
medial temporal lobes
21
Q

Describe the possible symptoms of brainstem dysfunction

A 
coma
vertigo
nausea/vomiting
cranial nerve palsy
ataxia
hemiparesis
hemisensory loss
visual field deficits
crossed sensory-motor deficits
22
Q

What are the aims of treatment for acute ischaemic stroke?

A

Restore blood supply
Prevent extension of ischaemic damage
Protect vulnerable brain tissue

23
Q

What is t-PA?

A

tissue Plasminogen Activator

  • given IV to teat acute ischaemic stroke
  • works by dissolving the clot and therefore inproving blood flow to the ischaemic part of the brain
24
Q

Describe the criteria for use of t-PA (there are 4)

A

Less than 45 hours from symptom onset
Disabling neurological deficit
Symptoms present for over 60 minutes
Consent obtained

25
Q

Describe the exclusion criteria for use of t-PA

A

Anything that increaes the possibility of haemorrhage
- blood on CT
- recent surgery
- recent episodes of bleeding
- coagulopathies
BP greater than 185 systolic or 110 diastolic
Glucose less than 2.8

26
Q

Describe how intracranial haemorrhages are classified (in general terms)

A 
Traumatic
 - extradural haematoma
 - subdural haematoma
 - traumatic subarachnoid haemorrhage
 - intra-parenchymal contusions
Non-traumatic (a form of stroke)
 - subarachnoid haemorrhage
 - intracerebral haemorrhage
 - vascular malformations
27
Q

Where are brain aneurysms most likely to occur?

A

In the major blood vessels at the base of the skull

28
Q

Give three conditions that are associated with a higher risk of subarachnoid haemorrhage

A

Polycystic kidney disease
Ehler’s-Danlos
Marfans
(the latter two are connective tissue disorders which cause blood vessels to be more fragile and therefore more likely to bleed)

29
Q

Describe the presentation of subarachnoid haemorrhage

A

Severe headache, often “thunderclap”
May also experience a sentinel headache; a lesser “warning” headache a few hours/days before the SAH
Meningism (caused by irritation of the meninges because blood is an irritant)
Focal neurological deficits
Seizures
ECG changes (brain activity can caue changes in the heart)
Reduced level of consciousness, coma, death

30
Q

When a patient’s conscious level decreases, at what point should they be intubated and why?

A

GCS of eight or less

At this point there is a risk that the patient will not be able to maintain their own airway

31
Q

Why can SAH lead to hydrocephalus?

A

Damage caused by haemorrhage disrupts the production and/or drainage of CSF

32
Q

Describe the complications of SAH

A 
Rebleeding (if caused by aneurysm)
Vasospasm
Hydrocephalus
Seizures
Electrolyte abnormalities e.g. hypernoatraemia
33
Q

When is the risk of aneurysmal rebleeding the highest after an SAH?

A

First day after the haemorrhage

34
Q

What is vasospasm and why is it a problem?

A

Spasm of cerebral arteries (form of stroke)

  • blood in SA space is an irritant
  • this causes release of inflammatory cytokines
  • results in smooth muscle contraction in vessel wall
  • brain area supplied by spastic artery is starved of oxygen
  • leads to permenant deficit/weakness if untreated
35
Q

Which drug can be used to reduce the risk of vasospasm? How long should it be taken for?

A

Nimodipine

1-3 weeks

36
Q

How is vasospasm diagnosed?

A

Clinical signs (i.e. neurological deficit)
Transcranial doppler
CT-Angiogram
Digital subtraction angiography (DSA)

37
Q

How is vasospasm treated?

A

“triple H”: hypertension, hypervolaemia, haemodilution
- Admit to ICU; boost BP and give fluids
Endovascular techniques to dilate vessel if spasm is focal

38
Q

Which type of stroke has the worst prognosis? What proportion of strokes are caused by this?

A

Intracerebral haemorrhage
15% of strokes are IH
- twice as common as SAH

39
Q

What are the risk factors for intracerebral haemorrhage?

A

Hypertension
Increasing age
Substance abuse
Underlying lesion such as tumour or vascular lesion

40
Q

Describe the clinical features associated with an intracerebral haemorrhage

A

Developing neurological deficit, often more gradual than embolic stroke
- contralateral weakness of face/arm/leg
- dysphasia is bleed is in the dominant hemisphere
Symptoms relating to raised intracranial pressure
- headache
- vomiting
- deteriorating consciousness level
- death
- herniation syndromes

41
Q

What is an arteriovenous malformation?

A

An abnormal connection that develops between arteries and veins - no capillary bed

42
Q

How can AVMs cause problems?

A

High flow and high pressure of blood
Veins are not designed to cope with this
Risk of haemorrhage 2-4% per year

43
Q

What types of haemorrhage are most associated with AVMs?

A

Intraparenchymal (most common)

Subarachnoid

44
Q

Which type of brain haemorrhage may present after trauma with an initial lucid period (where the patient recovers) followed by a decline in neurological function?

A

Subdural haemorrhage

Neuro (18 decks)

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