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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
Q

What arteries are affected in a posterior circulation syndrome?

A

Vertebral basilar arteries

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26
Q

What arteries are affected in a lacunar stroke?

A

Multiple small vessel infarcts in basal ganglia an thalamus

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27
Q

What is the diagnostic criteria for a total anterior circulation stroke?

A

All 3 of:

  • Unilateral weakness +/- sensory loss of face, arm or leg
  • Homonymous hemianopia
  • Higher cerebral dysfunction: dysphasia, visuospatial problems
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28
Q

What is the diagnostic criteria for a partial anterior circulation stroke?

A

2 of:

  • Unilateral weakness +/- sensory loss of face, arm or leg
  • Homonymous hemianopia
  • Higher cerebral dysfunction: dysphasia, visuospatial problems
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29
Q

What is the diagnostic criteria for posterior circulation syndrome?

A

1 of:
- Isolated homonymous hemianopia
- Cerebellar or brainstem syndromes (dysarthria, ataxia, hiccups, vomiting)
- Ataxia, facial weakness, nystagmus, diplopia
+/- confusion or mood changes

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30
Q

What is the diagnostic criteria for a lacunar stroke?

A

1 of:

  • Purely sensory stroke
  • Ataxic hemiparesis
  • Unilateral weakness +/- sensory symptoms in face, arms or legs
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31
Q

What is the criteria in a ROSIER score?

A 
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
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32
Q

What is the acute management of a stroke?

A
  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
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33
Q

When are CTs done and when are MRIs done in a stroke presentation?

A

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

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34
Q

How does imaging help in differentiating between ischamic and haemorrhagic stroke?

A

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

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35
Q

What is the management of ischaemic stroke?

A

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)

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36
Q

What is Alteplase?

A

A tissue plasminogen activator

37
Q

What are the contraindications for thombolysis with alteplase?

A 
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
Q

What investigations is done to try to determine the cause of a stroke?

A

Bloods: glucose, lipids, immunology screen
24 hour ECG and BP monitoring
Imaging: echo, carotid artery ultrasound

39
Q

What management is done for secondary prevention of a stroke?

A 
Lifestyle modification - diet, smoking etc.
Anticoagulation if thromboembolic stroke
Medication
- antihypertensives if HTN
- anti-platelet (aspirin, clopidogrel)
- statin
40
Q

What is a transient ischaemic attack (TIA)?

A

Sudden onset of focal neurological deficit due to temporary artery occlusion with symptoms lasting <24 hours

41
Q

What is a crescendo TIA?

A

2 or more TIAs within a week - high risk of developing into a stroke

42
Q

What is the presentation of a TIA?

A

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
Q

What assessment is done in TIA?

A

ABCD2 score

44
Q

What is involved in the assessment of TIA?

A

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
Q

What investigations should be done in TIA?

A

Bloods - FBC, U&E, glucose, lipids
ECG, CXR, carotid doppler,
CT brain

46
Q

What is the management for TIA?

A

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
Q

Where can intracranial venous thrombosis occur?

A

Any dural venous sinus - most commonly in sagittal or transverse sinus

48
Q

What are risk factors for intracranial venous thrombosis?

A

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
Q

What is the presentation of intracranial venous thrombosis in the sagittal sinus?

A 
Headache
Vomiting
Seizures
Reduced vision
Papilloedema
50
Q

What is the presentation of intracranial venous thrombosis in the transverse sinus?

A 
Headache
\+/- Mastoid pain
Seizures
Focal signs
Papilloedema
51
Q

What is the presentation of intracranial venous thrombosis in the cavernous sinus?

A 
Ophthalmoplegia
Swollen conjunctiva/eyelids
Proptosis
Photophobia
Fever
Focal/raised ICP symptoms
52
Q

What structures pass through the cavernous sinus?

A

CN III, IV, V1 and V2, VI, internal carotid, sympathetic fibres

53
Q

Where does thrombosis in cavernous sinus usually spread from?

A

Infection from the face

54
Q

What are differential diagnoses for intracranial venous thrombosis?

A

Meningitis
Tumour
Subarachnoid haemorrhage

55
Q

What investigation is done for intracranial venous thrombosis?

A

Bloods
Lumbar puncture
CT/MRI - delta sign in superior sagittal thrombosis

56
Q

What is the management for intracranial venous thrombosis?

A

Anti-coagulation: heparin + warfarin +/- streptokinase

Manage symptoms of raised ICP

57
Q

What are intracranial haemorrhages?

A

Bleeding within the skull

58
Q

What are the subtypes of intracranial haemorrhages?

A

Subarachnoid
Subdural
Extradural
Intracerebral

59
Q

What is a haematoma?

A

Collection of blood within the skull

60
Q

What is a subarachnoid haemorrhage?

A

Spontaneous bleeding into the subarachnoid space from any of the cerebral arteries

61
Q

What are causes of subarachnoid haemorrhage?

A

Arteriovenous malformation

Rupture of Berry aneurysms (most common)

62
Q

What conditions are associated with Berry aneurysms?

A

Polycystic kidney disease
Coarction of the aorta
Ehlers Danlos

63
Q

What are common signs of development of Berry aneurysms?

A

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
Q

What is the presentation of subarachnoid haemorrhage?

A

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
Q

What investigations are done for subarachnoid haemorrhage?

A

CT brain (1st line)
Lumbar puncture if CT negative - positive if Xanthochromatic CSF (yellow)
Angiography to assess vasculature and identify any AVM/aneurysm

66
Q

What is the management of subarachnoid haemorrhage?

A

Maintain cerebral perfusion - induce HTN with IV saline
Nimodipine
Refer to neurosurgery for aneurysm clipping, endovascular coiling

67
Q

What is nimodipine?

A

Calcium channel antagonist that reduces chance of cerebral artery spasm and ischaemia

68
Q

What are possible complications of subarachnoid haemorrhage?

A

Re-bleeding (50% chance in first 6 months)
Delayed ischaemic neurological deficits
Hydrocephalus
Hyponatraemia

69
Q

How can delayed ischaemic neurological deficits be prevented?

A

Nimodipine

Hypertension, hypervolemia, haemodilution

70
Q

Why does hydrocephalus occur in subarachnoid haemorrhage?

A

Due to blockage of the arachnoid granulations with blood

Usually transient and non-symptomatic but will require a shunt if it becomes symptomatic

71
Q

Why does hyponatremia occur in subarachnoid haemorrhage?

A

Develops due to the release of salt wasting compounds from the cerebrum
Common and transient

72
Q

What is the management of hyponatremia as a complications of subarachnoid haemorrhage?

A

Sodium supplements
Fludrocortisone
Not fluid restriction

73
Q

What is a subdural haemorrhage?

A

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
Q

What are risk factors for subdural haemorrhage?

A

Increased age
Alcoholism
Epilepsy
Anti coagulation

75
Q

What are causes of subdural haemorrhage?

A

Trauma, especially deceleration injury

Associated trauma may be minor, with patient often not remembering any distinct event

76
Q

What is the presentation of subdural haemorrhage?

A

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
Q

What investigation is done for subdural haemorrhage?

A

CT brain: crescent shaped haematoma

78
Q

What is the management of subdural haemorrhage?

A 
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
Q

What is an extradural haemorrhage?

A

Arterial bleed from the middle meningeal artery, with blood collecting between the temporal bone and dura

80
Q

What are the causes of an extradural haemorrhage?

A

Temporal bone fracture is most common)

Recent head injury will be apparent

81
Q

What is the presentation of an extradural haemorrhage?

A

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
Q

What investigation is done for extradural haemorrhage?

A

CT brain: lens shaped (biconvex) haematoma

LP is contraindicated due to apparent increased in ICP

83
Q

What is the management of extradural haemorrhage?

A

Surgical: clot evacuation and ligation of middle meningeal artery

84
Q

What is an intracerebral haemorrhage?

A

Bleeding within the brain parenchyma

85
Q

What are the causes of an intracerebral haemorrhage?

A

HTN
Bleeding from tumours
Blood vessel abnormalities: AVM, vasculitis

86
Q

What is the presentation of an intracerebral haemorrhage?

A

Quick onset headache
Focal neurological deficits
Decreased level of consciousness

87
Q

What investigation is done for intracerebral haemorrhage?

A

CT: variable shaped clots within the cerebral cortex
Angiography: to assess the vasculature

88
Q

What is the management of intracerebral haemorrhage?

A

Surgical: clot evacuation
Medical: treat underlying cause

Y3 - Neuro (14 decks)

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