Stroke presentation & investigation Flashcards

1
Q

Why is prevention of stroke important to the NHS?

A

Commonest cause of long term disability in the UK

Patients who’ve had a stroke occupy 20% of NHS beds

Annual cost of over £5 billion treating stroke

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2
Q

What age demographic has the most strokes?

A

The elderly

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3
Q

Define what a stroke is

A

Clinical syndrome of sudden onset, causing a neurological deficit (loss of function)

Lasting more than 24 hours or until death

Of Vascular origin

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4
Q

Symptoms of a stroke are defined as being negative symptoms

What does this mean?

A

Symptoms are more to do with ‘loss of _______’

Symptoms of stroke:
Loss of power 
Loss of speech 
Loss of sensation 
Loss of vision 
Loss of coordination
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5
Q

Describe the clinical signs, on history/examination, that would indicate a stroke

A

Motor - clumsy/weak

Sensory loss

Speech - Dysarthria/dysphasia

Neglect / visuospatial problems

Vision - loss in one eye or hemianopia

Gaze palsy

Ataxia / vertigo / nystagmus

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6
Q

What is hemianopia?

A

Blindness over half the field of vision

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7
Q

What is gaze palsy?

A

Inability to move both eyes in the same direction

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8
Q

What is ataxia?

A

lack of voluntary coordination of muscle movements that can include gait abnormality, speech changes, and abnormalities in eye movements

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9
Q

What is nystagmus?

A

Dancing eyes

Rapid fluttery eye movements

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10
Q

What are the 2 types of causes of strokes?

A

Cerebral infarction

Haemorrhage

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11
Q

What are the 2 artery groups that supply the brain

A

Vertebral arteries (L & R)

Common carotid arteries (L & R)

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12
Q

What does the common carotid arteries split into?

A

Internal & external carotid arteries

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13
Q

What is the fate of the vertebral arteries?

A

Left and right vertebral arteries join together to form the single Basilar artery

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14
Q

What arteries branch off the Basilar artery?

A

Posterior inferior cerebellar arteries

Superior cerebellar arteries

Posterior cerebral arteries

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15
Q

What arteries make up the circle of willis?

A

Anterior communicating artery top

Anterior cerebral arteries

Internal carotid arteries/middle cerebral arteries

Posterior communicating arteries

Posterior cerebral arteries bottom

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16
Q

Most cerebral infarctions involve thrombus lodging in what arteries?

A

Middle cerebral arteries

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17
Q

The brain’s arterial supply can be thought of as an anterior and posterior circulation

What areas of the brain does the carotid system supply?

A

Anterior

The carotid system (via internal carotid arteries) supplies most of the hemispheres and cortical deep white matter

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18
Q

What areas of the brain does the vertebral artery system supply?

A

Posterior

Vertebro-basilar system supplies the brainstem, cerebellum and occipital lobes

19
Q

In the deep white matter of the brain, a small stroke can cause major deficits

Why?

A

In the deep white matter of the brain or in the pons, neural fibres from different areas of the brain run alongside each other in tight, internal capsules

A small stroke in this area will affect all these fibres thus have affect lots of different areas

20
Q

What are the causes of a ischaemic stroke (cerebral infarction)?

A

Large artery atherosclerosis:
- Typically in the carotid

Cardioembolic:
- Atrial fibrillation most common cause of this

Small artery occlusion - Lacunar

Less common:

  • Cryptogenic
  • Arterial dissection
  • Venous sinus thrombosis
21
Q

What are the causes of a hemorrhagic stroke?

A

Primary intracerebral haemorrhage:

  • Blood vessel bursting within the brain
  • Most common (70% HS’s)

Subarachnoid haemorrhage:
- Blood in the space around the brain

Arteriovenous malformation:
- Poorly formed blood vessels that ‘leak’

22
Q

What does a hemorrhagic stroke look like on a CT?

A

Darker grey area

Will extend to the peripheries if subarachnoid haemorrhage

23
Q

What is a lacunar stroke?

A

Happens when the small arteries to lacunae (gaps in the brain) are blocked

On a CT, it is a hard to see, slightly darker patch

On an MRI, it is a slightly lighter patch

24
Q

What is a carotid dissection?

A

When the intimal layer of a carotid artery separates from the media

Blood clot fills in the space

Can be idiopathic or caused by trauma

It is a rarer cause of cerebral infarction strokes (ischaemic stroke)

25
Q

A patient presents with a stroke

They have homonymous hemianopia

What is this, and what is likely to have caused it?

A

They have lost half of the field of view in each eye

Sight lost from the same side on both eyes

A stroke in the left occipital cortex would cause the patient to lose the right half of the field of view of both the eyes

26
Q

Clinically, strokes are classed into 4 subtypes according to the Oxford clinical stroke classification

What are these?

A

TACS - total anterior circulation stroke

PACS - partial anterior circulation stroke

LACS - lacunar stroke
- pure motor / pure sensory / sensorimotor

POCS - posterior circulation stroke

27
Q

A patient presents with:

  • Weakness
  • Sensory deficit
  • Homonymous hemianopia
  • Dysphasia (slurring)
  • Dyspraxia

What type of stroke do they have?

A

TACS

28
Q

A patient presents with:

  • Weakness of their left arm
  • Weakness of their left side of their face

What type of stroke do they have?

A

Pure motor LACS

“Complete or incomplete weakness in 1 side of the body in 2 of either the face, arm or leg”

29
Q

A patient presents with:

  • Dysphasia
  • Dyspraxia

What type of stroke is the patient having?

A

PACS (partial anterior)

2/3 of TACS criteria, basically the patient will have some signs of TACS but will be fine in other ways

Ie - Weakness in limbs/face but still able to talk normally

30
Q

A patient presents with:

  • Bilateral motor/sensory deficit
  • Disordered breathing
  • Tinnitus
  • Isolated homonymous hemianopia

What type of stroke are they having?

A

POCS (posterior)

POCS present with variable, unique symptoms

Stuff like tinnitus, Horner’s, coma, = POCS

31
Q

A patient presents with:
- Loss of feeling in the right arm and right leg

What type of stroke are they having?

A

Pure sensory LACS

32
Q

What is the most common subtype of stroke?

A

PACS (partial anterior) - 35%

33
Q

TACS are usually caused by occlusion of what vessels ?

A

Proximal middle cerebral artery
or
Internal carotid

34
Q

What causes PACS to happen?

A

More restricted cortical infarcts - occlusion of branches of middle cerebral artery

35
Q

What areas of the brain are affected by POCS?

A

Brainstem, Cerebellum or Occipital lobes

36
Q

Which is the most dangerous type of stroke?

A

TACS

60% mortality at 1 year

37
Q

What is the one year prognosis for someone who survives a TACS?

A

Lowest recurrence of all subtypes at only 6% @ 1 year

38
Q

What is the mortality and recurrence rate for PACS?

A

16% mortality in 1 year

17% recurrence rate in 1 year
high chance of recurrence in early stages

39
Q

What is the mortality and recurrence rate for LACS?

A

11% mortality at 1 year

9% recurrence at 1 year

40
Q

What is the mortality and recurrence rate for POCS?

A

19% mortality at 1 year

20% recurrence at 1 year (highest)

41
Q

What are the risk factors for stroke?

A
Age
Race (chinese most at risk) 
Family history
Hypertension
Atrial fibrillation 
Also: 
Smoking & alcohol
Diet & Exercise 
Stress & Depression 
Diabetes
Hyperlipidaemia & all that shite
42
Q

Why is atrial fibrillation a risk factor for stroke?

A

Atrial fibrillation can cause a cardioembolic ischaemic stroke

43
Q

Which gender is most at risk of a stroke?

A

In adult to early old age (<75) - men are more at risk

In > 75 age group, women are more at risk