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YEAR 4 NEURO > Stroke and TIA > Flashcards

Stroke and TIA Flashcards

1
Q

What is a TIA?

A

New passmed defintion:

A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

Old definition we have been taught:

A sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, brought on by a transient decrease in blood flow.

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2
Q

Presentation of TIA?

A

Similar to stroke but features resolve, usually within 1 hour.

  • unilateral weakness or sensory loss
  • aphasia or dysarthria
  • ataxia, vertigo, loss of balance
  • visual problems
    —> sudden transient loss of vision in one eye (amaurosis fugax)
    —> diplopia
    —> homonymous hemianopia
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3
Q

What is aphasia?

A

Inability to produce or understand speech / language

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4
Q

What is dysarthria?

A

Difficulty speaking, inability to control muscles used in speech

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5
Q

What is amaurosis fugax?

A

Transient loss of vision in one eye

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6
Q

Immediate management of suspected TIA?

A

Aspirin 300mg immediately unless contraindicated

Need specialist review - by stroke specialist (within 24hrs if possible).

Advise pt not to drive until they have been seen by specialist (usually within 24hrs-7days)

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7
Q

Reasons for 300mg aspirin being contraindicated for immediate management of TIA?

A

Pt has bleeding disorder.
Pt is taking anticoagulant
Pt is already on low dose aspirin
Allergy/ other contraindication

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8
Q

Investigations for TIA?

A

Neuroimaging:
- MRI is preferred to see area of ischaemia/detect haemorrhage area. Should be done on the same day
- CT = NICE says that CT shouldn’t be done unless there is a clinical suspicion of an alternative Dx that a CT could detect.

Carotid imaging = urgent carotid doppler
- look for atherosclerosis as may be source of emboli.

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9
Q

Management of TIA?

(assume you have already done immediate management)

A

Note: immediate management is 300mg aspirin.

1) Prescribe clopidogrel. If contraindicated, give aspirin + dipyridamole.

2) If suffered TIA in carotid territory and aren’t severely disabled, consider a carotid artery endarterectomy

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10
Q

Risk factors for a TIA?

A

DM
hyperlipidaemia
HTN
Smoking
Hx of CVD/stroke
A fib

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11
Q

Differentials for TIA?

A

Stroke
Hypoglycaemia
MS
SOL
BPPV - differential for potential posterior circulation infarct

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12
Q

Pathophysiology of haemorrhage stroke?

A

Weakening of cerebral vessels —> cerebral vessel rupture —> haematoma formation —>reduction in blood flow —> cause clinical deficit.

Clinical deficit is caused directly by neuronal injury.

Clinical deficit is caused indirectly by cerebral oedema

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13
Q

Risk factors for haemorrhagic stroke?

A

Age
Male
FHx of haemorrhagic stroke
Haemophillia
Anticoag therapy
Drug use - cocaine, amphetamines
Vascular malformations e.g AVM

Weaker RFs:
NSAIDs
Heavy alcohol use
Thrombocytopenia

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14
Q

Management of haemorrhagic stroke?

A

Neurosurgery and critical care evaluation - may need surgery e.g. decompressive hemicraniectomy

Admit to neuro ICU / stroke unti

Manage BP <140/80 - poor BP control = poor outcomes later on.

May need to stop anticoagulants and antithrombotic meds - minimise further bleeds.

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15
Q

What are the two main types of stroke?

A

Ischaemic
Haemorrhagic

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16
Q

What is an ischaemic stroke?

A

Get a blockage in the blood vessels supplying the brain -> stops blood flow.

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17
Q

What are subtypes of ischaemic stroke?

A

Thrombotic - thrombosis from a large vessel e.g. carotid.

Embolic - blood clot, fat, air can act as embolus

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18
Q

Name an important cause of embolic stroke?

A

AF!!

Forms blood clot in heart —> can go up to brain

19
Q

What are the subtypes of haemorrhage stroke?

A

Intracerebral haemorrhage = bleed within the brain

Subarachnoid haemorrhage = bleed on the surface of the brain

20
Q

Risk factors for ischaemic stroke?

A

Age
HTN
Smoking
Hyperlipidaemia
DM
AF (if cardioembolism)

21
Q

Presentation of stroke?

A

Motor weakness
Dysphasia
Swallowing problems
Visual field defects - homonymous hemianopia
Balance problems

22
Q

Presentation of stroke with cerebral hemisphere infarcts?

A

Contralateral hemiplegia - flaccid at first, then spastic
Contralateral sensory loss
Homonymous hemianopia
Dysphasia

23
Q

Presentation of stroke with brainstem infarction?

A

Severe symptoms:
Lock-in-syndrome
Quadriplegia

24
Q

Presentation of stroke with lacunar infarcts?

A

Could be:
- purely motor
- purely sensory
- mixed motor and sensory
- ataxia

25
Q

Where are lacunar infarcts?

A

Around basal ganglia, internal capsule, thalamus and pons

26
Q

What classification system is used for stroke?

A

Oxford Stroke Classification (aka Bamford classification)

This classifies stroke based on initial symptoms

27
Q

What criteria are assessed in Oxford stroke classification?

A
  1. unilateral hemiparesis and/or hemisensory loss of the face, arm and leg
  2. homonymous hemianopia
  3. higher cognitive dysfunction e.g. dysphasia
28
Q

What blood vessels are involved in Total Anterior Circulation Infarct (TACI)?

A

Middle cerebral artery
AND
Anterior cerebral artery
on the affected side

29
Q

What blood vessels are involved in partial anterior circulation infarct (PACI)?

A

Smaller arteries of anterior circulation e.g. upper or lower division of the MCA on the affected side.

30
Q

What features of Oxford criteria are present in TACI?

A

All three!! :

Unilateral hemiparesis and/or hemisensory loss of face, arm and leg
Homonymous hemianopia
AND higher cognitive dysfunction

31
Q

What features of Oxford criteria are present in PACI?

A

2 of the following:

Unilateral hemiparesis and/or hemisensory loss of face, arm and leg
Homonymous hemianopia
Higher cognitive dysfunction

32
Q

What blood vessels are involved in LACI?

LACI = lacunar infarct

A

Perforating arteries around the internal capsule, thalamus and basal ganglia

33
Q

What features are present in LACI?

A

Presents w/ 1 of the following:

  • unilateral weakness of face and arm, arm and leg or all three
  • pure sensory stroke
  • ataxic hemiparesis
34
Q

What blood vessels are involved in POCI?

POCI = posterior circulation infarct

A

Vertebrobasilar arteries

35
Q

What features are present in POCI?

A

Presents w/ 1 of the following:

  • cerebellar or brainstem syndromes
  • conjugate eye movement disorder
  • LOC
  • isolated homonymous hemianopia
  • bilateral motor/sensory deficit
  • ipsilateral cranial nerve palsy with contralateral motor/sensory deficit
36
Q

What features is a pt with a haemorrhage stroke more likely to have (compared to a pt presenting with ischaemic stroke)?

A

Reduced level of consciousness
Headache
N+Vom
Seizures

37
Q

Describe FAST campaign mnemonic

A

Face - has face fallen on one side? Can they smile?

Arms - can they raise both arms and keep them there?

Speech - is speech slurred?

Time - call 999 if you see any of these signs

38
Q

What investigations would you do for presentation of suspected stroke?

A

Emergency neuroimaging = CT, diffusion weighted MRI

39
Q

How are ischaemic strokes managed?

A

Once established it is ischameic, give 300mg aspirin asap rocky.

Alteplase within 4.5hrs of symptom onset

Anterior circulation stroke = mechanical thrombectomy within 6hrs of symptom onset.

Posterior circulation stroke = mechanical thrombectomy within 12 hrs of symptom onset.

Rehab and supportive management - MDT needed for physio, OT, speech and language therapy, neurorehab.

40
Q

Why is neuroimaging v important to do in pts with presentation of stroke?

A

Can see if it is ischameic or haemorragic. This will then decide treatment needed.

If ischameic = need thrombolysis as blood flow is blocked by clot.

If haemorrhagic = they are already bleeding!!! so giving thrombolysis would just make it worse.

41
Q

Further investigations for ischaemic stroke, after initially managing it?

A
  • Carotid ultrasound = to find carotid artery stenosis
  • CT/MRI angiography = to find any intracranial and extra cranial stenosis
  • Echocardiogram = if cardio-embolic stroke is suspected
  • Vasculitis screen or thrombophilia screen = if young pt.

Serum glucose, serum lipids

42
Q

Further investigations for haemorrhagic stroke?

A

Serum toxicology screen - for drugs, cocaine is a strong RF.

Serum glucose, serum lipids

43
Q

What is involved in secondary stroke prevention?

A

HALTSS

H = HTN. Prescribe anti-HTN, start 2weeks post stroke

A = Antiplatelet therapy. Prescribe Clopidogrel 75mg OD. If stroke was secondary to AF, may need DOAC or warfarin - start this 2 weeks post stroke

L = Lipid lowering therapy. Prescribe atorvastatin 20-80mg OD.

T = Tobacco = smoking cessation support

S = Sugar. Screen for DM and manage if necessary

S = Surgery. If pt has ipsilateral carotid artery stenosis more than 50% —> refer for carotid endarterectomy

44
Q

Tool used to differentiate stroke between stroke mimetics?

A

Recognition of Stroke in the Emergency Room (ROSIER) scale

YEAR 4 NEURO (37 decks)

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