Stroke Presentation and Investigation Flashcards
What are the symptoms of a stroke?
Loss of power
Loss of sensation
Loss of speech – loss of comprehension or loss of ability
Loss of vision
Loss of coordination
What are the essential things to ask about when taking a history?
Time of onset
Witnesses
Headache, vomiting, neck stifness, photophobia
Loss of consciousness
Fit
Incontinence
What is the neurological history likely to be?
Motor (clumbsy or weak limb)
Sensory (loss of feeling)
Speech (dysarthia - unclear articulation of speech that is otherwise linguistically normal) Dysphasia (deficiency in the generation of speech, and sometimes also in its comprehension)
Neglect / visospatial problems
Vision: Loss in one eye or hemianopia (blindness over half the field of vision). Gaze palsy (symmetric limitation of the movements of both eyes in the same direction)
What are the causes of stroke?
- Blockage of a vessel with thrombus or clot
- Disease of vessel wall
- Disturbance of normal properties of blood
- Rupture of vessel wall
–(haemorrhage)
Damage to part of the brain due to blockage of a blood vessel by thrombus or embolus (85% infarction)
Or due to haemorrhage from rupture of a blood vessel (15% haemorrhage)
Look at the different arteries
What part of the brain does the carotid system supply?
The carotid system supplies most of the hemispheres and cortical deep white matter
What does the vertebro-basilar system supply?
Brainstem
Cerebellum and occipital lobes
What is the motor cortex responsible for?
Movement
What is the frontal lobe responsible for?
Judgement, foresight and voluntary movement.
Smell
What is Broca’s arch responsible for?
Speech
What is the temporal lobe responsible for?
Intellectual and emotional functions
What is the brainstem responsible for?
Swallowing, breathing, heartbeat, wakefulness centre and other involuntray functions
What is the cerebellum responsible for?
coordination
What is Wernicke’s area responsible for?
SPeech comprehension
What is the occipital responsible for?
Primary visual area
What is the temproal lobe responsible for?
Hearing
What is the parietal lobe responsible for?
Comprehension of language
What is the sensory cortex responsible for?
Pain heat and other sensations
Summary
What are the causes of ischaemic stroke?
- Large artery atherosclerosis (e.g. Carotid) 35%
- Cardioembolic (e.g. atrial fibrillation) 25%
- Small artery occlusion (Lacunar) 25%
- Undetermined/Cryptogenic 10-15%
- Rare causes <5%
- arterial dissection
- venous sinus thrombosis
What are the causes of haemorrhagic stroke?
- Primary intracerebral haemorrhage 70%
- Secondary haemorrhage 30%
Subarachnoid haemorrhage
Arteriovenous malformation
What is the danger of PCI in a carotid stenosis?
PCI can dislodge clot and cause a stroke
What is the most common cause of cardioembolic stroke?
Atrial fibrillation - blood that isn’t flowing will clot
What vessels does a lacunar stroke involve?
What are the parts of the brain that can be affected by a stroke?
Left or right
Carotid territory or vertibrobasilar territory
Cerebral hemispheres or brainstem
Cortex or deep white matter
What do symptoms tell you about the likely diagnosis of the type of stroke?
What side of the brain is affected
Whether the lesion is in the brainstem (a brainstem stroke)
Whether the cortex is involved (a cortical stroke)
or if the lesion is in the deep white matter (a lacunar stroke)
What blood vessel is involved
Why do we localise the origin of the stroke?
Confirms the diagnosis of the stroke
Allows better selection of imaging
Gives an indication of the cause
Gives an indication of the prognosis
What are the stroke subtypes?
TACS: Total anterior circulation stroke
PACS: Partial anterior circulation stroke
LACS: Lacunar stroke
POCS: Posterior circulation stroke
Describe the lesion and what would cause this defect?
Unilateral field loss
Left optic nerve compression
What is the name of the following visual defect and the example lesion
Bilateral hemianopia - chiasmal compression from pituitary tumour
What is the visual defect associated and give an example lesion
Homonmous hemianopia - left cerebrovascular event.
What are the symptoms of total anterior circulation strokes (make up 20% of strokes in the community)?
Patient usually has weakness, sensory deficit
Homonymous hemianopia (loss of vision)
Higher cerebral dysfunction (eg dysphasia, dyspraxia)
What is TACS usually due to?
Occlusion of proximal MCA or ICA (Middle carotid artery or internal carotid artery)
What are the features of PAC strokes? (35% of strokes)
2 of 3 of TACS criteria or restricted motor/sensory deficit
eg. one limb, face and hand or higher cerebral dysfunction alone
What causes PACS?
Occlusion of branches of MCA - more restricted cortical infarcts
What are the features of a lacunar stroke?
_Pure motor (commonest)_ Complete or incomplete weakness of 1 side, involving the whole of 2 of 3 body areas (face/arm/leg)
Pure sensory
Sensory symptoms and/or signs, same distribution
Sensorimotor
Combination of the above
Ataxic hemiparesis
Hemiparesis and ipsilateral cerebellar ataxia
Small infarcts in basal ganglia or pons.
What is the cause of Lacunar strokes? (20% of strokes)
Intrinsic disease of single basal perforating artery (end arteries).
What part of the brain does the posterior circulation stroke affect?
25% of stroke
Affecting brainstem, cerebellar or occipital lobes.
What are the features of a POCS?
Bilateral motor/sensory deficit
disordered conjugate eye movement
isolated homonymous hemianopia
ipsilateral cranial nerve palsy with contralateral motor/sensory deficit
coma
disordered breathing
tinnitus
vertigo
Horner’s
Variable, frequently complex presentation (may include any of the above)
Summary of the Stroke epidaemiolgy
TACS - 20 %
PACS - 35%
POCS - 25%
LACS - 20%
