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Y3 - Neuro > Stroke/TIA > Flashcards

Stroke/TIA Flashcards

1
Q

What is the definition of a stroke?

A

Sudden onset of focal neurological deficits that have a vascular origin and that last longer than 2 hours or use death

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2
Q

Is ‘stroke’ a diagnosis and why?

A

No - it is the experience of persisting neurological complications of cardiovascular disease

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3
Q

What is the distribution of the anterior cerebral artery?

A

Superior and medial cerebrum

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4
Q

What is the distribution of the middle cerebral artery?

A

Bulk of the lateral surface of the cerebrum

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5
Q

What is the distribution of the posterior cerebral artery?

A

Occipital lobe

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6
Q

What are the problems associated with the anterior cerebral artery?

A

Contralateral weakness and sensory loss in the legs
Loss of voluntary control of urination
Visual disturbance

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7
Q

What are the problems associated with the middle cerebral artery?

A

Contralateral weakness and sensory loss, especially of arm and face
Homonymous hemianopia
Aphasia
Visuospatial problems

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8
Q

What are the problems associated with the posterior cerebral artery?

A

Macular sparing homonymous hemianopia

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9
Q

What are the types of stroke and the proportion of those?

A

Ischaemic stroke - 80%
Haemorrhagic stroke - 17%
Other - 3%

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10
Q

What is an ischaemic stroke?

A

Cerebral vessel occlusion and subsequent infarction

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11
Q

What are the types of ischaemic stroke, and what are they?

A

Thrombotic - blockage of vessels at the site of clot development
Embolic stroke - clots that arise distally, break off from site of origin and block downstream

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12
Q

Where can embolic strokes come from?

A

Break off from atherosclerotic plaques at for example the carotid arteries or the heart in MI/AF/endocarditis

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13
Q

What are haemorrhage strokes?

A

Consequence of intracerebral haemorrhage reducing blood supply to certain areas of the brain
or mass effect of the clot

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14
Q

What are the causes of haemorrhagic strokes?

A 
Uncontrolled hypertension
Trauma
Aneurysm
Clotting disorders
Tumours
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15
Q

What are causes of strokes other than ischaemic and haemorrhagic?

A

Antiphospholipid syndrome, vasculitis
Septic
Carotid artery dissection

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16
Q

How does sepsis cause a stroke?

A

Sudden drop in BP can result in hypoperfusion of areas of the brain that are the border zones between 2 artery territories

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17
Q

What causes carotid artery dissection?

A

Hypertension

Whiplash-like trauma

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18
Q

Who are strokes caused by carotid artery dissection more likely in?

A

People under 40 - account for 20%

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19
Q

What are the presenting features of a stroke caused by carotid artery dissection?

A

Focal neurological deficits
Pain in the neck or face
Horner’s syndrome - dilated pupil and droopy eyelid
Lower cranial nerve symptoms - facial weakness, vision loss, dysarthria

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20
Q

What are conditions that can mimic a stroke?

A 
SOL
Hypoglycaemia
Epilepsy and Todd's palsy
Delirium
Syncope
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21
Q

What are the risk factors for a stroke?

A 
CVD such as angina, MI, peripheral vascular disease
Previous stoke or TIA
AF
Carotid artery disease
HTN
Diabetes
Smoking
Vasculitis
Thrombophilia
Combined contraceptive pill
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22
Q

What are the types of stroke under the Oxford Classification?

A

Total anterior circulation stroke (TACS)
Partial anterior circulation stroke (PACS)
Posterior circulation syndrome (POCS)
Lacunar stroke (LACS)

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23
Q

What arteries are affected in a total anterior circulation stroke?

A

Blockage of both anterior and middle cerebral arteries

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24
Q

What arteries are affected in a partial anterior circulation stroke?

A

Blockage of one of anterior or middle cerebral arteries

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25
What arteries are affected in a posterior circulation syndrome?
Vertebral basilar arteries
26
What arteries are affected in a lacunar stroke?
Multiple small vessel infarcts in basal ganglia an thalamus
27
What is the diagnostic criteria for a total anterior circulation stroke?
All 3 of: - Unilateral weakness +/- sensory loss of face, arm or leg - Homonymous hemianopia - Higher cerebral dysfunction: dysphasia, visuospatial problems
28
What is the diagnostic criteria for a partial anterior circulation stroke?
2 of: - Unilateral weakness +/- sensory loss of face, arm or leg - Homonymous hemianopia - Higher cerebral dysfunction: dysphasia, visuospatial problems
29
What is the diagnostic criteria for posterior circulation syndrome?
1 of: - Isolated homonymous hemianopia - Cerebellar or brainstem syndromes (dysarthria, ataxia, hiccups, vomiting) - Ataxia, facial weakness, nystagmus, diplopia +/- confusion or mood changes
30
What is the diagnostic criteria for a lacunar stroke?
1 of: - Purely sensory stroke - Ataxic hemiparesis - Unilateral weakness +/- sensory symptoms in face, arms or legs
31
What is the criteria in a ROSIER score?
``` Loss of consciousness (-1) Seizure activity (-1) New acute onset (or on awakening from sleep): - Asymmetric facial weakness (+1) - Asymmetric arm weakness (+1) - Asymmetric lek weakness (+1) - Speech disturbance (+1) - Visual field defect (+1) Score >0 stroke is likely = does not rule out stroke completely ```
32
What is the acute management of a stroke?
1. ABCDE 2. Monitor BP, allow to be increased as decrease may compromise cerebral perfusion 3. Urgent imaging - CT or MRI brain 4. Determine ischaemic or haemorrhagic 5. Admit to stroke uniting rehabilitation
33
When are CTs done and when are MRIs done in a stroke presentation?
CT brain first line in acute phase of stroke | MRI brain first line if presenting after 1 week or with mild deficits suggesting a small lesion
34
How does imaging help in differentiating between ischamic and haemorrhagic stroke?
CT shows haemorrhagic well until about a week - then MRI is better MRI shows infarct better as it takes a while to show up on CT, by which time the damage has been done
35
What is the management of ischaemic stroke?
If presented <4.5 hours ago - thrombolysis with IV Alteplase If presented >4.5 hours ago and within 48 hours - 300mg aspirin continued for at least 14 days Clot retrieval with thrombectomy as an addition or alternative to thrombolysis if confirmed large vessel occlusion (unless >24 hours)
36
What is Alteplase?
A tissue plasminogen activator
37
What are the contraindications for thombolysis with alteplase?
``` Seizures Recent surgery Prolonged CPR Major infarct haemorrhagic stroke Mild non-disabling symptoms Currently on anticoagulant therapy Previous ischaemic stroke in last 3 months BP >180/110 (reduce before thrombolysis) ```
38
What investigations is done to try to determine the cause of a stroke?
Bloods: glucose, lipids, immunology screen 24 hour ECG and BP monitoring Imaging: echo, carotid artery ultrasound
39
What management is done for secondary prevention of a stroke?
``` Lifestyle modification - diet, smoking etc. Anticoagulation if thromboembolic stroke Medication - antihypertensives if HTN - anti-platelet (aspirin, clopidogrel) - statin ```
40
What is a transient ischaemic attack (TIA)?
Sudden onset of focal neurological deficit due to temporary artery occlusion with symptoms lasting <24 hours
41
What is a crescendo TIA?
2 or more TIAs within a week - high risk of developing into a stroke
42
What is the presentation of a TIA?
The same as a stroke | Amaurosis fugax - temporary loss of vision that lasts <5 minutes and described as a curtain coming down over one eye
43
What assessment is done in TIA?
ABCD2 score
44
What is involved in the assessment of TIA?
Age (>60 = 1) BP (>140/90 = 1) Unilateral weakness = 2, speech disturbance (no weekness) = 1 Duration (>1 hour = 2, 10-59mins = 1, symptoms <10 mins = 0) Diabetes = 1 Score out of 7 - 0-3 is low risk - 4-5 is intermediate risk - 6-7 is high risk If <4 refer for investigation and management within 7 days If >4 refer within 1 day
45
What investigations should be done in TIA?
Bloods - FBC, U&E, glucose, lipids ECG, CXR, carotid doppler, CT brain
46
What is the management for TIA?
Aspirin 300mg for 14 days Don't drink for 1 month Lifestyle modification and secondary prevention as with stroke Carotid endarterectomy if carotid atherosclerosis found
47
Where can intracranial venous thrombosis occur?
Any dural venous sinus - most commonly in sagittal or transverse sinus
48
What are risk factors for intracranial venous thrombosis?
Pregnancy Dehydration Head injury Drugs: OC, tranexamic acid Malignancy: intracranial and extracranial Systemic disease: hyperthyroidism, antiphospholipid, SLE, nephrotic syndrome, heart failure, Crohn's/UC
49
What is the presentation of intracranial venous thrombosis in the sagittal sinus?
``` Headache Vomiting Seizures Reduced vision Papilloedema ```
50
What is the presentation of intracranial venous thrombosis in the transverse sinus?
``` Headache +/- Mastoid pain Seizures Focal signs Papilloedema ```
51
What is the presentation of intracranial venous thrombosis in the cavernous sinus?
``` Ophthalmoplegia Swollen conjunctiva/eyelids Proptosis Photophobia Fever Focal/raised ICP symptoms ```
52
What structures pass through the cavernous sinus?
CN III, IV, V1 and V2, VI, internal carotid, sympathetic fibres
53
Where does thrombosis in cavernous sinus usually spread from?
Infection from the face
54
What are differential diagnoses for intracranial venous thrombosis?
Meningitis Tumour Subarachnoid haemorrhage
55
What investigation is done for intracranial venous thrombosis?
Bloods Lumbar puncture CT/MRI - delta sign in superior sagittal thrombosis
56
What is the management for intracranial venous thrombosis?
Anti-coagulation: heparin + warfarin +/- streptokinase | Manage symptoms of raised ICP
57
What are intracranial haemorrhages?
Bleeding within the skull
58
What are the subtypes of intracranial haemorrhages?
Subarachnoid Subdural Extradural Intracerebral
59
What is a haematoma?
Collection of blood within the skull
60
What is a subarachnoid haemorrhage?
Spontaneous bleeding into the subarachnoid space from any of the cerebral arteries
61
What are causes of subarachnoid haemorrhage?
Arteriovenous malformation | Rupture of Berry aneurysms (most common)
62
What conditions are associated with Berry aneurysms?
Polycystic kidney disease Coarction of the aorta Ehlers Danlos
63
What are common signs of development of Berry aneurysms?
Bifurcation of internal carotid into anterior and middle cerebral arteries Junction of the posterior communicating and internal carotid Junction between anterior communicating and anterior cerebral arteries
64
What is the presentation of subarachnoid haemorrhage?
Sudden onset thunderclap headache (occipital, develops within seconds, worst headache ever) Collapse Decreased or loss of consciousness Meningism: photophobia o, neck stiffness Focal neurological signs - 3rd nerve palsy
65
What investigations are done for subarachnoid haemorrhage?
CT brain (1st line) Lumbar puncture if CT negative - positive if Xanthochromatic CSF (yellow) Angiography to assess vasculature and identify any AVM/aneurysm
66
What is the management of subarachnoid haemorrhage?
Maintain cerebral perfusion - induce HTN with IV saline Nimodipine Refer to neurosurgery for aneurysm clipping, endovascular coiling
67
What is nimodipine?
Calcium channel antagonist that reduces chance of cerebral artery spasm and ischaemia
68
What are possible complications of subarachnoid haemorrhage?
Re-bleeding (50% chance in first 6 months) Delayed ischaemic neurological deficits Hydrocephalus Hyponatraemia
69
How can delayed ischaemic neurological deficits be prevented?
Nimodipine | Hypertension, hypervolemia, haemodilution
70
Why does hydrocephalus occur in subarachnoid haemorrhage?
Due to blockage of the arachnoid granulations with blood | Usually transient and non-symptomatic but will require a shunt if it becomes symptomatic
71
Why does hyponatremia occur in subarachnoid haemorrhage?
Develops due to the release of salt wasting compounds from the cerebrum Common and transient
72
What is the management of hyponatremia as a complications of subarachnoid haemorrhage?
Sodium supplements Fludrocortisone Not fluid restriction
73
What is a subdural haemorrhage?
Venous haemorrhage from the veins that connect the cortex to the dural venous sinus, with the blood accumulating between the dura and arachnoid matter
74
What are risk factors for subdural haemorrhage?
Increased age Alcoholism Epilepsy Anti coagulation
75
What are causes of subdural haemorrhage?
Trauma, especially deceleration injury | Associated trauma may be minor, with patient often not remembering any distinct event
76
What is the presentation of subdural haemorrhage?
Fluctuations in consciousness Insidious physical or mental slowing (confusion) Sleepiness Dull headache Unsteadiness Focal neurological symptoms + symptoms of raised ICP Symptom development can be over weeks to months as blood can slowly accumulate
77
What investigation is done for subdural haemorrhage?
CT brain: crescent shaped haematoma
78
What is the management of subdural haemorrhage?
``` Medical: - Correction of coagulopathy - Prophylactic anti epileptics: Phenytoin for 7 days - Maintenance of ICP within normal range - Follow up CT scan and review Surgical: - 1st line: burr hole craniotomy - 2nd line: craniotomy ```
79
What is an extradural haemorrhage?
Arterial bleed from the middle meningeal artery, with blood collecting between the temporal bone and dura
80
What are the causes of an extradural haemorrhage?
Temporal bone fracture is most common) | Recent head injury will be apparent
81
What is the presentation of an extradural haemorrhage?
Head injury, followed by a lucid period that can last from hours to days Increasingly severe headache associated with a sudden decline in level of consciousness Confusion Seizures Vomiting Hemiparesis Focal neurological symptoms and signs of raised ICP
82
What investigation is done for extradural haemorrhage?
CT brain: lens shaped (biconvex) haematoma | LP is contraindicated due to apparent increased in ICP
83
What is the management of extradural haemorrhage?
Surgical: clot evacuation and ligation of middle meningeal artery
84
What is an intracerebral haemorrhage?
Bleeding within the brain parenchyma
85
What are the causes of an intracerebral haemorrhage?
HTN Bleeding from tumours Blood vessel abnormalities: AVM, vasculitis
86
What is the presentation of an intracerebral haemorrhage?
Quick onset headache Focal neurological deficits Decreased level of consciousness
87
What investigation is done for intracerebral haemorrhage?
CT: variable shaped clots within the cerebral cortex Angiography: to assess the vasculature
88
What is the management of intracerebral haemorrhage?
Surgical: clot evacuation Medical: treat underlying cause

Y3 - Neuro (14 decks)

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