Stroke Presentation and Investigation Flashcards by Becca M

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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

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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

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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)

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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)

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Look at the different arteries

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What part of the brain does the carotid system supply?

The carotid system supplies most of the hemispheres and cortical deep white matter

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What does the vertebro-basilar system supply?

Brainstem

Cerebellum and occipital lobes

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What is the motor cortex responsible for?

Movement

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What is the frontal lobe responsible for?

Judgement, foresight and voluntary movement.

Smell

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What is Broca’s arch responsible for?

Speech

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What is the temporal lobe responsible for?

Intellectual and emotional functions

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What is the brainstem responsible for?

Swallowing, breathing, heartbeat, wakefulness centre and other involuntray functions

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What is the cerebellum responsible for?

coordination

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What is Wernicke’s area responsible for?

SPeech comprehension

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What is the occipital responsible for?

Primary visual area

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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 ## Footnote 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%