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Neurology > Stroke/TIA > Flashcards

Stroke/TIA Flashcards

1
Q

ANTERIOR stroke syndromes:

A

MCA
Contralateral:
HEMIPLEGIA: ARMS> legs
LOWER face
Hemisensory loss
Homonymous hemianopia
Dysphasia/ aphasia (DOM SIDE L)
Hemi Neglect (NON DOM R)

ACA
Also contralat hemisensory/hemiplegia, but:
LEGS > arms
Frontal functions (executive, personality)
Urinary incontinence + perineum

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2
Q

POSTERIOR STROKE syndromes:

A

1- CEREBELLAR stroke
- Ataxia
- Vertigo
- Nystagmus (direction-changing)
- Dysarthria
- Rebound (slip out of grip)
- DDK
- Dysmetria

2- PCA/ OCCIPITAL stroke
- Homonymous hemianopia (contra)
- Contralateral homonymous hemianopia with MACULAR SPARING
- Visual agnosia
- Facial blindness

3- BRAINSTEM stroke
- CROSSED signs- cranial nerves one side, motor/sensory the other
- Decerebrate
*PICA stroke (Wallenberg)

4- BASILAR stroke
- LOC (RAS)
- Locked-in (pons)

4- THALAMIC stroke
- Many!

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3
Q

Wallenberg Syndrome:

A

Lateral medullary syndrome (PICA)
CN 9-12

Ataxia (fall to side of lesion), vertigo
Dysphagia (gag loss, hoarse)
Ipsi Horner’s
Ipsi pain/ temp loss to FACE
+ CONTRAlat pain/temp loss to BODY

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4
Q

What is a ‘lacunar’ stroke?

A

Small perforating vessels
Affects small areas, deep in brain
Clinically subtle
Associated with chronic HTN

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5
Q

What features suggest POSTERIOR STROKE over peripheral cause of vertigo:

A

More gradual onset
Vertigo milder
N&V rare
Unaffected by movement/ position
Ataxia/ trunkal instability prominent
No ear symptoms
Other brainstem or cerebellar signs
Stroke RFs/ older

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6
Q

HINTS exam:

A

Indicated when persistent acute vestibular syndrome indicate ?central cause:

HEAD IMPULSE
Normal person/ Central has VO reflex: can stay fixed on nose.
- Peripheral: Abnormal corrective saccade as VO gone
- Central: VO unaffected. As per normal person.

NYSTAGMUS
- Peripheral: Horizontal, unidirectional
TOWARD affected side.
- Central: Pure torsional, Pure vertical, Bidirectional

TEST of SKEW
- Peripheral: stays focused
- Central: vertical correction

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7
Q

ROSIER scale

A

Recognition of Stroke in the Emergency Room.
>0 = stroke likely
0 = stroke unlikely

Widely recommended

Only one validated for this purpose

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8
Q

APPROACH to acute stroke:

A
  • CODE stroke
  • Rapidly assess:
    –> ?last seen normal
    –> Contraindications to lysis
    –> BSL + bloods
    –> CONSIDER ?DISSECTION + mimics
    –> ECG
  • Immediate neuroimaging
    –> Ideal: CT series incl. perfusion scan
    –> Other: Thin-slice CT, MRI.
  • NIHSS score
  • If not a lysis candidate: antiplatelet load, medical Mx incl. BP <220/120, +/- thrombectomy/ catheter-directed thrombolysis.
  • If for lysis: ensure BP <185/110, withhold AP, lyse.

Ongoing Mx:
- NBM + NGT
- Neuroprotective
- Stroke unit

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9
Q

What NIHSS scores preclude thrombolysis?

A

<5
>25

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10
Q

Time windows for reperfusion in acute ischaemic stroke:

A

Thombolysis
Was 3 - 4.5 hours since last seen normal(ECASS-II)
(up to 9 hours if favourable perfusion scan)

Thrombectomy
6 hours
(Up to 24 if significant penumbra)

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11
Q

Indications for thrombolysis in stroke:

A
  • 18 years +
  • Diagnosis of ischaemic stroke
  • Symptoms deemed ‘disabling’
  • NIHSS not <4, not >25
  • Will get lysis within 3 (to 4.5 ECAS-III) hours of symptom onset
  • If unknown onset (ie. woke): perfusion showing <1/3 MCA territory + penumbra (and liaison with Stroke physician) and will let lysis within 4.5 hours of recognition
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12
Q

ABSOLUTE CONTRAindications to lysis in stroke:

A

Stroke too severe (NIHS <4) or too mild (>25)
CVA in last 3/12
Spontaneous ICH ever
AVM/ mets
Significant trauma
Dissection
Active bleeding

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13
Q

RELATIVE CONTRAindications to lysis in stroke:

A

Pregnancy
CPR >10mins
Anticoagulated
SBP >180
Major surgery < 3/52
Isch CVA >3/12 ago
GI bleed incl PUD
Non-compressible vascular puncture

SEIZURE” Todd’s paresis may overestimate deficit…

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14
Q

ACEM’s position on thrombolysis:

A

ACEM worried evidence wasn’t solid, so ran an independent review.

Outcome:
- No mortality benefit
- Potential functional benefit
- NNT/ NNH not great.
…always discuss above with patient.

Not clear if best.

Lysis only if:
- Access to Stroke Team (incl. telemed)
- Streamlined prehosp/ED/allied response
- Immediate imaging/ interpretation
- Data collection

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15
Q

Numbers needed to treat/harm for thrombolysis in acute ischaemic stroke:

A

NNT for functional independence: 10-13 (12)
NNH for symptomatic ICH: 42
NNH for death: 122

No mortality benefit, only functional.

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16
Q

Thombolysis dosing in acute ischaemic stroke:

A

Alteplase

0.9mg/kg (max 90mg) IV
10% as bolus, rest over 1 hour

17
Q

Blood pressure targets in acute stroke:

A

Ischaemic:
<220/120
<185/110 pre and post lysis

Haemorrrhagic:
<140/90

18
Q

Thrombectomy in acute ischaemic stroke:

A

Less effective than lysis

Option for LARGE vessel occlusion only (MCA, ICA, basilar)

Do within 6 hours (up to 24 if favourable penumbra)

19
Q

Antiplatelet/ anticoagulation in ischaemic stroke/ TIA:

A

ALL should get an antiplatelet load initially, as soon as ICH/ SOL ruled out,
except if for lysis.

No antiplatelet within 24/24 of lysis

Ongoing:
–> Aspirin/dypyridamole 25/200 BD
OR
–> Clopidogrel 175mg daily
- Aspirin alone is inferior

AntiCOAGULATE only if:
- non-endocarditis cardioembolic source (not ED decision)

20
Q

Discuss CT in acute stroke:

A
  • Fast initial test to rule out ICH/SOL to guide rapid Tx decisions
  • MAY see ‘hyperdense MCA sign’ if lucky.
  • Most nc-CTB will be normal in first 24+ hours of ischaemic stroke
  • Thin-slice ideal
  • Even better is stroke series:
    –> Thin slice CT (ICH/ SOL)
    –> CTA from arch (clot location/ size)
    –> Perfusion (penumbra)
21
Q
A

Hyperdense artery (MCA) sign

Not seen often (30%), but very specific for isch. stroke.

More likely to see if thin slice CT (or CTA)

22
Q

Other imaging options in acute stroke:

A

CTA alone
–> Primarily for Dx location/cause in an ICH seen on nc-CTB

MRI
–> Definitive for ischaemic stroke (DWI image)
–> Just as accurate for ICH/isch
–> Can combine with MRA
—> Not appropriate in acute code stroke

Angiography
–> Can do thrombectomy
–> If CTA/MRA equivocal/ vascular lesion seen/ suspected

________
- Acute stroke (within 4.5 hrs) = stroke series incl. CT perfusion
- ‘Missed’ stroke (longer) = MRI (DWI)
- CTA not enough!!!!

23
Q

Causes of stroke to consider in young adults with stroke:

A

Dissection (20%)
Substances (amphetamine, cocaine, LSD
Cardioembolic (HOCM, dilated CM, RHD, endocarditis)
Air embolism (diving)
Migrainous/ OCP

Underlying: Ca, procoag

24
Q

Stroke mimics:

A

Focal seizure/ post-ichtal/ Todd’s paresis
Hemiplegic migraine
Encephalopathy
SOL
MS exacerbation

Toxic (antiepileptics)

Functional/ facticious

Hypoglycaemia, hypoNa

DISSECTION (DON’T LYSE THIS!!)

25
Q

What is the risk of a stroke following a TIA episode?

A

HIGH

10-20% will stroke within 3 months
*HALF of these will be within 40 hours

Aggressive TIA Mx reduces risk by 80%

26
Q

What features in a TIA presentation infer HIGH risk of subsequent stroke:

A
  • Crescendo Sx
  • AF
  • Bruit
  • Anticoagulated
  • ABCD2 score >4
27
Q

APPROACH to TIA

A
  • ECG on presentation (?AF)
  • Immediate rule out of ICH/SOL
    –> MRIB best
    –> CTB non con at minimum (CTA at RHH)
  • Antiplatelet load

Timing of complete work up depends on risk:
- ‘High risk’* or ABCD2 4+ = admit Stroke Unit for WU
- ABCD2 <4 = can DC, WU within 48 hours

COMPLETE WORK UP
- MRIB (if not already)
- Carotid imaging (anterior Sx)
–> Doppler, CTA, MRA
- Echo (if cardioembolic suspected)
- Secondary RFs
–> HTN, BSL, lipids,+- Holter

On DC:
- Antiplatelet and statin for all (regardless of lipid profile)
- Consider anticoag instead if cardio source (NOT endocarditis)

DEFINITIVE
- Endarterectomy if carotid stenosis >50%
- Medical Mx only if <, or posterior

28
Q

ABCD2 score. List components, and describe use:

A
  • Risk of stroke in TIA at 2, 7 and 90 days
  • Risk stratify for disposition
  • If 4+, admit to stroke unit for work up. If less than 4, can go home and complete work up within 48 hours.
29
Q

Indications for carotid endarterectomy:

A

Stenosis >50%

30
Q

What is RIND?

A

‘Reversible Ischaemic Neurological Deficit’- Like a prolonged TIA!

Lasts >24 hours and has resolved by 1 week

31
Q

Is neglect a dominant or non-dominant hemisphere problem?

A

Non-dominant

32
Q

Is aphasia a dominant or non-dominant hemisphere problem?

A

Dominant

Neurology (7 decks)

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