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NSB Lectures > Stroke and its consequences > Flashcards

Stroke and its consequences Flashcards

1
Q

What is a TIA?

A

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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2
Q

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

A

Systolic >160
Diastolic >95

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3
Q

Which ethnicity has a higher risk of stroke?

A

Afro-carribean

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4
Q

What is no longer considered a risk factor for stroke?

A

Post-menopausal oestrogen

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5
Q

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

A

Homocysteine

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6
Q

What is the most common cause of stroke?

A

Atherosclerosis

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7
Q

What types of arteries does atherosclerosis mainly affect?

A

Large and medium sized muscular and elastic arteries.

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8
Q

Which arteries are usually most severely affected by atherosclerosis?

A

Internal carotid and basilar arteries

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9
Q

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

A

Monocytes and SMC

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10
Q

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

A

growth factors

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11
Q

Small vessel disease can predispose you to which conditions?

A

Vascular dementia
Parenchymal brain haemorrhage

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12
Q

How would SVD present on an MRI?

A

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

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13
Q

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

A

Cerebral amyloid angiopathy (CAA)

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14
Q

What is CADASIL?

A

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

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15
Q

Which arteries would be involved in an anterior circulation stroke?

A

Internal carotid
Middle cerebral
Anterior cerebral
Opthalmic

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16
Q

What are the common features of an anterior circulation stroke?

A

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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17
Q

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

A

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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18
Q

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

A

Towards

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19
Q

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

A

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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20
Q

What is homonymous hemianopia?

A

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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21
Q

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

A

MCA

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22
Q

What features are seen in a posterior circulation stroke?

A

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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23
Q

What supplies the posterior of the brain?

A

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

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24
Q

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

A

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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25
Q

What are lacunar infarcts?

A

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

26
Q

What are four types of lacunar infarcts?

A

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

27
Q

What is the management of an acute stroke?

A

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

28
Q

How does thrombolysis reduce the risk of severe disability?

A

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

29
Q

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

A

4.5 hours

30
Q

What is the main medication given in thrombolysis?

A

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

31
Q

What is the swollen area around an infarction called?

A

The ischaemic penumbra

32
Q

When would thrombolysis be contraindicated?

A

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

33
Q

What recent conditions/procedures would prevent thrombolysis being given?

A

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

34
Q

If thrombolysis fails, is there an alternative treatment?

A

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

35
Q

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

A

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

36
Q

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

A

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

37
Q

Carotid endarterectomy should be performed in which circumstances?

A

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

38
Q

What risk is there of a carotid endarterectomy?

A

3% risk of causing a stroke

39
Q

Is asymptomatic carotid stenosis treated with endarterectomy?

A

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

40
Q

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

A

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

41
Q

What is the medical treatment for a TIA?

A

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

42
Q

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

A

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

43
Q

What is a intracerebral haemorrhage?

A

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

44
Q

What can cause a intracerebral haemorrhage?

A

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

45
Q

Where does a intracerebral haemorrhage occur?

A

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

46
Q

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

A

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

47
Q

What are millary aneurysms?

A

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.

48
Q

What are the clinical features of a SAH?

A

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

49
Q

What is Kernig’s sign?

A

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.

50
Q

What are sentinal bleeds?

A

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

51
Q

What is the main cause of a SAH?

A

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

52
Q

What risk factors can increase the chances of a SAH?

A

Female
Old age
HTN
Smoking
+ve FH of ASAH

53
Q

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

A

x50
40% heritability

54
Q

What is the most common type of brain aneurysm?

A

Berry aneurysm

55
Q

How is a SAH treated?

A

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

56
Q

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

A

Glue embolisation.

57
Q

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

A

Left anterior circulation infarct.

58
Q

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

A

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

59
Q

Which common conditions can mimic stroke symptoms?

A

Migraines
Bells palsy

60
Q

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

A

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

61
Q

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

A

A stroke.

62
Q

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

A

Steroids +/- aciclovir if VZV suspected.

NSB Lectures (48 decks)

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