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R-Cradio-illness > Stroke Presentation and Investigation > Flashcards

Stroke Presentation and Investigation Flashcards

1
Q

What percentage of NHS beds are occupied by stroke patients?

A

20%

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2
Q

What is a stroke?

A

A neurological deficit of sudden onset, lasting more than 24 hours, of vascular origin

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3
Q

What is a transient ischaemic attack?

A

A neurological deficit of sudden onset and vascular origin but lasting less than 24 hours

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4
Q

What causes stroke?

A

Occlusion of a blood vessel by thrombus or embolus

Haemorrhage from rupture of a blood vessels

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5
Q

What percentage of strokes are ischaemic and what percentage are haemorrhage?

A

85% ischaemic

15% haemorrhagic

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6
Q

What are the symptoms of stroke?

A 
Loss of;
Power
Sensation
Speech 
Vision
Coordination
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7
Q

What areas of the brain are supplied by the carotid system?

A

Most of the hemispheres and cortical deep white matter

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8
Q

What areas of the brain are supplied by the vertebro-basilar system?

A

Brain stem, cerebellum and occipital lobes

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9
Q

What are the potential causes of a stroke?

A

Vessel occlusion
Disease of vessel wall
Disturbance of normal properties of blood
Rupture of vessel wall

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10
Q

What are the main causes of an ischaemic stroke?

A

Large artery atherosclerosis (35%)
Cardioembolic e.g. atrial fibrillation (25%)
Small artery occlusion (25%)
Undetermined/cryptogenic (10-15%)
Rarer causes e.g. arterial dissection (<5%)

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11
Q

What are the main causes of haemorrhagic stroke?

A

Primary intracerebral haemorrhage (70%)

Secondary haemorrhage e.g. subarachnoid haemorrhage, arteriovenous malformation (30%)

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12
Q

What are the stroke subtypes?

A

TACS - total anterior circulation stroke
PACS - partial anterior circulation stroke
LACS - lacunar stroke
POCS - posterior circulation stroke

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13
Q

What are the features of TACS?

A 
20% of strokes
Patient usually has; 
weakness, 
sensory deficit, 
homonymous hemianopia

and higher cerebral dysfunction e.g. dysphasia

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14
Q

What are the features of PACS?

A

35% of strokes
2 of the 3 TACS criteria (weakness, sensory deficit,
homonymous hemianopia)
or
restricted motor/sensory deficit e.g. one limb, face and hand or higher cerebral dysfunction alone

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15
Q

What are the features of LACS?

A

20% of strokes

Can be pure motor, pure sensory, sensorimotor, or ataxic hemiparesis

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16
Q

What are the features of POCS?

A

25% of strokes
Affects brainstem, cerebellar or occipital lobes
Variable and frequently complex presentation

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17
Q

What are the risk factors for stroke?

A 
Hypertension
Atrial fibrillation
Age 
Race 
Family history
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18
Q

What is alteplase?

A

Firbinolytic agent

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19
Q

What can alteplase cause in the brain if there is established tissue damage?

A

Unexpected bleeding

Can also cause bleeding elsewhere e.g. in the gut

20
Q

Patients admitted with a stroke within 4.5 hours of definite onset of symptoms should be treated with what?

A

0.9mg/kg intravenous rtPA (alteplase)
IF considered suitable
Onset to treatment should be minimised with earliest possible delivery of IV rtPA within time window

21
Q

When should streptokinase not be used?

A

For treatment of patients in the acute phase of stroke

22
Q

Where should thrombolysis be administered?

A

Within an acute stroke service

23
Q

According to NICE guidelines, what should patients with a suspected stroke have?

A 
Ambulance priority in appropriate cases
Rapid triage on hospital arrival
Immediate access to specialist stroke services
Rapid brain imaging
Rapid specialist assessment
24
Q

What are the contraindications to thrombolysis?

A

Age - most RCTs have excluded < 16 and > 80 y/o
Recent bleeding
Severe hypertension

25
Q

What percentage of patients benefit from admission to a stroke unit in acute stroke treatment?

A

90%

26
Q

What percentage of patients benefit from thrombolysis within 0-3 hours in acute stroke treatment?

A

10% ischaemic strokes

27
Q

What percentage of patients benefit from aspirin in 0-48 hours in acute stroke treatment?

A

65% ischaemic

28
Q

What percentage of patients benefit from hemicraniectomy in acute stroke treatment?

A

0.5%

29
Q

Why are stroke units beneficial?

A

Well established evidence that patients do better up to 10 years after admission
Mobilise patients ASAP
Concentrate on simple but important things e.g. swallowing, positioning - swallowing problems present in 50% of stroke patients
Early therapy
Concentrated stroke expertise

30
Q

What is the effect of early mobilising in stroke patients on the probability of them returning home?

A

Probability of returning home decreases by 20% for each day that the patient is not moved

31
Q

What is the risk of early recurrent stroke in TIA and stroke?

A

Identical risk of early recurrent stroke - up to 14% within the first two weeks

32
Q

What fraction of people who have a TIA will have an acute stroke in the future?

A

1/3

33
Q

What is the stroke patient risk of recurrent event at 7 days, 30 days and 3 months?

A

7 day stroke risk 11.5%
30 day stroke risk 15%
3 month stroke risk 18.5%

34
Q

What is the TIA patient risk of recurrent event at 7 days, 30 days and 3 months?

A

7 days stroke risk 8%
30 day stroke risk 11.5%
3 month stroke risk 17.3%

35
Q

What effect can early initiation of preventative treatment following TIA have on the risk of recurrent stroke?

A

Can reduce the risk of early recurrent stroke by 80%

36
Q

For patients with a TIA, what is evaluation and initiation of treatment in a specialist outpatient clinic associated with?

A

Reduced risk of subsequent stroke

37
Q

What can be done for primary prevention of a stroke?

A

Thrombolysis
Aspirin
Hemicraniectomy
Admission to stroke unit

38
Q

What can be done for secondary prevention of a stroke?

A 
Clopidogrel 75mg or aspirin 75mg plus dipyridamole MR 200mg BD 
Statin 
Hypertension drugs (even if BP is within normal range)
39
Q

What should be done in phase 1 (0-30 months) of stroke treatment?

A

Daily appointment clinic

Treatment advice faxed to GP

40
Q

What should be done in phase 2 (30-60 months) of stroke treatment?

A

Emergency access to clinic

Treatment started in clinic

41
Q

What is the effect of carotid endarterectomy on the risk of stroke or death?

A

In 50-69% stenosis, risk of stroke or death is reduced by 7-9% at 5 years after surgery
In > 70% stenosis, risk of stroke or death is reduced by 14-19% at 5 years after surgery

42
Q

When is surgery for carotid stenosis done?

A

Anterior circulation stroke
TIA or stroke with good recovery
70% occlusion

43
Q

What are the necessary details to obtain from the history of a stroke?

A 
Time of onset 
Witnesses 
Headache, vomiting, neck stiffness or photophobia - suggest haemorrhage 
Loss of consciousness 
Fit 
Incontinence
44
Q

What are the signs of a stroke on neurological history/examination?

A 
Motor - clumsy or weak limb 
Sensory - loss of feeling 
Speech - dysarthria, dysphasia 
Neglect or visuospatial problems 
Vision loss in one eye or hemianopia 
Gaze palsy
Ataxia, vertigo, incoordination or nystagmus
45
Q

What is localisation useful for in stroke diagnosis?

A

Confirms diagnosis
Allows better selection of imaging
Gives an indication of cause
Gives an indication of prognosis

46
Q

What tests are done in the investigation of stroke?

A 
Blood tests - FBC, lipids
ECG, 24 hour ECG 
CT
MRI 
Carotid Doppler
Echocardiogram may be useful
47
Q

What are the benefits of CT and MRI?

A

CT is quick and will show blood

MRI takes up to 30 minutes and can be claustrophobic but will show an ischaemic stroke better than a CT

R-Cradio-illness (27 decks)

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