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Year 2 - Nervous > Stroke - pathology + clinical > Flashcards

Stroke - pathology + clinical Flashcards

1
Q

Risk factors of stroke

  • modifiable (7)
  • non-modifiable (4)
A 
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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2
Q

Define stroke

A

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

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3
Q

Define TIA

A

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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4
Q

Causes of ischaemic stroke (4)

A

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

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5
Q

Causes of haemorrhage stroke (2)

A

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

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6
Q

General symptoms/signs of stroke (5)

A

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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7
Q

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
A

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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8
Q

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
A

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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9
Q

Symptoms/signs of a right hemisphere stroke (3)

A 
Left hemiplegia
Homonymous hemianopia
Agnosias (neglect syndromes)
-visual agnosia
-sensory agnosia
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10
Q

Name the 4 stroke subtypes

A

Total anterior circulation stroke (TACS)

Partial anterior circulation stroke (PACS)

Lacunar stroke (LACS)

Posterior circulation stroke (POCS)

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11
Q

Common sites of lacunar stroke (3)

A

Basal ganglia
Brainstem
Cerebellum

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12
Q

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

A

MEDIAL

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13
Q

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

A

Lateral

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14
Q

What supplies the basal ganglia

A

Small end arteries of the MCA

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15
Q

Occlusion of what arteries causes lacunar strokes

A

Small end arteries of the MCA

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16
Q

Clinical features of lacunar strokes (LACS) (3)

A

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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17
Q

Name the 4 types of lacunar strokes

A

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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18
Q

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

A

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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19
Q

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

A

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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20
Q

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

A

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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21
Q

Signs of POCS (6)

A 
Vertigo
Nausea
Vomiting
Ataxia - esp fine motor co-ordination and gait if POCS
Coma
Diplopia
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22
Q

Investigations of stroke

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

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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23
Q

Acute treatment of ischaemic stroke (4)

A

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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24
Q

Secondary prevention of ischaemic stroke (5)

  • medical (4)
  • surgical
A

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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25
Q

Contra-indications to thrombolysis (7)

A

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

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26
Q

Criteria for thrombolysis (2)

A

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

Disabling neurological deficit

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27
Q

Acute treatment of haemorrhagic stroke

  • supportive care (4)
  • medical (2)
  • surgical (1)
A

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

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28
Q

Stroke differentials (4)

A

Hypoglycaemia
TIA
Seizure + post-ictal deficits
Brain tumour

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29
Q

What is the penumbra

A

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

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30
Q

List the main blood vessels in the brain (5)

A 
Vertebral arteries
Basilar artery
PCA
MCA (Arising from ICA)
ACA (Arising from ICA)
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31
Q

Main veins/venous sinuses in the brain (4)

A

Superior saggital sinus
Transverse sinus
Sigmoid sinus
IJV

32
Q

2 broad categories of cerebrovascular disease

A
  1. Focal or localised interrupted blood supply or hypoxia

2. Generalised problem with blood supply or hypoxia

33
Q

Transient symptoms are due to what

A

Reversible ischaemia = brain tissue still viable

34
Q

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

A

Irreversible ischaemia –> localised brain death = INFARCT

35
Q

Interruption of blood supply is due to changes in what triad

A

Virchow’s

36
Q

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

A

3 factors that cause thrombosis

Changes in vessel wall
Changes in pattern of blood flow
Changes in blood constituents

37
Q

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

A

Atheroma

Vasculitis

38
Q

Causes of changes in pattern of blood flow (part of Virchow’s triad)

  • stagnant flow (2)
  • turbulent flow (2)
A

Stagnant blood flow:
On planes
Post op/inactivity

Turbulent blood flow:
Atheroma
Aneurysm

39
Q

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

A

Hypercoagulability

  • pregnancy (Acquired) –> above
  • cancer (acquired)
  • thrombophilia (inherited)
40
Q

Thrombosis is often superimposed on what

A

Atheromas

41
Q

Causative factors of thrombosis (4)

A

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

42
Q

Causative factor of parenchymal haemorrhage into the brain

A

Ruptured aneurysm

43
Q

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

A

Atheroma + superimposed thrombosis –> ischaemia

Thromboemoblism –> ischaemia

Ruptured aneurysm –> haemorrhage

44
Q

Atheromas that commonly cause ischaemic strokes are located where

A

Bifurcation of the carotid artery

45
Q

Thrombosis (blood clot) is made of what 2 things

A

Platelets + fibrin

46
Q

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

A

MCA

47
Q

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

A

LA

LV

48
Q

Why do thromboemboli commonly come from the LA

A

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

49
Q

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

A

Travel up the ascending aorta and up the carotids

50
Q

Are cerebral artery walls thick or thin + why

A

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

51
Q

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

A

Hypertension

Weakens and stretches the wall –> aneurysm formation

52
Q

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

A

Basal ganglia

Circle of willis

53
Q

What type of aneurysms form in the basal ganglia

A

Microaneurysms

54
Q

What type of aneurysms form in the circle of willis vessels

A

Berry aneurysms (look like a berry)

55
Q

Most common type of aneurysm

A

Berry aneurysm

56
Q

3 main causes of generalised interrupted blood supply

A

Low blood O2,

Lack of blood supply,

Inability to use O2 - RARE, e.g. cyanide poisoning

57
Q

Causes of low blood O2 (2)

A

CO2 poisoning

Resp arrest

58
Q

Name 3 causes of lack of blood supply

A

Hypotension
Cardiac arrest
Brain swelling (Trauma)

59
Q

What are watershed areas

A

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

60
Q

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

A

Watershed infarcts

61
Q

Name a cause of inability to use O2

A

Cyanide poisoning

62
Q

2 causes of ischaemic strokes

A

Atheroma + thrombosis

Thromboembolism

63
Q

Cause of haemorrhage strokes

A

Ruptured aneurysm of a cerebral vessel

64
Q

Ischaemia =

A

Lack of blood flow

65
Q

Hypoxia =

A

Lack of oxygen

66
Q

Anoxia =

A

Complete absence of oxygen

67
Q

Ischaemia leads to what

A

Hypoxia

68
Q

Pathological appearance of an ischaemic stroke due to atheroma/thromboembolsim (5)

  • shape
  • texture
  • colour
A 
Wedge shaped
Soft and cystic like 
Yellow discolouration from foamy macrophages
Gliosis (Scarring)
Congested swollen vessels
69
Q

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

A

Symmetrical watershed infarcts

70
Q

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

A

Grey matter thinning/necrosis

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

71
Q

Pathological appearance of a haemorrhage stroke

A

Large area of old, black blood

72
Q

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

A

Unilateral weakness and/or sensory deficit of ≥2/3 of face/arm/leg

Pure sensory stroke

Ataxic hemiparesis

73
Q

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

A

Unilateral weakness and/or sensory deficit of face, arm and leg

Homonymous hemianopia

Higher cerebral dysfunction (dysphasia, visuospatial disorder)

74
Q

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

A

Unilateral weakness and/or sensory deficit of face, arm and leg

Homonymous hemianopia

Higher cerebral dysfunction (dysphasia, visuospatial disorder)

75
Q

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

A

Cerebellar or brainstem syndrome

Loss of consciousness

Isolated homonymous hemianopia

76
Q

INITIAL investigations of stroke

  • bloods (5)
  • imaging (1)
  • other
A

Bloods

  • FBC
  • glucose
  • cardiac enzymes
  • U+Es
  • lipids

CT head

Carotid doppler

ECG

77
Q

ACA supplies primarily motor output from brain to what extremity

MCA supplies primarily motor output from brain to what extremity

A

ACA - leg

MCA - arm

Year 2 - Nervous (39 decks)

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