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Stroke Infarction Flashcards

1
Q

What is the pathology of ischaemic stroke?

A

Acute occlusion of an intracranial vessel leading to hypoxia and infarction; if blood flow restored w/o significant infarction = TIA.

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2
Q

What is the aetiology of ischaemic stroke?

A
  • DM, HTN, smoking, hypercholesterolemia
  • FHx
  • AF, valvular lesions, cardiac congenital defects, hypercoaguable states, vasculitis
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3
Q

What are the symptoms of ACA occlusion?

A
  • Contralateral hemiplegia
  • Gait apraxia
  • Abulia (severe apathy)
  • Urinary incontinence
  • Lower limb sensory loss
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4
Q

What are the symptoms of MCA occlusion?

A

-Contralateral hemiplegia
-Homonymous hemianopia
-Contralateral sensory loss
-Dysarthria, dysphasia
Non-dominant symptoms: aphasia, neglect, contructional apraxia.

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5
Q

What are the symptoms of posterior cerebral artery occlusion?

A 
Homonymous hemianopia +/- macular sparing
Contralateral hemiplegia
Ataxia/hemiballismus
Visual agnosia
Cortical blindness
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6
Q

What are the symptoms of posterior inferior cerebellar artery occlusion?

A 
Syncope
Vertigo
Hemiplegia
Dysarthria
Ipsilateral face numbness
Contralateral limb numbness
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7
Q

What are the symptoms of basilar artery occlusion?

A

Dizziness, vertigo, diplopia, dysarthria, facial numbness, ipsilateral hemiparesis

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8
Q

What Ix in ischaemic stroke?

A

CT, MRI, MR angiography, carotid dopplers, ECG, echo.

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9
Q

Rx ischaemic stroke?

A

-Medical: aspirin, clopidogrel, dipyramidole, anticoagulation.
Thrombolysis as indicated.
-Collateral blood flow BP dependent - don’t lower BP unless signs of malignant HTN.
-Surgical: carotid endarterectomy

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10
Q

What is a stroke?

A

Sudden on set of neurological deficits of a vascular basis with infarction of CNS tissue

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11
Q

What is a TIA?

A

Sudden onset of neurological deficits of a vascular basis without infarction (i.e. resolution)

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12
Q

Pathophysiology of small vessel / lacunar ischaemic strokes?

A

Chronic HTN and DM cause vessel wall thickening and decreased luminal diameter

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13
Q

Where do small vessel / lacunar strokes generally occur?

A

Small penetrating arteries: primarily basal ganglia, internal capsule, thalamus

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14
Q

What are the different mechanisms of ischaemic stroke?

A
  • Arterial thrombosis
  • Cardioembolic
  • Systemic hypoperfusion
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15
Q

What is the most common mechanisms of hemorrhagic stroke?

A

Hypertensive: rupture of small micro aneurysms causing intraparenchymal haemorrhage

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16
Q

What are the most common sites of hemorrhagic stroke?

A

Putamen, thalamus, cerebellum, pons

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17
Q

ACA stroke syndrome?

A

Contralateral leg paresis and sensory loss

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18
Q

MCA stroke syndrome?

A

Proximal occlusion involves:

  1. Contralateral weakness and sensory loss of face and arm
  2. Cortical sensory loss
  3. +/- contralateral homonymous hemianopia or quadrantanopia
  4. L hemisphere: aphasia
  5. R hemisphere: neglect
  6. eye deviation towards the side of the lesion and away from the weak side
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19
Q

PCA stroke syndrome?

A
  1. Contralateral hemianopia or quadrantanopia
  2. Midbrain findings (CNIII/IV palsy/pupillary changes, hemiparesis)
  3. Thalamic findings: sensory loss, amnesia, dec LOC
  4. If bilateral: cortical blindness or prospagnosia
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20
Q

Basical artery stroke syndrome?

A

Locked in syndrome:

  1. Quadriparesis
  2. Dysarthria
  3. Impaired eye movements
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21
Q

PICA stroke syndrome?

A

Lateral medullary / Wallenburg syndrome:

  1. Ipsilateral ataxia
  2. ispilateral Horner’s
  3. ipsilateral facial sensory loss
  4. contralateral limb impairment of pain & temp
  5. nystagmus vertigo
  6. N/V
  7. Dysphagia
  8. Dysarthria
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22
Q

Anterior spinal artery stroke syndrome?

A

Medial medullary infarct:

  1. contralateral hemiparesis
  2. contralateral impaired proprioception and vibration
  3. ipsilateral tongue weakness
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23
Q

Lacunar infarct stroke syndrome to posterior limb of internal capsule?

A

-Pure motor: posterior limb of internal capsule => contralateral leg, arm, face

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24
Q

Thalamic lacunar infarct stroke syndrome?

A

Pure sensory loss: hemisensory loss

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25
Q

Assessment of stroke?

A
  • ABCs
  • Full vitals monitoring
  • BSLs
  • Urgent code stroke
26
Q

Hx features to ascertain in stroke?

A

-Onset: time when last known to be awake and Sx free

27
Q

Mimics to r/o in stroke Hx?

A
  • Seizure / post-ictal
  • Hypoglycemia
  • Migraine
  • Conversion disorder
28
Q

Ix in stroke work up?

A
  • Non contrast CT: r/o haemorrhage
  • ECG: r/o AF (Cardioembolic cuase)
  • FBE
  • UEC
  • Coags
  • Blood glucose
29
Q

What are the signs of stroke on imaging?

A
  • Loss of white-grey differentiation
  • Sulcal effacement (i.e. mass effect decreases visualisation of sulci)
  • Hypodensity of parenchyma
  • Insular ribbon sign
  • Hyperdense MCA sign
30
Q

Mx of acute stroke?

A
  1. Thrombolysis
  2. Anti-platelet therapy
  3. Anti-coagulant therapy
  4. Other
    - NBM if dysphagia
    - DVT prophylaxis
    - initiate early rehab
31
Q

Principles of thrombolysis?

A
  • rtPA (recombinant tissue plasminogen activator)

- given within 4.5h onset and no CIx

32
Q

Contraindications to thrombolysis?

A 
Hx:
- improving / minor Sx
-Seizure at stroke onset
-recent major surgery/trauma
-recent GI or urinary haemorrhage
-recent LP or arterial puncture at non-compressible site
-Pregnancy
PMHx:
-ICH
-Sx of: SAH/pericarditis/MI
PEx:
-sBP: >185 
-dBP: >110
-Uncontrolled serum glucose
-Thombocytopenia
CT: haemorrhage or mass
33
Q

When is anti-platelet therapy indicated in acute stroke management?

A

At presentation of TIA / stroke if rtPA not received

34
Q

Anti-platelet agents in acute stroke management?

A
  • Aspirin

- Clopidogrel (if aspirin CIx)

35
Q

Anti-coagulant therapy in acute stroke management?

A

Patients with TIA / stroke and atrial fibrillation if rtPA not received

36
Q

Anti-coagulant therapy in acute stroke management if pt already on warfarin?

A

IV heparin (or ensure INR 2-3)

37
Q

Maintenance of BSL in acute stroke management?

A

Avoid hyperglycemia (can increase infarct size)

38
Q

Principles of BP management in peri-stroke period?

A
  • Acutely elevated BP required to maintain brain perfusion to ischaemic penumbra
  • Do not lower BP unless sBP >220 / dBP >120
39
Q

Further investigations to consider in ascertaining stroke aetiology?

A
  • Additional neuroimaging (MRI)
  • Vascular imaging: CTA / MRA / carotid dopplers
  • Cardiac: echo, holter monitors
40
Q

Stroke primary prevention with anti platelets?

A

No current evidence for low risk pts w/o previous TIA/stroke

41
Q

Stroke secondary prevention with anti-platelets?

A
  • Aspirin first line

- Clopidogrel (if aspirin unsuitable / ongoing neuro Sx)

42
Q

What was demonstrated by the MATCH and CHARISMA trials?

A

No benefit and risk of major bleeding if combining aspirin and clopidogrel

43
Q

Primary prevention of stroke if carotid stenosis?

A

Carotid endarterectomy controversial:

  • if stenosis >60% RR stroke 2%/y
  • reduces risk by 1% per year
  • BUT 5% chance of complications
44
Q

Secondary prevention of stroke with carotid stenosis?

A

(Previous stroke / TIA)
-carotid endarterectomy of CLEAR benefit if symptomatic severe stenosis (less benefit if moderate symptomatic stenosis 50-69%).
Benefits time linked to last symptomatic event

45
Q

Role of CHADS2 score stroke primary / secondary prevention?

A

Risk stratification:

  • 0 = v low risk, anti platelet
  • 1 = low risk, anti platelet or anti coagulant (pt specific)
  • 2 = mod/high risk, anticoagulant
46
Q

Anticoagulation therapy in stroke secondary prevention?

A

-Warfarin (titrate to INR 2-3)
-Dabigatran (110 or 150mg bd)
Factor Xa also as effective as warfarin.

47
Q

BP target in stroke primary prevention?

48
Q

What is the role of ACEi in stroke primary prevention?

A

Reduce risk of stroke beyond their anti-hypertensive effects

49
Q

What was the outcome of the PROGRESS trial?

A

ACEi and thiazide diuretic recommended in pts with previous stroke / TIA

50
Q

What are the components of CHADS2?

A
  • CHF
  • HTN
  • Age (>75)
  • Diabetes
  • Previous stroke/TIA (2 pts)
51
Q

How does smoking affect stroke risk?

A

Smoking increases stroke risk in a dose dependent manner

52
Q

Features favouring stroke (v mimic)?

A

Stroke predicted by:

  • exact time of onset
  • pt could recall what they were doing at symptom onset
  • well in the last week
  • definite focal Sx or signs, worse NIHSS
53
Q

Features favouring mimic (v stroke)?

A
  • Known cog impairment
  • lost consciousness or seizure at onset
  • pt could still walk
  • no lateralising Sx
  • confusion, non-vascular or no neurological signs
54
Q

Classification of ICH?

A

Deep and lobar

55
Q

What are the areas affected by deep ICH?

A
  • Putamen
  • Thalamus
  • Brainstem
  • Cerebellum
56
Q

Aetiology of deep ICH?

A

Usually due to HTN and rupture of deep penetrating arteries

57
Q

Aetiology of superficial ICH?

A

Often secondary to:

  • amyloid angiopathy
  • tumour
  • arteriovenous malforamtion
  • aneurysm
58
Q

What is the aim of acute ischaemic stroke treatment?

A

Rescuing the penumbra; time is brain

59
Q

Non modifiable risk factors for ischaemic stroke?

A
  • Age
  • Gender
  • FHx
  • Ethnicity
  • OCP use
60
Q

Main modifiable ischaemic stroke RFx?

A
  • HTN
  • DM
  • Smoking
  • Obesity
61
Q

What does CHADS2 score of one or more recommend?

A

Oral anti-coagulant

62
Q

What is the ABCD2 score?

A

To predict / identify individuals at high risk of stroke after TIA:
-Age (>60)
-BP (>140/90 at presentation)
-Clinical features (2 for focal weakness, 1 for speech disturbance w/o weakness)
-Diabetes
-Duration (2 if 60min+)
0-3 = LOW; 4-5 = MODERATE; 6-7 = HIGH

Neurology (38 decks)

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