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Care of the Elderly > Stroke and TIA > Flashcards

Stroke and TIA Flashcards

1
Q

Define stroke

A

A cerebrovascular accidenct
Lasts >24hrs
Rapid development of symptoms/signs
Focal loss of cerebral function or global loss (coma)

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2
Q

What are the two different types of stroke?
How prevalence is each type?

A

Ischemic - 87%
Haemorrhagic - 13%

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3
Q

What is an ischemic stroke?

A

Ischemic - inadequate blood supply
Can cause infarction - tissue death
Often caused by a thrombus or embolus that blocks the arterial lumen
Typically affects the small blood vessels in the brain

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4
Q

What are the main risk factors for a thrombotic ischemic stroke?

A

Hypertension
Diabetes
Smoking
Lipid

Inc risk of atheroma formation with a superimposed thrombus

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5
Q

What are the main risk factors for an embolic ischemic stroke?

A

Atrial fibrillation
Cardiac Failure
Valvular disease
Diabetes
Lipids

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6
Q

What is an intra-cerebral haemorrhage?

A

Bleed from a blood vessel
Variable proganosis
Occasionally from an arteriovenous malformation or a tumour.

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7
Q

Define TIA

A

Transient Ischaemic attack
Acute temporary loss of focal cerebral function
Acute temporary monocular visual loss (amaurosis fugax)
Due to ischemia without infarction

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8
Q

What is meant by a crescendo TIA?

A

2+ TIAs within a week
Indicates higher risk of a stroke

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9
Q

What is the purpose of the ROSIER scale?
How is it interpreted?

A

Differentiates acute from from non-stoke conditions in emergency department
Ensures rapid intervention to maximise early treatment benefits for patients
O or less = stroke less likely
1 or more = stroke likely

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10
Q

How is the ROSIER score calculated?

A

Must record date of assessment and date of symptoms onset
GCS (E,M,V), BP and BM - then address BM if needed

Loss of consciousness -1
Seizure -1
New acute onset:
One side Facial weakness +1
one side Arm weakness +1
one side Leg weakness +1
Speech disturbance +1
Visual field defect +1

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11
Q

What factors are important in the history of a stroke patient?

A

TIme of onset of symptoms
Parts of the body affected
Nature of symptoms (negative or positive)
Accompanying symptoms
Previous TIA/stroke
Past medical history - vascular
Family history
Lifestyle

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12
Q

What screening questions are important to ask when worrying about previous TIA/stroke that was unrecorded?

A

Lost vision or gone blind in one eye?
Double vision for more than a few seconds?
Slurred speech/difficult talking
Weakness/loss of sensation in face/arms/leg
Clumsiness of arm or leg?
Unsteadiness walking
Spinning/dizzy sensation

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13
Q

What are some risk factors for a stroke or TIA?

A

Age
Previous stroke or TIA
Atrial fibrillation
Ischaemic heart disease
Peripheral vascular disease
Carotid artery stenosis
Hypertension
Diabetes
Raised cholesterol
Family history
Smoking
Alcohol
Combined Oral contraceptive pill
Recreational drugs.

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14
Q

What are the two main classification of stroke via the circulation that they affect?

A

Anterior (carotid) system
Posterior (vertebrobasilar system)

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15
Q

What are the signs of a middle cerebral artery stroke syndrome?

A

Affects the parietal, frontal and superior temporal lobes
UMN facial weakness
Hemiplegia (Arm more than leg)
Hemianopia
Aphasia
Visuospatial problems

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16
Q

What is the common presentation of a posterior circulation stroke?

A

Affects the vertebral and basillar arteries
Diplopia, disorders of eye movements
Nystagmus, vertigo, vomiting
Dysarthia, dysphagia, bulbar weakness
Ipsilateral LMN facial weakness
Resp failure, coma
Contralateral hemiparesis quadripareis.

17
Q

What are the different Bamford Classifications of stroke?

A

Lacunar (LACS)
Partial Anterior Circulation (PACS)
Total Anterior Circulation (TACS)
Posterior circulation (POCS)

18
Q

What is a Lacunar stroke?
How does it present?

A

Disease of the small blood vessels that affect the subcortical brain areas
(often a branch of the MCA to the basal ganglia)
Results in a motor ot sensory deficit only.

19
Q

How does a partial anterior circulation stroke present?

A

Two of the following
Unilateral Motor or sensory deficit
Higher cortical dysfunction (dysphasia or visuospatial disorder)
Hemianopia

20
Q

What are the presentation of a total anterior circulation stroke?

A

All of
1. unilateral motor or sensory deficit
2. Higher cortical dysfunction (dysphasia or visuospatial disorder)
3. Hemianopia

21
Q

What are the presentation of a psoterior circulation stroke? By Bamford classification

A

Isolated hemianopia
Brain stem signs (cranial nerve function)
Cerebellar ataxia

22
Q

What is the purpose of the National Institutes of Health Stroke Scale?
How do you interpret it?

A

Scoring system to help classify strokes based on severity
Multiple categories of symptoms e.g consciousness, ataxia and facial movements
Score from 0-42:
1-4 minor
5-15 moderate
-20 moderate to severe
-42 severe

23
Q

What sort of things are considered when calculating the NIHSS score?

A

Level of consciousness
Orientation (age and month)
Response to commands
Eye movement
Visual fields
Facial palsy
Motor control (arms and legs)
Coordination (limb ataxia)
Sensation
Language/speech
Attention

24
Q

What is the key pathway to managing a suspected stroke?

A
  1. Exclude hypoglycaemia
  2. Exclude haemorrhage with immediate CT head
  3. Aspirin 300mg daily for 2w (if ischemic)
  4. Admit to stroke unit
  5. Consider thrombolysis or thrombectomy
25
Q

What thrombolysis treatment is used for stroke?

A

Alteplase - tissue plasminogen activator to break down clot
Only used when haemorrhage ruled out
Must be given within 4.5hrs of onset
Complications include haemorrhage (intracranial or systemic) requires careful monitoring post-administration and immediate CT head is bleed suspected.

26
Q

What is mechanical thrombectomy for stroke patients?
When can it be used?

A

Removing a blood clot from the artery through a catheter and clot removal device.
Catheter isnerted through femoral artery
Constrast dye injected to visualise vessels and guide catheter (norm x-ray)
Clost visualised and device inserted to remove it

27
Q

When does mechanical thrombectomy tend to be used for stroke patients?

A

Most effective when done within 6hrs of symptoms onset but can be done up to 24hrs after in some patient groups.
May be used in contraindications to alteplase (DOACs), inadequate response to alteplase, proximal occlusion of internal carotid or MCA less likely to respond to thrombolysis.

28
Q

What secondary prevention is used for stroke/TIA patients?

A

Clopidogrel 75mg once daily
Atorvastatin 20-80mg (48hr delay)
Blood pressure and DM control
Addressing modifiable risk factors (smoking, obesity and exercise)
If known AF and haemorrhage excluded consider anti-coagulation.

29
Q

What treatment tends to be used for a TIA?

A

Aspirin 300mg daily (the refer to specialist)
Specialist assessment at TIA clinic within 24hrs
Diffuse weighted MRI head.

30
Q

What MDT input can be used in stroke/TIA patients?

A

SaLT
Physio
OT
Dietician

31
Q

What elective procedure may be done in stroke patients in carotid stenosis suspected

A

Carotid endarterectomy
Carotid imaging

32
Q

When might a blood pressure control be needed in a stroke patient?

A

Hypotensive - can cause watershed stroke - need to increased blood volume
Hypertensive - can worsen haemorrhagic stroke by increasing bleeding pressure - need to administer an anti-hypertensive.

33
Q

How to ischemic/haemorragic stroke look like on cranial imaging?

A

Ischemic - often not visible in initial non contrast CT - may have hyperintense signal to mark area of thrombis (acute sign)
MRI - more sensitive - hyperintense for acute.
Chronic sign often days after - loss of grey/white differentiation (generally hypodensity), loss of L/R symmetry

Acute haemorrhagic - hyperintensity signal on acute imaging.

Care of the Elderly (22 decks)

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