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N&SS - Neuro & Stroke > Stroke - Basics > Flashcards

Stroke - Basics Flashcards

1
Q

Where can strokes occur? (Think baaaaaasic)

A

Arteries and Veins

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2
Q

What are the 2 types of arterial stroke?

A

Ischaemic and haemorrhagic

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3
Q

What am I getting at when I say venous stroke?

A

Venous sinus thrombosis

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4
Q

What are the venous sinuses in the brain?

A

Folds between the layers of dura mater that carry the veins that drain the brain

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5
Q

Why might an adult pt get a venous sinus thrombosis?

A
  • Pregnancy and post-natal period (pro-coag state)
  • Clotting problems - antiphospholipid syndrome, Lupus anticoagulant, protein C and S deficiency, antithrombin III deficiency…
  • Cancer
  • Collagen vascular diseases
  • Intracranial hypotension
  • Obesity
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6
Q

What are the causes of ischaemic strokes?

A
  • Cardioembolic cause
  • Atherothrombotisis
  • Vessel dissection
  • Vasculitis
  • Hypercoagulability (High RBCs, thrombocthemia, sickle cell, antiphospholipid antibody syndrome)
  • Other (infection, migraine, pregnancy, COCP)
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7
Q

What are the causes of intracerebral haemorrhagic strokes?

A
  • Hypertension
  • AVM
  • Haematological disorders (idiopathic or inherited)
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8
Q

What are the types of haemorrhagic stroke? i.e. where does the blood go?

A

Extradural haemorrhage
Subdural haemorrhage
Subarachnoid haemorrhage
Intracerebral haemorrhage

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9
Q

What is the NIHSS?

A

National institue of health stroke scale - tool used to measure the severity and impact of a stroke on a pt and their ability to perform various tasks.

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10
Q

What is the first thing tested on the NIH stroke scale?

A

Level of consciousness

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11
Q

How is the level of consciousness measured on the NIHSS?

A
  1. AVPU
  2. Basic questions (current month and pt age)
  3. Motor commands (open and close eyes, then grip with unaffected hand)
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12
Q

What is a TIA?

A

Temporary inadequacy of the circulation in a part of the brain. It is transient and reversible, and gives a similar clinical picture to a stroke.

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13
Q

How long do TIAs usually last?

A

No more than 24 hours, but most last less than half an hour.

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14
Q

What % of stroke pts have had a preceeding TIA?

A

15%

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15
Q

What are the risk factors for TIA?

A

Same as for stroke:

  • HTN
  • Smoking
  • DM
  • Heart disease
  • Peripheral arterial disease
  • PCV
  • Carotid disease
  • COCP
  • Hyperlipidaemia
  • Alcohol
  • Clotting disorders
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16
Q

Where is the most common source of an embolus in TIAs and strokes?

What does this mean?

A

The carotids - if embolic TIA is suspected, carotids should be scanned.

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17
Q

What symptoms might a pt get if their carotid territory/anterior circulation is affected by a TIA/stroke?

A 
Usually unilateral
Usually motor
Dysarthria
Sensory symptoms in same area
(Broca's area -> expressive dysarthria)
May have fleeting loss of vision
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18
Q

What symptoms might a pt get if their vertibrobasilar territory/posterior circulation is affected by a TIA/stroke?

A

Homonymous hemianopia or bilateral visual impairment
Hemiparesis, hemisensory symptoms, diplopia, vertigo, vomiting, dysphagia, ataxia
Cranial nerve and cerebellar signs and symptoms

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19
Q

What are the main differentials for TIA?

A

V - stroke if before recovery, space occupying lesion e.g. subdural haematoma, cardiac arrhythmia -> syncope, retinal/vitreous haemorrhage, postural hypotension
I - Giant cell arteritis
T - head trauma causing secondary seizures
A
M - Hypoglycaemia
I
N - intracranial mass
N - migraine, seizure, Todd’s paralysis
D - Demyelination/MS
I - drugs e.g. cocaine, vasoconstricting OTC cold remedies.
C

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20
Q

How quickly do strokes or TIAs come on?

A

Very - within a few minutes.

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21
Q

What examinations can we do some someone who has had a TIA?

A

Cardiac - check for underlying pathology e.g. cartoid bruit, arrythmia, murmur suggestive of valve disease, BP in each arm.

22
Q

How can a TIA be distinguished from:

  1. A mass lesion
  2. Epilepsy
  3. Migraine

???

A
  1. Clinically very difficult, need imaging
  2. Epilepsy has limb jerking, symptoms onset takes longer than TIA, recovery period longer (post-ictal)
  3. Migraine has headache, confusion, and characteristic zig-zag visual disturbance
23
Q

A pt in a TIA clinic scores 3 on their ABCD2 score. What invetsigations should be done if they haven’t already?

A
  • Carotid doppler
  • ECG
  • Bloods inc. FBC, U&Es, cholesterol
  • Consider echo and brain imaging
24
Q

How should a TIA be managed immediately?

A

High dose aspirin for 2 weeks as long as cerebral haemorrhage has been ruled out.

25
Q

Where is the most common site affected in stroke presentations?

A

Middle cerebral artery

26
Q

What are the 2 types of infarct causing strokes?

A

Regional and lacunar infarcts

27
Q

Where are the symptoms when a pt has an MCA stroke?

A

On the contralateral side to where the stroke occurs

28
Q

When does aphasia occur with a stroke?

A

When the dominant hemisphere is affected - this usually confers a worse prognosis.

29
Q

What signs might we get that a stroke is haemorrhagic?

A

If there is headache and/or impaired consciousness, as that implies swelling which combined with acute onset suggests haemorrhage.

Also more likely to be progressive than ischaemic stroke.

30
Q

How do lacunar infarcts present?

A 
Very localised symptoms.
Often purely motor or purely sensory symptoms.
Aphasia
Hemiparesis
Hemisensory loss
Unilateral ataxia
31
Q

How should an acute stroke be managed?

A

ABCDE

Hx and Examination

Get urgent CT

Get neuro/stroke team/medical SpR involved asap

Thrombolysis if not haemorrhagic or otherwise contraindicated

32
Q

How should haemorrhagic strokes be managed?

A

Supportively.

Stop anti-coags and antiplatelets/reverse wiith Vit K/FFP/Platelets

33
Q

After 2 weeks of aspirin, what do pts need to be on long term following an ischaemic stroke?

A

Clopidogrel 75mg daily

OR if they can’t tolerate clopidogrel, Dipyridamole can be substituted.

34
Q

What is assessed in the NIHSS?

A 
Level of consciousness
Gaze and visual fields
Facial palsy
Motor in legs and arms
Ataxia
Sensory
Language
Speech
Extinction and Inattention (aka neglect)
35
Q

What do we look for in the gaze section of the NIHSS?

A

Horizontal eye movements, both voluntary and reflexive, looking for partial gaze palsy, or total gaze paresis/forced deviation.

36
Q

What visual field defects score points on the NIHSS?

A

Partial hemianopia
Complete hemianopia
Bilateral hemianopia inc. cortical blindness

37
Q

What are the grades of facial palsy according to the NIHSS?

A

0 - normal
1 - minor paralysis (flattened nasolabial fold, asymmetry on smiling)
2 - partial paralysis (total/near total paralysis of lower face)
3 - complete paralysis of one or both sides

38
Q

What are the motor gradings for the upper and lower limb according to the NIHSS?

A 
0 - no drift
1 - drift
2 - some effort against gravity
3 - no effort against gravity
4 - no movement
UN - amputation/joint fusion
39
Q

What is limb ataxia assessment aimed at finding? How is this assessed?

A

If there are any unilateral cerebellar lesions.

Finger-nose-finger test and heel-shin test on both sides. Scored according to whether ataxia (out of proportion to any weakness present) in present on both/either side.

40
Q

How is sensory loss assessed and scored according to the NIHSS?

A

Pinprick test, or withdrawal from noxious stimulus in an aphasic pt.

0 - normal
1 - mild to moderate sensory loss
2 - severe to total sensory loss

41
Q

What is described as mild to moderate aphasia according to the NIHSS?

A

Some obvious loss of fluency or comprehension
No significant limitation of expression
Reduced speech &/or comprehension

42
Q

What is described as severe aphasia according to the NIHSS?

A

All communication is through fragmentary expression.

Lots of guessing, inference, and questioning needs to be done by examiner.

43
Q

What is described as mutism/ global aphasia according to the NIHSS?

A

No usable speech or auditory comprehension

44
Q

How can dysarthria be assessed and what are the levels of dysarthria according to the NIHSS?

A

Ask pt to read or repeat words from a specific list.

0 - normal
1 - mild/moderate (slur some words -> can be understood with some difficulty)
2 - severe (slurring as to be unintelligible in absence of/out of proportion to dysphasia present)
UN - intubated, or other physical barrier

45
Q

What are extinction and inattention, and how are they assessed?

A

Extinction is impaired ability to perceive multiple stimuli of the same type simultaneously.
Inattention is impaired ability to recognise or acknowledge one side of space.

Only fill in half the face of a clock, bilateral stimulus not recognised by pt.

46
Q

What might cause a stroke in a younger patient?

A
  • Vasculitis
  • Thrombophilia
  • Subarachnoid haemorrhage
  • Venous sinus thrombosis
  • Carotid artery dissection
  • Antiphospholipid syndrome
47
Q

Describe the basic blood supply to the brain?

A

The anterior cerebral arteries supply the anteromedial area of the cerebrum.

The middle cerebral arteries supply the majority of the lateral cerebrum.

The posterior cerebral arteries supply a mixture of the medial and lateral areas of the posterior cerebrum

48
Q

According to the Bamford/Oxford Classification of stroke, what needs to be present to diagnose a total anterior circulation stroke?

A

All of:

  • Unilateral weakness (and/or sensory deficit) of the face, arm and leg
  • Homonymous hemianopia
  • Higher cerebral dysfunction (dysphasia, visuospatial disorder)
49
Q

According to the Bamford/Oxford Classification of stroke, what needs to be present to diagnose a partial anterior circulation stroke?

A

Two of the following:

  • Unilateral weakness (and/or sensory deficit) of the face, arm and leg
  • Homonymous hemianopia
  • Higher cerebral dysfunction (dysphasia, visuospatial disorder)
50
Q

According to the Bamford/Oxford Classification of stroke, what needs to be present to diagnose a posterior circulation syndrome?

A

One of the following:

  • Cranial nerve palsy and a contralateral motor/sensory deficit
  • Bilateral motor/sensory deficit
  • Conjugate eye movement disorder (e.g. horizontal gaze palsy)
  • Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
  • Isolated homonymous hemianopia
51
Q

According to the Bamford/Oxford Classification of stroke, what needs to be present to diagnose a lacunar syndrome?

A

One of the following:

  • Pure sensory stroke
  • Pure motor stroke
  • Senori-motor stroke
  • Ataxic hemiparesis
52
Q

What are the consequences of a stroke in the long term?

A

Pts may recover almost fully depending on the pt.
Psychological effects (mood disorders, anxiety, poor concentration and cognition)
Physical effects (dysphagia, dysphasia, ataxia, reduced mobility)
Poor eyesight
Pneumonia
Falls

N&SS - Neuro & Stroke (10 decks)

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