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NSB > Stroke and its Consequences > Flashcards

Stroke and its Consequences Flashcards

1
Q

What is a stroke?

A

rapid onset of neurological deficit caused by focused cerebral, spinal or retinal infarcation or haemorrhage with symptoms lasting over 24 hours

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2
Q

Stroke is a syndrome:

A
  • placeholders to guide investigation
  • not a diagnosis
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3
Q

Transient Ischaemic Accident (TIA):

A

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

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4
Q

What are the types of stroke?
Which type is more common?

A
  • Ischaemic = 80-85% = blocked
    blood vessels
  • Haemorrhagic = 15-20%
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5
Q

What are the three main causes of ischaemic stroke?

A
  • small vessel disease (20%)
  • atherosclerosis (30%)
  • cardio-embolic (30%)
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6
Q

Ischaemic Stroke: Small Vessel Disease:

A
  • 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
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7
Q

Ischaemic Stroke: Atherosclerosis:

A
  • 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
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8
Q

Atherosclerosis:

A

insert diagram

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9
Q

Arterial dissection causes what % of strokes in people under 60?

A
  • 25%
  • pain localised to side
  • carotid/back of neck for vertebral
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10
Q

Ischaemic Stroke: Cardio-embolic:

A
  • 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
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11
Q

Risk Factors for ischaemic stroke:

A
  • age/gender/genetics
  • hypertension
  • hyperlipidaemia
  • smoking
  • diabetes mellitus
  • obesity
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12
Q

Rarer Risk Factors for Ischaemic Stroke:

A
  • drugs
  • cancer
  • thrombophilia
  • obstructive sleep apnoea
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13
Q

Haemorrhagic Stroke: Pathophysiology:

A

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

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14
Q

how does haemorrhage cause brain injury?

A

insert slide

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15
Q

How does haemorrhagic stroke kill?

A
  • herniation of the temporal lobe
    uncus
  • herniation of cerebellar tonsils
  • hydrocephalus
  • compression of brainstem
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16
Q

Intracerebral Haemorrhage that isn’t stroke:

A
  • hematomas
  • extra-axial
  • not a stroke
  • pressure upon the brain
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17
Q

Intracerebral Haemorrhage on CT:

A

insert slide

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18
Q

What important stroke risk factor is an important part of pathophysiology of both ischaemic and haemorrhagic stroke?

A

hypertension

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19
Q

Circle of Willis:

A

insert diagram

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20
Q

Anterior and Posterior Circulation:

A

insert diagram

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21
Q

Anterior, Middle, and Posterior Cerebral Artery Supply:

A

insert diagrams

22
Q

Anterior, Middle and Posterior Cerebral Artery Supply (Axial):

A

insert diagram

23
Q

Stroke Symptoms:

A
  • 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)
24
Q

Stroke: Anterior Cerebral Artery: Symptoms:

A
  • circulation syndromes
  • hemiparesis/anaesthesia,
  • leg>arm weakness
    (partial weakness on one side)
  • frontal lobe signs: disinhibition,
    apathy
25
Q

Stroke: Middle Cerebral Artery: Symptoms:

A
  • circulation syndrome
  • hemiparesis/anaesthesis
  • arm>leg weakness
  • dysphasia, inattention/neglect
  • higher cortical functions and
    mathematical ability affected
26
Q

Stroke: Posterior Cerebral Artery: Symptoms:

A
  • circulation syndrome
  • homonymous hemaniopia (loss of
    half the visual field)
27
Q

Stroke: Basilar/Cerebellar Artery: Symptoms:

A
  • hemiparesis (partial weakness one
    side)
  • hemianaethesia + diplopia
  • ataxia, crossed signs

can mimic anterior cerebral artery stroke symptoms

28
Q

Middle Cerebral Artery Strokes and Hemispheric Dominance:

A
  • 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
29
Q

Patient has left sided weakness and inattention.

Location of stroke?

A

Right middle cerebral artery stroke

30
Q

Patient has right sided weakness and dysphasia,

Location of stroke?

A

Left middle cerebral artery

31
Q

Acute Treatment of Stroke:

A
  • ABCDE (+ glucose!!)
  • exclude mimincs like
    hypoglycaemaia
  • is it ischaemic/haemorrhagic?
  • hyperacute = recanalisation
    therapy
  • acute = reduce complication/
    preventative
  • long term = rehab, secondary
    prevention
32
Q

Acute Treatment of Ischaemic Stroke:

A
  • 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
33
Q

Contraindications of IV thrombolysis as part of recanalisation therapy:

A
  • haemorrhage
  • abnormal clotting
  • high BP
  • head injury
34
Q

Acute Haemorrhagic Stroke Treatment:

A
  • 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
35
Q

Secondary Prevention of Ischaemic Stroke:

A
  • antiplatelets
  • anticoagulants if atrial fibrillation
    is cause
  • antihypertensives (ACE inhibitors,
    CCB, diuretics)
  • statins
  • insulin or metformin for diabetic
    causes of stroke
36
Q

Secondary Prevention of Haemorrhagic Stroke:

A
  • avoidance of antithrombotic
    treatment
  • antihypertensive treatment
37
Q

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
A

Symptoms still present = stroke

Left sided middle cerebral artery stroke???

probably ischaemic but without imaging can not say

38
Q

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?

A
  • aspirin not given until
    haemorrhage excluded
  • contact local stroke team
  • urgent head CT
39
Q

What is often seen in CT brain during acute stroke?

A
  • dense middle cerebral artery;
    showing in situ thrombosis
  • early ischaemic changes
40
Q

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
A

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

41
Q

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
A
  • 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

42
Q

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
A

left tempero-parietal haemorrhage

43
Q

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
A

anticoagulation with warfarin

otherwise hypertension, arteriovenous

44
Q

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
A

reversal of INR

45
Q

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

A
  • anterior cerebral artery infarct
    (left)
  • cause more weakness in arm>leg
46
Q

Biggest risk of haemorrhagic stroke is

A

rebleeds
reversal of anticoagulation is most helpful (vitamin K)

47
Q

Penumbra:

A
  • part of brain threatened by
    ischaemic stroke but not yet dead
48
Q

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

A

blood sugar

49
Q

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
A

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

50
Q

Stroke mimics:

A
  • sugar (low or high)
  • seizures
  • syncope
  • sepsis (ppl with history of stroke)
  • psychogenic
  • migraines

(6 S)

NSB (50 decks)

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