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BPT exam revision > Stroke - College lecture series > Flashcards

Stroke - College lecture series Flashcards

College lecture series

1
Q

What is the incidence of CVA within the general population?

A

One in Four

Number 2 cause of death worldwide!
Number 1 cause of disability in adults!

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2
Q

What Stroke syndrome is being described?

” RIGHT sided hemiparesis of face/arm > Leg + Sensory/visual innatention + LEFT heminaopia “

A

LEFT MCA syndrome

In a Left MCA stroke you USUALLY get Aphasia

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3
Q

What Stroke syndrome is being described?

” LEFT sided hemiparesis of face/arm > Leg + Sensory/visual innatention + RIGHT heminaopia “

A

RIGHT MCA syndrome

In a right MCA stroke you usually get a “dysarthria” rather than aphasia

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4
Q

What Stroke syndrome is being described:
- Isolated face / arm / leg weakness that is equal in all zones
- isolated face / arm / leg sensory loss that is equal in all zones
- ataxic hemiperisis
- (can be a mixture of sensory and motor)

A

LACUNAR syndrome

absence of CORTICAL signs (innatention, aphasia, hemianopia)

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5
Q

What Stroke Syndrome is being described:

  • Diplopia
  • vertigo
  • dysarthria
  • dysphagia
  • ataxia
  • Hemi/tetraperesis
  • IPSIlateral face / CONTRAlateral body numb/weakness
A

POSTERIOR CIRCULATION syndrome

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6
Q

What is this CVA’s underlying pathology?

A

Anterior communicating Artery bleed

Here you see blood in the base of the skull anteriorly

be suspicious of an anterior communicating aneurysm bleed!

ORDER a CTAngiogram

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7
Q

What is this CVA’s underlying pathology?

A

Here blood is located around the sylvian fissure

be suspicious of a MCA aneurysm

ORDER a CTAngiogram

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8
Q

What is this CVA’s underlying pathology?

A

Venous Sinus Thrombosis
Here there is a hyperdense sign near the venous sinus area

order a CT Venogram

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9
Q

What is the term used to classify this sign on imaging?

A

HYPERDENSE SIGN

Seen when there is an occlusion in an artery - here the Left MCA

you see these better in 1mm slices (so make sure you have the right window)

90% sensitive for an ACUTE thrombus - Reidal et al Stroke 2012

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10
Q

How would you describe this sign on imaging?

A

Here you see loss of grey white differentiation

  • an established stroke ( > 4.5Hrs)

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11
Q

What is the estimated % threshold for cerebral blod flow used in CT perfusion to determine an area of core infarct?

A

Less than 30%

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12
Q

What is the threshold in seconds used in CT perfusion imaging to determine an area ‘At risk’ of irreversible injury?

A

More than 6 seconds

you combine this with area of cerebral blood flow of < 30% to determine CORE INFARCT

Then calculate the mismatch and whether its worth reperfusing.

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13
Q

What is this sign called on CTa?

(indicated by the arrow)

A

SPOT sign

There is active bleeding here as there is contrast extravasation

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14
Q

What is the underlying pathophysiological process seen on Diffusion weighted imaging MRI in stroke patients?

A

You get cytotoxic oedema
as water rushes into the infarcted cells
which has LESS motion on MRI therefore RESTRICTED DIFFUSION(bouncing around)

Note: also seen in MS plaques and dense tumours (Glioblastomas.)

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15
Q

A patient who is a surgical canditate presents with an ischeamic CVA (after 48 hours) due to a carotid stenosis of > 50%

The initial antiplatelet plan has been instigated

what is the next best step?

1) Yearly surveillance with a Carotid US
2) vascular review for ? Endarterectomy

A

Endarterectomy

The general rule is:
If symptomatic (TIA / CVA) and known stenosis (of > 50%) - should be considered for surgery

the risk of a repeated stroke is highest in the 2 weeks following an event

if > 70% (AFP says 80%) - then surgery should be considered regardless

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16
Q

A patient has been managed for a hemorrhagic stroke

At what time interval do you perform a follow up MRI post discharge?

A

8 Weeks

To look for mass lesions, cavernomas, AVMs, microangiopathy,

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17
Q

How does Alteplase / Tenecteplase work?

A

Converts Plasminogen to Plasmin (which breaks down the clot)

18
Q

What is the time window for use of ANECTEPLASE/TENECTEPLASE ?

A

Up to 4.5 hours in ALL (eligible) patients

or

up to 9 Hours in WUS patients / those still favourible on CT perfusion - *EXTEND 2019 meta analysis *

19
Q

Which of these is a contraindication to TPa?

  • Recent GI/UGI bleeding / surgery / trauma
  • Bp < 185/105
  • BSL of 4 mmol
  • infective endocarditis
A

contraindications to TPa:

  • Haemorhhage on CTP
  • Extensive hypdensity? (check the onset time again)
  • active non compresible systemic bleeding
  • Recent GI/UGI bleeding / surgery / trauma = Risk Vs Benefit > ? Thrombectomy
  • Bp > 185/105
  • BSL < 2.7mmol (need to fix this and reexamine need)
  • infective endocarditis
  • Aortic dissection
  • Malignant brain tumours
  • INR > 1.7
  • platelets < 100
  • DOAC < 48 hours - Dabigatran (reversible with idracuzimab) - this guideline might change soon

https://elearning.racp.edu.au/mod/forum/view.php?id=36309

20
Q

What is this a sign of (post TPa administration)

A

Orolingual angiooedema post tPA

  • swelling around lips and tongue
  • 2% of patients (5% if on Acei)
  • usually CONTRALATERAL to brain lesion
  • 15 - 105mins post tPA bolus
  • DDX: Tongue hematoma
  • Hydrocortisone / antihistamine
  • ICATIBANT? - as thought to be bradykinin mediated
  • usually does not need airway support
21
Q

What receptor does Clopidogrel act on?

A

PY12 receptor agonist

22
Q

Approximately what % of Asians are resistant to clopidogrel

A

**20% **
as it is activated in the liver
20% of asians are thought to have a defect in the **CYP2C19 Allele **

23
Q

What investigation would you order to investigate someone with a potential PFO?

A

BUBBLE TTE - note patient has to be able to Valsalva (TOE is an alternative)

24
Q

the ‘MR CLEAN’ Trial was a study thatsignificantly contributed to the “time is brain” concept, emphasizing the importance of fast and efficient stroke treatment.

How long following the onset of sx (in hours) did it show a benefit for thrombectomy, in CTa selected patients?

A - 4 hours
B - 6 hours
C - 8 hours
D - 12 Hours

A

B - 6 HOURS

25
Q

The DAWN and DIFFUSE trials showed that you could extend the thrombectomy window up to ____ hours in patients that had a:
< 70 ml Core + ICA / M1 occlusion

A - 10 Hours
B - 18 Hours
C - 24 Hours
D - 48 Hours

A

C - Showed an MRS benefit in patients with an extended window out to 24 hours!

26
Q

How long following an Intracranial Haemorhage would you perform an MRIB, when looking for underlying malformations/lesions?:

A - 4 weeks
B - 8 weeks
C - 12 weeks
D - 16 weeks

A

B - 8 weeks

27
Q

A patient with ischeamic stroke has a confirmed carotid stenosis as the likely aeitology

What percentage of stenosis shows the strongest evidence for endarterectomy?

A - 40%
B - 50%
C - 60%
D - 70%

A

D - 70% and above

Strongest evidence - < 2 weeks of TIA / CVA or Amurosis fugax in patients with a stenosis of 70 - 99%

modest benefit for stenosis of 50-70% - depends on local expertise - usually optimise medical management in first instance

28
Q

A patient that has had an ischeamic CVA is found to be in AF.
A decision is made to anticoagulate.
- TTE shows severe mitral stenosis
- Normal renal function

What is the drug of choice for anticoagulation?

A - Apixaban
B - Rivaroxaban
C - Warfarin
D - Aspirin

A

the 3 cases where NOACS are not preferred as anticoagulation in AF are:

  • mod to severe MS
  • Rheumatic heart disease
  • Mechanical heart valves

Based off the RE-LY trial 2016

LAA closure - is an option if they cant be on Warfarin / DOACs

29
Q

What long term blood pressure target do you aim for in patients that have had a CVA.

A - < 180/90
B - < 160 / 90
C - < 140 / 90
D - < 130 / 90

A

C - 140/ 90

ALL patients with TIA/Stroke - should have long term intervention started
PROGRESS trial (lancet 2001)

NNT 25
Perindopril + Indapamide showed reduced 4 year incidence of recurrent stroke

Meta analysis have shown that the reduction in RISK is INDEPENDENT of agent used

emerging evidence that a target < 130mmHg may be better than 140!

30
Q

What gene is defective (affected) in CADASIL ( cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)

A

NOTCH 3 Gene - is defective

  • Rare - inherited cause of stroke and vascular dementia
  • Multiple small infarcts in brain
  • presents as Migraine and depression in teens
  • CVA and TIAs by 30s - Dementia by 40/50’s
31
Q
A

BPT exam revision (2 decks)

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