Stroke COPY Flashcards by Georgia Leggett

What is a stroke?

Rapidly developing clinical signs of focal (or global) disturbance of cerebral function + lasting > 24h

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Give the incidence of each type of stroke

Ischaemic 85%
Intracerebral Haemorrhage 10%
SAH 5%

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List 3 causes of ischaemic stroke

Thrombus
Embolism
Hypoperfusion

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List 3 causes of intracerebral haemorrhage causing stroke

Ruptured cerebral artery
Trauma
Reperfusion injury after ischaemic stroke

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List 3 causes of subarachnoid haemorrhage causing stroke

Ruptured Berry aneurysm
Arteriovenous malformation
Trauma

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List 5 risk factors for ischaemic stroke

Age >65
HTN
Diabetes
AF
Carotid artery stenosis

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List 5 risk factors for intracerebral haemorrhage stroke

Age >65
HTN 
Vasculitis
Malignancy
Altered haemostasis e.g. Anticoagulant

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List 3 risk factors for subarachnoid haemorrhage stroke

HTN
Smoking
FHx

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Describe the epidemiology of stroke

COMMON
Largest cause of disability
3rd most common cause of death in UK
Usual age of stroke patients: 70+

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Which vessel is most commonly affected in embolic strokes?

Middle cerebral artery

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What are the origins of thrombotic stroke?

Large vessels: Atherosclerosis

Small vessel occlusion (Lacunar)

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What causes hypo perfusion and subsequent stroke?

Shock/ bilateral large artery atherosclerosis decreases O2 to whole brain
Results in watershed infarct

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Give 5 signs of anterior cerebral artery ischaemic strokes

Hemiparesis (contralateral LOWER LIMB)
Hemisensory loss (contralateral LOWER LIMB)
Abulia
Disinhibition
Executive dysfunction

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List 5 signs of middle cerebral artery ischaemic strokes

Hemiparesis (contralateral FACE + UPPER LIMB)
Hemisensory loss (contralateral FACE + UPPER LIMB)
Visual field deficits
Apraxia (Parietal lobe)
Speech deficits

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List 4 signs of posterior cerebral artery ischaemic strokes?

Contralateral homonymous Hemianopea with macular sparing
Contralateral sensory loss
Memory impairment
Vertigo + nausea

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What 8 structures are affected in brainstem stroke?

Medial longitudinal fasciculus; impaired ipsilateral adduction
Motor tract of UMN (corticospinal); ipsilateral face, contralateral body weakness
Medial lemniscus; contralateral loss of proprioception/ vibration
Motor nuclei of CN 3,4,6,12 (ipsilateral)
Spinothalamic tract (contralateral pain + temp): ipsilateral face, contralateral body
Spinocerebellar tract: Ipsilateral ataxia arm + leg
Sympathetic chain: ipsilateral Horner’s
Sensory CN nuclei

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List 6 signs seen in intracerebral haemorrhage strokes

Headache
Meningism 
Focal neurological signs 
N+V
Signs of raised ICP 
Seizures

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List 3 signs of SAH strokes

Rapid onset severe headache
Meningeal signs
Sudden onset focal neurological deficits

What bloods should be taken in suspected stroke?

FBC: exclude anaemia + thrombocytopenia
Electrolytes: exclude electrolyte imbalance
Cardiac enzymes: exclude concurrent MI
Glucose
Urea + creatinine: exclude renal failure (choosing tx)
Toxicology screen
Clotting screen: exclude coagulopathy

Why measure serum glucose in suspected stroke?

Hypoglycaemia MIMICS stroke

Hyperglycaemia associated with intracerebral bleeding

Why take a toxicology screen in suspected stroke?

Alcohol/ drugs may mimic

Cocaine + sympathomimetrics associated with ICH

What is the first line investigation in suspected stroke? What can this detect?

Non contrast CT head
Acute hemorrhage: hyperattentuation (blood) + surrounding hypoattenuation (oedema)
Ischemic changes after 6–24h

What further investigations may be performed to identify the cause of a stroke?

ECG: arrhythmias
MRI: if uncertain of dx

How should an ischaemic stroke presenting in less than 4.5 hours be treated medically?

Alteplase (rtPA) IV (after CT excludes haemorrhage)

Aspirin 300mg or Clopidogrel 75mg 24hrs later

What surgical intervention may be considered in ischaemic stroke patients? What is the time frame for this?

Mechanical thrombectomy | < 24 hours since onset

How should an ischaemic stroke presenting later than 4.5 hours be treated?

Aspirin 300mg or Clopidogrel 75mg to prevent further thrombosis Formal swallow assessment (NG tube may be needed) GCS monitoring Thromboprophylaxis

Describe the secondary prevention of stroke

``` Aspirin 300mg or Clopidogrel 75mg Manage RF: HTN: Antihypertensive AF/ Thrombophilia: anticoagulant e.g. Warfarin High cholesterol: Atorvostatin ```

What surgical intervention may be performed in an ischaemic stroke no matter the timeframe? In which patients?

``` Carotid endarterectomy (removal of plaque in carotid artery) In those with carotid stenosis >70% or those with previous stroke stenosis >50% ```

List 3 sources of emboli that may result in ischaemic stroke

Carotid dissection Carotid atherosclerosis Atrial fibrillation

Give 2 prothrombotic states that increase risk of thrombus formation and thus ischaemic strokes

Dehydration | Thrombophilia

Describe the management of haemorrhagic strokes

Mannitol to reduce BP Reversal of concomitant anticoagulation Head elevation Consider craniotomy + surgical clipping of vessel

List 7 complications of stroke

``` Aspiration pneumonia Cerebral oedema (increased ICP) Immobility: pressure sores, constipation, depression Infections DVT Cardiovascular events Death ```

What is the prognosis in stroke?

10% mortality in 1st month Up to 50% that survive will be dependent on others 10% recurrence within 1y Prognosis for haemorrhagic is WORSE than ischaemic

What speech deficits may manifest in a middle cerebral artery stroke?

``` Expressive aphasia (Broca's areas) Receptive aphasia (Wernicke's area) ```

What visual field deficits may arise in middle cerebral artery strokes?

Gaze deviates towards side of infarction Homonymous hemianopia without macular sparing (contralateral) Quadrantopia (if superior/ inferior optic radiations affected)

Ischaemic stroke in the right MCA stopping flow to the parietal lobe will cause what additional sign?

Hemineglect (contralateral)

What happens to neurones in ischaemic stroke?

Cell membrane of neurones not getting O2- functionality stops thus electrical signals not working Brain cell needs functional membrane for transport- begins to fail. Water seeps in uncontrollably as membrane loses integrity, cell swells Swollen cells may undergo apoptosis + necrosis Whilst swelling with water, density decreases, appears darker (water less dense that brain cells)

How does ischaemic stroke lead to formation of a fluid filled cavity?

Swollen cells go through necrosis + inflammation + permanent damage Broken down brain cells in brain activates immune system Macrophages remove necrotic tissue Results in fluid filled cavity

List 9 common sources of emboli causing ischaemic stroke

``` Intracranial atherosclerosis (in brain, travels downstream) Small artery disease (in brain- clot break off) Carotid plaque Carotid stenosis Aortic arch plaque AF Cardiogenic emboli Valve disease Ventricular thrombi ```

What scoring system can assess risk of stroke in patients with AF, and thus guide as to whether anticoagulants would be beneficial?

``` CHA2DS2VASc CHF HTN Age (2 points if > 75) Diabetes Stroke or clot Hx(2 points) Vascular disease Age (1 point if 65-74) Sex (1 point if F) ```

Which scoring system estimates risk of major bleeding for patients on anticoagulation for AF?

``` HAS BLED HTN Abnormal Renal/ Liver Function (1 each) Stroke Hx Bleeding tendency Labile INR (<60% of time in therapeutic range) Elderly (>65) Drugs predisposing to Bleeding or Alcohol Use ```

What are anticoagulants?

``` Inhibit clotting factors Red clots: AF + DVT Slow clotting + formation of fibrin Heparin Warfarin Apixaban Rivaroxaban ```

What are anti platelets?

``` inhibit platelet aggregation White clots: Stroke + MI Clump when blood is stagnant Aspirin Clopidogrel ```