Stroke Syndromes Flashcards
What are the key clinical features of a MCA stroke?
Contralateral hemiparesis (upper>lower limbs; forehead spared)
Contralateral hemisensory loss (all modalities)
Contralateral homonymous hemianopia
Aphasia (if dominant hemisphere affected)
What are the key clinical features of an ACA stroke?
Contralateral hemiparesis (lower>upper limbs; forehead spared)
Contralateral hemisensory loss (all modalities)
Dysarthria
Urinary incontinence
What are the key clinical features of a PCA stroke?
Homonymous hemianopia with macula sparing
Visual agnosia
Alexia without agraphia
Weber’s syndrome is caused by disease of which vessels? What are the key clinical features?
Perforating arteries to the midbrain from PCA
Ipsilateral CN III palsy + Contralateral limb hemiparesis
Lateral Medullary Syndrome is caused by disease of which vessel? What are the key clinical features?
Posterior Inferior Cerebellar Artery (PICA)
Ipsilateral loss of pain and temperature sensation in face
Contralateral loss of pain and temperature in body
Nystagmus Ataxia Dysphagia Horner's syndrome Nausea + vomiting Hoarse voice Vertigo
What syndrome would result after complete, bilateral occlusion of basilar arteries? What are the key clinical features?
Locked-in Syndrome
Paralysis of all muscles except extra-occular muscles
What areas of the brain and vessel is most likely to be affected in a patient presenting with:
- hemiparesis (right)
- lateral gaze weakness (left)
- facial weakness (left)
Left Pons
Branches of Basilar artery
This is ventral pontine syndrome:
Contralateral hemiparesis
Ipsilateral CN VI palsy
Ipsilateral CN VII palsy
What is amaurosis fugax and what vessel is involved in it’s development?
Temporary monocular blindness
Retinal artery occlusion
What are the criteria for a TACI?
- Contralateral hemisensory loss and hemiplegia
- Contralateral homonymous hemianopia
- Evidence of higher dysfunction (e.g. inattention/neglect if non-dominant side), aphasia (if dominant side),
What are the criteria for a PACI?
2 of:
- Contralateral hemisensory loss and hemiplegia
- Contralateral homonymous hemianopia
- Evidence of higher dysfunction
OR
Motor loss of an isolated area (e.g. Leg weakness only)
OR
Higher dysfunction only
What are the criteria for a POCI
Isolated homonymous hemianopia
OR
Ipsilateral cerebellar syndrome features (ataxia, nystagmus, dysarthria)
OR
Cranial nerve palsy and contralateral motor/sensory deficit
What are the criteria for a LACI?
Pure Motor
-Unilateral paralysis involving at least 2 of face/arm/leg
Pure Sensory
-Unilateral sensory loss involving at least 2 of face/arm/leg
Sensorimotor
- Combination of pure motor and pure sensory
- Without visual field defect or higher dysfunction
Ataxic hemiparesis
- Ipsilateral cerebellar signs and hemiparesis
- with/without dysarthria
- Without visual field defect or higher dysfunction
Name the common stroke mimics
Seizure Migraine aura Brain tumour Subdural haematoma MS Bell's palsy
Sepsis
Hypo-/hyper- glycaemia/calcaemia/natraemia
Glaucoma
What screening tool can be used to assess likelihood of a stroke?
ROSIER
>0 = stroke likely
What is the most appropriate 1st line investigation for a patient presenting with a likely stroke? What is the exception to this?
Non-contrast CT head scan
Exception is if patient is presenting >7 days after symptoms, when a diffusion-weighted MRI is better
What other baseline investigations should be conducted?
Bloods:
- FBC, U&Es, LFTs, TFTs, CRP
- glucose
- INR if anticoagulated
- lipids
BP
ECG
When should a carotid USS+doppler be conducted? How is it interpreted?
If the patient would be suitable for endarterectomy
> 70% ECST (or 50% NASCET) stenosis indicates likely recurrence
Give the 4 criteria required for a patient to be eligible for thrombolysis
1) >18yrs
2) symptoms and signs of acute stroke
3) within 4.5hrs symptom onset
4) haemorrhage excluded on non-contrast CT
What are the major contraindications to thrombolysis?
- Active bleeding
- Previous intracranial haemorrhage
- Intracranial neoplasm
- Seizure at stroke onset
- Stroke/brain injury within 3 months
- LP within 3 days
- Pregnancy
- Uncontrolled hypertension (>200/120)
What and how is thrombolysis given? Are any tests required after thrombolysis?
IV Alteplase
Repeat head CT 24hrs later to ensure no haemorrhage
What is an equally effective alternative to thrombolysis, available in some parts of the UK?
Clot revival (mechanical thrombectomy)
How do you manage a patient who is ineligible for thrombolysis?
Immediate aspirin 300mg (oral or rectal)
How long is aspirin therapy continued after a stroke and at what dose?
2 weeks of 300m
Describe secondary prevention interventions after a stroke
Start life-long Clopidogrel when aspirin therapy is withdrawn
Satin if cholesterol raised
Good BP and glycaemic control
When should anticoagulation be started after a stroke secondary to AF?
14 days
How do you manage a haemorrhagic stroke?
Antihypertensives if BP> 180 systolic or 130 diastolic
What are the 3 main risk factors for haemorrhagic stroke?
1) Hypertension
2) Arteriovenous malformations
3) Secondary to cerebral infarction
what are the 3 main causes of TIA?
1) cardioembolism
2) Intracranial thromboembolism
3) extracranial thromboembolism (e.g. carotid artery embolism)
How do you treat a TIA?
300mg aspirin immediately and continued for 2 weeks
Then lifelong Clopidogrel 75mg
Secondary prevention
What score can be used to assess risk of stroke following TIA?
ABCD2
