Stroke and its Consequences Flashcards
What is a stroke?
rapid onset of neurological deficit caused by focused cerebral, spinal or retinal infarcation or haemorrhage with symptoms lasting over 24 hours
Stroke is a syndrome:
- placeholders to guide investigation
- not a diagnosis
Transient Ischaemic Accident (TIA):
rapid onset of neurological deficit caused by focused cerebral, spinal or retinal infarcation or haemorrhage with symptoms lasting less than 24 hours
may herald a stroke
What are the types of stroke?
Which type is more common?
- Ischaemic = 80-85% = blocked
blood vessels - Haemorrhagic = 15-20%
What are the three main causes of ischaemic stroke?
- small vessel disease (20%)
- atherosclerosis (30%)
- cardio-embolic (30%)
Ischaemic Stroke: Small Vessel Disease:
- high up on surface of brain,
smaller vessels - hypertension and diabetes
- hyalinisation = deposition
proteinaceous material - thickened, concentric smooth
muscle cell layer, duplicated
basement membrane - lumen gradually narrows until
occlusion - commonly affecting perforating
arteries from the middle cerebral
artery
Ischaemic Stroke: Atherosclerosis:
- medium to large vessels brain,
neck, aorta - accumulation and migration of
monocytes and lymphocytes and
foam cells - plaque is formed with a necrotic
core and fibrous cap - narrows the artery
Atherosclerosis:
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Arterial dissection causes what % of strokes in people under 60?
- 25%
- pain localised to side
- carotid/back of neck for vertebral
Ischaemic Stroke: Cardio-embolic:
- atrial fibrillation is the most
common cause - multiple vascular territories are
affected - disrupted contraction of atrium,
often dilation, blood pools and
naturally clots when static
Risk Factors for ischaemic stroke:
- age/gender/genetics
- hypertension
- hyperlipidaemia
- smoking
- diabetes mellitus
- obesity
Rarer Risk Factors for Ischaemic Stroke:
- drugs
- cancer
- thrombophilia
- obstructive sleep apnoea
Haemorrhagic Stroke: Pathophysiology:
1) Weakening of blood vessel wall:
small vessel disease/ amyloid
angiopathy
2) Abnormal vascular anatomy: high
pressure arterial blood in veins,
veins burst
3) Erosion into blood vessels: cancer
4) Abnormal Blood Clotting:
congenital haemophilia, acquired
how does haemorrhage cause brain injury?
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How does haemorrhagic stroke kill?
- herniation of the temporal lobe
uncus - herniation of cerebellar tonsils
- hydrocephalus
- compression of brainstem
Intracerebral Haemorrhage that isn’t stroke:
- hematomas
- extra-axial
- not a stroke
- pressure upon the brain
Intracerebral Haemorrhage on CT:
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What important stroke risk factor is an important part of pathophysiology of both ischaemic and haemorrhagic stroke?
hypertension
Circle of Willis:
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Anterior and Posterior Circulation:
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Anterior, Middle, and Posterior Cerebral Artery Supply:
insert diagrams
Anterior, Middle and Posterior Cerebral Artery Supply (Axial):
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Stroke Symptoms:
- FAST
- facial weakness
- arm weakness
- speech problems
- time to call 999
- hemiparesis/hemianaesthesis/
speech problems - diplopia, ataxia, hemianopia
(double vision, impaired
coordination, loss of half the visual
field)
Stroke: Anterior Cerebral Artery: Symptoms:
- circulation syndromes
- hemiparesis/anaesthesia,
- leg>arm weakness
(partial weakness on one side) - frontal lobe signs: disinhibition,
apathy
Stroke: Middle Cerebral Artery: Symptoms:
- circulation syndrome
- hemiparesis/anaesthesis
- arm>leg weakness
- dysphasia, inattention/neglect
- higher cortical functions and
mathematical ability affected
Stroke: Posterior Cerebral Artery: Symptoms:
- circulation syndrome
- homonymous hemaniopia (loss of
half the visual field)
Stroke: Basilar/Cerebellar Artery: Symptoms:
- hemiparesis (partial weakness one
side) - hemianaethesia + diplopia
- ataxia, crossed signs
can mimic anterior cerebral artery stroke symptoms
Middle Cerebral Artery Strokes and Hemispheric Dominance:
- most people are left handed
- most people are left hemisphere
dominant - Broca’s and wernicke’s on left
- dominant hemisphere MCA
strokes can cause language
problems (dysphasia) - non-dominant hemisphere MCA
strokes affects the attentional
centers resulting in
inattention/neglect/sensory
extinction
Patient has left sided weakness and inattention.
Location of stroke?
Right middle cerebral artery stroke
Patient has right sided weakness and dysphasia,
Location of stroke?
Left middle cerebral artery
Acute Treatment of Stroke:
- ABCDE (+ glucose!!)
- exclude mimincs like
hypoglycaemaia - is it ischaemic/haemorrhagic?
- hyperacute = recanalisation
therapy - acute = reduce complication/
preventative - long term = rehab, secondary
prevention
Acute Treatment of Ischaemic Stroke:
- can we clear the blockage?
- recanalisation therapy:
1) IV thrombolysis: tissue
plasminogen activator
2) Mechanical Thrombectomy:
arterial puncture, wire passed
into cerebral circulation,
thrombus removed by stent
retriever - antiplatelets as prevention
- BP control if thrombolysis given
- therapy input: physio, OT, speech
and language therapy - surgery is rare; decompressive
hemicraniectomy
Contraindications of IV thrombolysis as part of recanalisation therapy:
- haemorrhage
- abnormal clotting
- high BP
- head injury
Acute Haemorrhagic Stroke Treatment:
- no equivalent to
thrombolysis/thrombectomy - bp control to reduce risk of
rebleed - clotting (correct any abnormalities)
- therapy: physio, OT, speech and
language - surgery: selected case cause
decompression/drain insertion
Secondary Prevention of Ischaemic Stroke:
- antiplatelets
- anticoagulants if atrial fibrillation
is cause - antihypertensives (ACE inhibitors,
CCB, diuretics) - statins
- insulin or metformin for diabetic
causes of stroke
Secondary Prevention of Haemorrhagic Stroke:
- avoidance of antithrombotic
treatment - antihypertensive treatment
56 year old man brought in by ambulance crew.
Right sided weakness and dysphasia one hour ago
Symptoms ‘back to normal’ worse for 20 mins
On examination he walks in from ambulance
BP 156/88 mmHg PR 60 /min BM 5.5 mmol/L
He has mild expressive speech problems
Slight drift of his right arm
He tells you the symptoms are continuing to get better
What is the diagnosis?
- ischaemic stroke affecting left
hemisphere territory - stroke affecting left
hemisphere territory - transient ischaemic attack
Symptoms still present = stroke
Left sided middle cerebral artery stroke???
probably ischaemic but without imaging can not say
85 year old right handed woman. Background hypertension. Usually independent.
Witnessed sudden onset right sided weakness and dysphasia at 16.30
Arrival to A&E at 17.30
On examination dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous hemianopia.
ECG shows sinus rhythm, BP 210/106 mmHg, Blood sugar 6.3 mmol/L
What is the best next course of action?
- aspirin not given until
haemorrhage excluded - contact local stroke team
- urgent head CT
What is often seen in CT brain during acute stroke?
- dense middle cerebral artery;
showing in situ thrombosis - early ischaemic changes
85 year old right handed woman. Background hypertension. Usually independent.
Witnessed sudden onset right sided weakness and dysphasia at 16.30
Arrival to A&E at 17.30
On examination dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous hemianopia.
ECG shows sinus rhythm, BP 210/106 mmHg, Blood sugar 6.3 mmol/L.
What is shown/the cause?
- acute haemorrhage in the left
hemisphere - calcification in flax cerebri
- subarachnoid haemorrhage
- thrombus in the left middle
cerebral artery
Thrombus in the left middle cerebral artery
could be subarachnoid normally presents with severe headache
could be haemorrhage but is small so not proportional to symptoms
85 year old right handed woman. Background hypertension. Usually independent.
Witnessed sudden onset right sided weakness and dysphasia at 16.30
Arrival to A&E at 17.30
On examination dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous hemianopia.
ECG shows sinus rhythm, BP 210/106 mmHg, Blood sugar 6.3 mmol/L.
thrombus in left cerebral artery
What treatments is she eligible for?
- aspirin
- decompressive hemicraniectomy
- IV thrombolysis
- mechanical thrombectomy
- Aspirin largely preventative
- Decompressive hemicraniectomy
only needed in malignant MCA
syndrome - IV thrombolysis effective but many
patients don’t benefit - Mechanical thrombectomy only in
large vessel occlusion but very
effective treatment
Eligible for all but most likely IV thrombolysis
87 year old right handed woman. Background hypertension, AF (on warfarin), OA. Lives alone, independent.
Onset of speech disturbance and started bumping into things on her right according to husband, from around midday.
On examination receptive dysphasia and right homonymous hemianopia.
BP 179/87 mmHg
BM 7.5
What can you see on the CT?
- left cerebellar haemorrhage
- left occipital haemorrhage
- left frontal haemorrhage
- left tempero-parietal
haemorrhage
left tempero-parietal haemorrhage
87 year old right handed woman. Background hypertension, AF (on warfarin), OA. Lives alone, independent.
Onset of speech disturbance and started bumping into things on her right according to husband, from around midday.
On examination receptive dysphasia and right homonymous hemianopia.
BP 179/87 mmHg
BM 7.5
CT = left tempero-parietal
haemorrhage
What is the most likely cause of this haemorrhage?
- anticoagulation with warfarin
- hypertensive small vessel disease
- underlying arteriovenous
malformation - malignant tumour
anticoagulation with warfarin
otherwise hypertension, arteriovenous
87 year old right handed woman. Background hypertension, AF (on warfarin), OA. Lives alone, independent.
Onset of speech disturbance and started bumping into things on her right according to husband, from around midday.
On examination receptive dysphasia and right homonymous hemianopia.
BP 179/87 mmHg
BM 7.5
CT = left tempero-parietal haemorrhage
What treatment is most likely to help?
- ICP bolt insertion for intercranial
pressure management - left temporal craniectomy
- hypertension treatment
- reversal of INR
reversal of INR
63 year old man
Presents to stroke team with right leg weakness
Woke up with symptoms
Unable to walk
Mild drift in right arm only
Which arterial territory affected?
- anterior cerebral artery
- middle cerebral artery
- posterior cerebral artery
- cerebellar artery
- basilar artery
- anterior cerebral artery infarct
(left) - cause more weakness in arm>leg
Biggest risk of haemorrhagic stroke is
rebleeds
reversal of anticoagulation is most helpful (vitamin K)
Penumbra:
- part of brain threatened by
ischaemic stroke but not yet dead
76 year old man, with history of hypertension, type one diabetes, previous stroke and ischaemic heart disease
Elective admission for a coronary angiogram
Nil by mouth from midnight the day prior to procedure
On morning of angiogram, the nurse in charge notices that he has become very pale, clammy and slumped to the left hand side
What test to be done?
- blood sugar
- CT
blood sugar
72 year old woman
Bumping into things for one month on her right
A week ago developed gradual onset headache
Yesterday could not read properly ‘I can’t see the end of the word when I look at it…’
On examination - right homonymous hemianopia.
Past medical history of breast cancer.
- left occipital haemorrhagic stroke
- left occipital metastatic cancer
- left posterior territory ischaemic
stroke - subarachnoid haemarrhage
progressive symptoms suggests a space occupying lesion
can be seen in subdural haematoma
red flag for cancer
subarachnoid haematoma causes sudden onset of very severe headaache with focal neurology later
Answer: space occupying lesion in left occipital lobe
Stroke mimics:
- sugar (low or high)
- seizures
- syncope
- sepsis (ppl with history of stroke)
- psychogenic
- migraines
(6 S)
