Symptoms/signs of ACA occlusion stroke (think about the homunculus and what ACA supplies) (4) - what's more affected - face/arm/leg (may be more than 1) - which side affected - contralateral/ipsilateral - speech - co-ordination - vision

Contralateral: - Weakness/paralysis of esp LEG/face (hemiparesis/plegia) - Sensory loss of esp LEG/face Aphasia - more likely if left MCA affected as that's where Broca's and wernicke's is Ataxia (--> impaired gait) Homonymous hemianopia

Stroke - pathology + clinical Flashcards by Heo Mun Ho

Risk factors of stroke

modifiable (7)
non-modifiable (4)

Hypertension
Atrial fibrillation - BIG RF FOR EMBOLIC STROKES
Recent MI
Smoking
Alcohol
Hyperlipidaemia
Diabetes

Old age
Male
Race
Family history of stroke

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Define stroke

focal neurological deficit caused by ischaemia or haemorrhage and lasting more than 24 hours

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Define TIA

transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia lasting <24 hrs, usually resolve within an hour

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Causes of ischaemic stroke (4)

Atherosclerosis
Thromboembolism (e.g. from LA/LV)
Small artery occlusion (lacunar stroke)
Rare causes – venous sinus thrombosis

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Causes of haemorrhage stroke (2)

Ruptured aneurysm of a cerebral vessel –> primary haemorrhage
Secondary haemorrhage e.g. subarachnoid haemorrhage

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General symptoms/signs of stroke (5)

Vision loss
Unilateral weakness or paralysis of face/arm/leg (hemiparesis/hemiplegia)
Unilateral sensory deficit/loss
Aphasia (impaired expression/comprehension of speech)
Ataxia (impaired co-ordination and speech)

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Symptoms/signs of ACA occlusion stroke (think about the homunculus and what ACA supplies) (4)

what’s more affected - face/arm/leg (may be more than 1)
which side affected - contralateral/ipsilateral
speech
co-ordination
vision

Contralateral:

Weakness/paralysis of esp LEG/face (hemiparesis/plegia)
Sensory loss of esp LEG/face

Aphasia - more likely if left MCA affected as that’s where Broca’s and wernicke’s is

Ataxia (–> impaired gait)

Homonymous hemianopia

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Symptoms/signs of MCA occlusion stroke (think about the homunculus and what ACA supplies) (6)

what’s more affected - face/arm/leg (may be more than 1)
which side affected - contralateral/ipsilateral
vision
speech

Contralateral:

Weakness/paralysis of esp face/ARM (hemiparesis/plegia)
Sensory loss of esp face/ARM

Homonymous hemianopia

Gaze paralysis to weak side

Aphasia (unable to understand + produce speech) - more likely if LEFT MCA AFFECTED as that’s where Broca’s and wernicke’s is

Unilateral neglect/agnosia - if RIGHT MCA affected

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Symptoms/signs of a right hemisphere stroke (3)

Left hemiplegia
Homonymous hemianopia
Agnosias (neglect syndromes)
-visual agnosia
-sensory agnosia

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Name the 4 stroke subtypes

Total anterior circulation stroke (TACS)

Partial anterior circulation stroke (PACS)

Lacunar stroke (LACS)

Posterior circulation stroke (POCS)

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Common sites of lacunar stroke (3)

Basal ganglia
Brainstem
Cerebellum

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ACA occlusion would cause stroke of what surface of the cerebral hemispheres

MEDIAL

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MCA occlusion would cause stroke of what surface of the cerebral hemispheres

Lateral

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What supplies the basal ganglia

Small end arteries of the MCA

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Occlusion of what arteries causes lacunar strokes

Small end arteries of the MCA

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Clinical features of lacunar strokes (LACS) (3)

Motor weakness of ≥2/3 of face/arm/leg AND/OR sensory loss of ≥2/3 of face/arm/leg

No hemianopia/dysphasia

No brainstem/cerebellar signs

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Name the 4 types of lacunar strokes

Pure motor (commonest) - unilateral paralysis or weakness of ≥2/3 of face/arm/leg

Pure sensory - sensory loss of ≥2/3 of face/arm/leg

Sensorimotor - combo of above

Ataxis hemiparesis

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Clinical features of total anterior circulation strokes (TACS) (4)

Motor weakness of ≥2/3 of face/arm/leg AND/OR sensory loss of ≥2/3 of face/arm/leg

Hemianopia
+ ≥1/2 of dysphasia or neglect

No brainstem/cerebellar signs

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Clinical features of partial anterior circulation strokes (PACS) (3)
-very similar to TACS

Motor weakness of ≥2/3 of face/arm/leg AND/OR sensory loss of ≥2/3 of face/arm/leg

1 of hemianopia/dysphasia/neglect

No brainstem/cerebellar signs

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Clinical features of posterior circulation strokes (POCS) (4)

May/may not have motor weakness of ≥2/3 of face/arm/leg

May/may not sensory loss of ≥2/3 of face/arm/leg

May/may not have any of hemianopia/dysphasia/neglect

Brainstem/cerebellar signs - usually have this but some may not

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Signs of POCS (6)

Vertigo
Nausea
Vomiting
Ataxia - esp fine motor co-ordination and gait if POCS
Coma
Diplopia

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Investigations of stroke

imaging (3)
bloods (5)
other (2)

CT - better at showing haemorrhagic stroke
MRI - better at showing ischaemic stroke
CT angiogram - identifies arterial occlusion (e.g. thrombus) or stenosis

Serum glucose - to exclude hypo/hyperglycaemia
U+Es - to exclude electrolyte disturbance
Cardiac enzymes - may be raised if concomitant with MI
FBC - to detect any contraindications to acute stroke treatment like anaemia
Lipids

ECG - to check for arrhythmia
Carotid Doppler

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Acute treatment of ischaemic stroke (4)

Thrombolysis (give within 4.5 hours) - IV tPA (tissue plasminogen activator) or alteplase (recombinant tPA)

Emergency thrombectomy - for severe large ischaemic strokes; not done that often

300mg aspirin (24 hrs after thrombolysis)

+/- venous thromboembolism prophylaxis - with anticoagulant (heparin) if have higher risk of clotting, e.g. if have AF

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Secondary prevention of ischaemic stroke (5)

medical (4)
surgical

Antiplatelets - clopidogrel/aspirin (reduce form 300 to 75mg)
Statins
Anti-hypertensives - thiazide diuretics, ACEI, CCBs
Anticoagulants (if have AF) - warfarin

Carotid endarterectomy - correcting stenosis of the carotid arteries

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Contra-indications to thrombolysis (7)

Recent/CURRENT brain haemorrhage Brain mass/tumour Recent ischaemic stroke within 3 months Recent neurosurgery within 3 months Bleeding diathesis - very vulnerable to bleeding Recent head trauma within 3 months Uncontrolled hypertension - systolic >185 or diastolic >110

Criteria for thrombolysis (2)

Symptom onset <4.5 hrs (CANNOT BE DONE AFTER 4.5 HOURS OF PRESENTATION) Disabling neurological deficit

Acute treatment of haemorrhagic stroke - supportive care (4) - medical (2) - surgical (1)

Immediate emergency care is crucial - focusing on controlling the bleeding in brain and reducing the pressure caused by the bleeding: Supportive care - oxygen, intubation (if unconsciousness), fluids, feeding BP control (to prevent further bleeding) - labetalol DVT prophylaxis - heparin Emergency craniotomy occasionally - to remove any clots

Stroke differentials (4)

Hypoglycaemia TIA Seizure + post-ictal deficits Brain tumour

What is the penumbra

area surrounding an ischaemic event - flow and therefore oxygen transport is reduced locally, leading to hypoxia of the cells near the location of the original insult

List the main blood vessels in the brain (5)

``` Vertebral arteries Basilar artery PCA MCA (Arising from ICA) ACA (Arising from ICA) ```

Main veins/venous sinuses in the brain (4)

Superior saggital sinus Transverse sinus Sigmoid sinus IJV

2 broad categories of cerebrovascular disease

1. Focal or localised interrupted blood supply or hypoxia | 2. Generalised problem with blood supply or hypoxia

Transient symptoms are due to what

Reversible ischaemia = brain tissue still viable

Longstanding symptoms (i.e. not transient) due to what

Irreversible ischaemia --> localised brain death = INFARCT

Interruption of blood supply is due to changes in what triad

Virchow's

What is Virchow's triad + what 3 things does it consist of

3 factors that cause thrombosis Changes in vessel wall Changes in pattern of blood flow Changes in blood constituents

Name 2 causes of a change in vessel wall (part of Virchow's triad)

Atheroma | Vasculitis

Causes of changes in pattern of blood flow (part of Virchow's triad) - stagnant flow (2) - turbulent flow (2)

Stagnant blood flow: On planes Post op/inactivity Turbulent blood flow: Atheroma Aneurysm

Causes of changes in blood constituents (part of Virchow's triad) (3)

Hypercoagulability - pregnancy (Acquired) --> above - cancer (acquired) - thrombophilia (inherited)

Thrombosis is often superimposed on what

Atheromas

Causative factors of thrombosis (4)

Atheroma Stagnant flow - inactivity Turbulent flow - atheroma Hypercoagulability - pregnancy, cancer, thrombophilia

Causative factor of parenchymal haemorrhage into the brain

Ruptured aneurysm

3 main causes of localised interrupted blood supply which lead to stroke

Atheroma + superimposed thrombosis --> ischaemia Thromboemoblism --> ischaemia Ruptured aneurysm --> haemorrhage

Atheromas that commonly cause ischaemic strokes are located where

Bifurcation of the carotid artery

Thrombosis (blood clot) is made of what 2 things

Platelets + fibrin

Thrombosis in the ICA typically leads to ischaemia of which cerebral artery

MCA

Thromboembolism in the carotid arteries commonly comes from where + what other place

LA LV

Why do thromboemboli commonly come from the LA

Because the left atrial appendage (auricle) is a reservoir of stagnant blood so the blood is more likely to thrombose

How do emboli from the LA or LV get to the carotid arteries

Travel up the ascending aorta and up the carotids

Are cerebral artery walls thick or thin + why

Thin Because little smooth muscle so don't constrict/expand much as we don't want the brain to respond to small things that change BP like caffeine

Cerebral vessels don't handle ... well + what does this do to the vessels + what can then form from this

Hypertension Weakens and stretches the wall --> aneurysm formation

2 common sites of ruptured aneurysm (i.e. common sites of haemorrhage strokes)

Basal ganglia | Circle of willis

What type of aneurysms form in the basal ganglia

Microaneurysms

What type of aneurysms form in the circle of willis vessels

Berry aneurysms (look like a berry)

Most common type of aneurysm

Berry aneurysm

3 main causes of generalised interrupted blood supply

Low blood O2, Lack of blood supply, Inability to use O2 - RARE, e.g. cyanide poisoning

Causes of low blood O2 (2)

CO2 poisoning | Resp arrest

Name 3 causes of lack of blood supply

Hypotension Cardiac arrest Brain swelling (Trauma)

What are watershed areas

When area A supplied by a an artery different from area B meet

Pure hypotension but still with oxygenated blood leads to what kind of infarctions

Watershed infarcts

Name a cause of inability to use O2

Cyanide poisoning

2 causes of ischaemic strokes

Atheroma + thrombosis | Thromboembolism

Cause of haemorrhage strokes

Ruptured aneurysm of a cerebral vessel

Ischaemia =

Lack of blood flow

Hypoxia =

Lack of oxygen

Anoxia =

Complete absence of oxygen

Ischaemia leads to what

Hypoxia

Pathological appearance of an ischaemic stroke due to atheroma/thromboembolsim (5) - shape - texture - colour

``` Wedge shaped Soft and cystic like Yellow discolouration from foamy macrophages Gliosis (Scarring) Congested swollen vessels ```

Pathological appearance of an ischaemic stroke due to hypotension (1)

Symmetrical watershed infarcts

Pathological appearance of an ischaemic stroke due to cardiac arrest (2)

Grey matter thinning/necrosis | Laminar necrosis of cortical ribbon (i.e. necrosis of the line of grey matter lining the brain)

Pathological appearance of a haemorrhage stroke

Large area of old, black blood

To be diagnosed as a LACS, patient must be presenting with one of following (3)

Unilateral weakness and/or sensory deficit of ≥2/3 of face/arm/leg Pure sensory stroke Ataxic hemiparesis

To be diagnosed as a TACS, patient must have all 3 of the following

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

To be diagnosed as a PACS, patient must have 2 of the following 3

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

To be diagnosed as a POCS, patient must have 1 of the following 3

Cerebellar or brainstem syndrome Loss of consciousness Isolated homonymous hemianopia

INITIAL investigations of stroke - bloods (5) - imaging (1) - other

Bloods - FBC - glucose - cardiac enzymes - U+Es - lipids CT head Carotid doppler ECG

ACA supplies primarily motor output from brain to what extremity MCA supplies primarily motor output from brain to what extremity

ACA - leg MCA - arm