Stroke and its consequences Flashcards by Hannah Wilkinson

What is a TIA?

Transient Ischaemic Attack
Brief episode of neurological dysfunction due to temporary focal cerebral or retinal ischaemia without infarction.
Lasts seconds or minutes with complete recovery.

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Blood pressure above what level is a risk factor for stroke?

Systolic >160
Diastolic >95

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Which ethnicity has a higher risk of stroke?

Afro-carribean

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What is no longer considered a risk factor for stroke?

Post-menopausal oestrogen

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High levels of which amino acid can increase the risk of stroke?

Homocysteine

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What is the most common cause of stroke?

Atherosclerosis

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What types of arteries does atherosclerosis mainly affect?

Large and medium sized muscular and elastic arteries.

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Which arteries are usually most severely affected by atherosclerosis?

Internal carotid and basilar arteries

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In plague formation, injured epithelium attracts which cells from the media into the intima?

Monocytes and SMC

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What does the damaged endothelium release to promote proliferation of smooth muscle cells, resulting in plaque formation?

growth factors

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Small vessel disease can predispose you to which conditions?

Vascular dementia
Parenchymal brain haemorrhage

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How would SVD present on an MRI?

Symmetric, multifocal abnormality within the white matter and basal ganglia.

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Which type of SVD occurs when amyloid is deposited in blood vessels?

Cerebral amyloid angiopathy (CAA)

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What is CADASIL?

Cerebral autosomal dominant arteriopathy with sub-cortical infarcts and leukoencephalopathy.
Heritable cause of stroke.

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Which arteries would be involved in an anterior circulation stroke?

Internal carotid
Middle cerebral
Anterior cerebral
Opthalmic

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What are the common features of an anterior circulation stroke?

Contralateral hemiplegia and facial weakness
Contralateral hemisensory loss
Neglect syndrome
Aphasis
Homonymous hemianopia
Hemiparesis (Leg more than arm)
Apathy or apraxia (frontal lobe deficits)

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What is neglect syndrome and what type of stroke is this classically present in?

Where the patient ignores (reduced awareness) the side of the body that is affected.
Commonly affects the parietal lobe - so anterior circulation stroke.

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In an anterior circulation stroke, would there be eye deviation towards or away from the affected side?

Towards

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What is aphasia and why is this present in anterior circulation strokes?

Full loss of language.
Anterior circulation supplies the hemispheres,
Left hemisphere particularly involved in speech, is there is a lesion here/interruption of supply - can cause speech problems.

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What is homonymous hemianopia?

Visual field loss of the same side of each eye.
Right side of brain controls left visual field for both eyes, left controls right visual field.

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Which artery is most commonly affected in an anterior circulation stroke?

MCA

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What features are seen in a posterior circulation stroke?

Diplopia (double vision), vertigo, vomiting.
Dysphagia (partial loss of language), dysarthria (slurred speech)
Ataxia (poor muscle control)
Hemisensory loss
Hemianopic visual loss
Hemi/Quadraparesis
LOC

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What supplies the posterior of the brain?

Vertebrobasilar system.
Two vertebral arteries join to form basilar artery.

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Why is there a broad range of symptoms in a posterior circulation stroke?

Posterior circulation (vertebrobasilar system) supplies the brainstem, cerebellum, spinal cord, thalamus and occipital lobes. A stroke in this circulation can affect the several different areas, thus causing a wide range of symptoms.

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What are lacunar infarcts?

Small infarcts in arteries that are branched off large arteries. <1.5cm in size. No cortical features (not extending into cortex)

What are four types of lacunar infarcts?

Pure motor Pure sensory Sudden unilateral ataxia (ataxic hemiparesis) Dysarthria with a clumsy hand

What is the management of an acute stroke?

ABCDE CT head - thrombolysis if indicated or 300mg aspirin Stroke unit Swallow assessment Thromboembolism prophylaxis Treat medical conditions e.g. HTN, AF, infection

How does thrombolysis reduce the risk of severe disability?

Dissolves the blood clot, improving blood flow and preventing further ischaemia. Area around ischaemia - the ischaemic penumbra is swollen + can regain function once revascularised.

From the onset of stroke symptoms, what time must thrombolysis be given in?

4.5 hours

What is the main medication given in thrombolysis?

Alteplase Tissue plasminogen activator 0.9mg/kg up to 90mg

What is the swollen area around an infarction called?

The ischaemic penumbra

When would thrombolysis be contraindicated?

SAH Persistent HTN Pregnancy Low platelets (<100,000mm3) INR >1.7 on warfarin Elevated partial thromboplastin time on heparin

What recent conditions/procedures would prevent thrombolysis being given?

Stroke/head trauma in past 3/12 Hx of ICH Major surgery within 14/7 GI or genitourinary bleeding within 21/7 Arterial puncture in non-compressible site within 7/7 Lumbar puncture within 7/7

If thrombolysis fails, is there an alternative treatment?

Yes - mechanical clot retrieval. Intra-arterial cathater via groin to remove clot.

Does having a TIA increase someones chances of having a stroke?

Yes 30% have a stroke within 5 years of TIA.

What investigations would be done if someone presents with a TIA?

Doppler, USS carotid arteries ECG, ECHO, 24hr tape MRI brain + MR or CT angiography

Carotid endarterectomy should be performed in which circumstances?

For a carotid stenosis of 70-99% with symptoms, if initial stroke not severely debilitating. Symptomatic moderate stenosis (50-69%)

What risk is there of a carotid endarterectomy?

3% risk of causing a stroke

Is asymptomatic carotid stenosis treated with endarterectomy?

For 70-99% stenosis - surgery debatable but currently recommended. Moderate stenosis treated conservatively.

Why is a total chronic occlusion of the carotid arteries always treated conservatively?

There is no risk of distal embolisation + carotid endarterectomy or stenting could instead cause a stroke.

What is the medical treatment for a TIA?

High dose aspirin (300mg od) for two weeks then switch to clopidogrel Anticoagulant for those with AF associated cardio-embolic stroke Treat medical conditions + lifestyle factors

What are the four type of haemorrhage and which ones are usually post trauma related?

Subarachnoid haemorrhage Subdural haemorrhage (usually post-trauma) Extradural haemorrhage (post-trauma) Intracerebral haemorrhage

What is a intracerebral haemorrhage?

A bleed/haemorrhage from an arterial source directly into the substance of the brain.

What can cause a intracerebral haemorrhage?

AVM Blood dyscrasias + anti-coagulants Tumours Cocaine, amphetamines Cerebral amyloid angiopathy

Where does a intracerebral haemorrhage occur?

Mainly in deep portion of cerebral hemispheres Putamen is most common location. Also subcortical WM, cerebellum, thalamus and pons.

Do the main, larger arteries usually cause a intracerebral haemorrhage?

No - it's usually small deep arteries that perforate - the same arteries that cause lacunar infarcts.

What are millary aneurysms?

Small aneurysms that arise from arterioles and thought to be related to ICH. Histologically seen as lipohyalinosis - abnormality in arterial walls + material deposited into walls causing an infarct.

What are the clinical features of a SAH?

Sudden severe headache, often occipital Vomiting Comatose for hours or days Neck stiffness Positive kernig's sign Papilloedema (usually comes on a lot later - retinal/subhyaloid hamorrhage) Seizures

What is Kernig's sign?

Severe stiffness of the hamstrings causes an inability to straighten leg when hip is flexed at 90 degrees. It's a sign of meningeal irritation.

What are sentinal bleeds?

Small bleeds in the brain causing headaches in the weeks leading up to a SAH. If recognised early, can prevent SAH.

What is the main cause of a SAH?

Intracranial aneurysm - dilation of cerebral blood vessel. Rupture leads to aneurysmal subarachnoid haemorrhage (severe form of stroke). AVM rupture.

What risk factors can increase the chances of a SAH?

Female Old age HTN Smoking +ve FH of ASAH

Having two or more first degree relatives with ASAH increases the risk of developing ASAH by what?

x50 40% heritability

What is the most common type of brain aneurysm?

Berry aneurysm

How is a SAH treated?

Bed rest Treat HTN Nimodipine - calcium blocked to reduce vasospasm Thrombosis + ablation of aneurysm - 1st line treatment Endovascular treatment Direct surgical clipping

What surgical treatment can be given to someone with an AVM, to reduce the risk of SAH?

Glue embolisation.

In what type of stroke would you see right sided weakness, sensory loss, severe mixed dysphasia and right homonymous hemianopia?

Left anterior circulation infarct.

Why is it important when treating HTN in an acute stroke, not to suddenly drop the blood pressure?

It's important to maximise blood supply to the brain - lowering BP especially rapidly, will reduce this blood supply.

Which common conditions can mimic stroke symptoms?

Migraines Bells palsy

How is facial weakness in bells palsy different to a stroke?

BP - whole side facial weakness, unable to close eye properly. Stroke - still able to wrinkle forehead and close eyes

Having migraines, especially with aura, can increase the risk of what?

A stroke.

Bells palsy occurs gradually, usually secondary to a recent viral illness. How is it treated?

Steroids +/- aciclovir if VZV suspected.