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MS4 - Geriatrics > Stroke/TIA > Flashcards

Stroke/TIA Flashcards

1
Q

Definition of stroke?

A

Rapid onset, focal neurological deficit due to a vascular lesion lasting >24h

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2
Q

Pathogenesis of stroke

A
  • Infarction due ischaemia (80%)

- intracerebral haemorrhage (20%).

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3
Q

Causes of ischaemic strokes?

A

I. Atheroma- Large (e.g. MCA)
- Small vessel perforators (lacunar)
II. Embolism- Cardiac (30% of strokes):AF, endocarditis, MI - Atherothromboembolism: e.g. from carotids

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4
Q

Causes of haemorrhagic stroke?

A
  • ↑BP
  • Trauma
  • Aneurysm rupture
  • Anticoagulation
  • Thrombolysis
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5
Q

Watershed stroke

A

sudden ↓ in BP (e.g. in sepsis)

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6
Q

Risk factors for stroke?

A
  1. IHD RFs: ↑BP, Smoking, DM, ↑ lipids
  2. Cardiac: AF, valve disease
  3. Peripheral vascular disease4. ↑ PCV/Hct5. OCP
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7
Q

Which ethnicity is more prone to strokes?

A

↑ in Blacks and Asians

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8
Q

Overview of Oxford (/Bamford) classification of stroke?

A
  • Based on clinical localisation of infarct- S=syndrome: prior to imaging- I=infarct: after imaging when atheroembolic infarctconfirmed
    TACS PACS POCS LACS
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9
Q

4 oxford classifications of stroke?

A

TACS- Total Anterior Circulation Stroke
PACS- Partial Anterior Circulation Stroke
POCS- Posterior Circulation Stroke
LACS- Lacunar Stroke

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10
Q

TACS stroke: mortality?

A

Highest mortality (60% @ 1yr) + poor independence

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11
Q

Site of TACS stroke?

A

Large infarct in carotid / MCA, ACA territory

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12
Q

Signs of TACS stroke?

A

All 3 of:

  1. Hemiparesis (contralateral) and/or sensory deficit (≥2 of face, arm and leg)
  2. Homonymous hemianopia (contralateral)
  3. Higher cortical dysfunction
    - Dominant (L usually): dysphasia
    - Non-dominant: hemispatial neglect
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13
Q

PACS stroke site?

A

Carotid / MCA and ACA territory

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14
Q

PACS stroke signs?

A

2/3 of TACS criteria, usually:

  1. Hemiparesis (contralateral) and/or sensory deficit (≥2 of face, arm and leg)
  2. Higher cortical dysfunction
    - Dominant: dysphasia
    - Non-dom: neglect, constructional apraxia
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15
Q

constructional apraxia

A

an inability or difficulty to build, assemble, or draw objects.

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16
Q

Site of POCS stroke?

A

Infarct in vertebrobasilar territory

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17
Q

Signs of POCS stroke?

A

Any of

  1. Cerebellar syndrome (DANISH P)
  2. Brainstem syndrome
  3. Contralateral homonymous hemianopia
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18
Q

Site of LACS stroke?

A
  • basal ganglia
  • internal capsule
  • thalamus
  • pons
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19
Q

Absence of which signs makes the diagnosis LACS stroke more likely?

A

Absence of

  • Higher cortical dysfunction
  • Homonymous hemianopia
  • Drowsiness
  • Brainstem signs
20
Q

Potential syndromes of LACS?

A
  1. Pure motor: posterior limb of internal capsule (Commonest)
  2. Pure sensory: posterior thalamus (VPL)
  3. Mixed sensorimotor: internal capsule
  4. Dysarthria (slurred speech) / clumsy hand
  5. Ataxic hemiparesis: ant. limb of internal capsule- Weakness + dysmetria
21
Q

Dysmetria

A
  • a lack of coordination of movement

- eg dysdiadochokinesis

22
Q

Signs of brainstem infarct?

A

Complex signs depending on relationship of infarct to CN nuclei, long tracts and brainstem connections eg

  • facial weakness with CN7 infarct
  • Nystagmus and vertigo with CN8,
  • Horner’s syndrome with sympathetic fibres infarct
23
Q

Site of lateral medullary syndrome ( Wallenberg Syndrome)

A

PICA or vertebral artery territory

24
Q

Features of lateral medullary syndrome ( Wallenberg Syndrome)

A

DANVAH

  • Dysphagia
  • Ataxia (ipsilateral)
  • Nystagmus (ipsilateral)
  • Vertigo
  • Anaesthesia (Ipsilateral facial numbness, Contralateral pain loss)
  • Horner’s syndrome (ipsilateral)
25
Q

Locked-in Syndrome features?

A

Pt. is aware and cognitively intact but completely paralysed except for the eye muscles.

26
Q

Locked-in Syndrome causes?

A
  • Ventral pons infarction: basilar artery

- Central potine myelinolysis: rapid correction of hyponatraemia

27
Q

Overview of Acute management of stroke?

A
  1. Resus (NBM)
  2. Monitor
  3. Imaging
  4. Medical
  5. Surgery
28
Q

Monitoring of acute stroke?

A
  1. Glucose: 4-11mM: sliding scale if DM2.

BP: <185/110 for thrombolysis(Rx of HTN can → ↓ cerebral perfusion)

29
Q

Imaging of acute stroke?

A

Urgent CT/MRII.
Diffusion-weighted MRI is most sensitive for acute infarctII.
CT will exclude primary haemorrhage

30
Q

Medical management of acute stroke?

A

I. Thrombolysis
II. Aspirin 300mg PO/PR once haemorrhagic stroke excluded ± PPI
(If CI, give Clopidogrel instead)

31
Q

Thrombolysis for stroke?

A
  • Consider if 18-80yrs and <4.5hrs since onset of symptoms
  • Alteplase (rh-tPA)- → ↓ death and dependency
  • CT 24h post-thrombolysis to look for haemorrhage
32
Q

Surgical management for stroke?

A
  • May coil bleeding aneurysms

- Decompressive hemicraniectomy for some forms of MCA infarction.

33
Q

Primary prevention of stroke (before)?

A
  • Control RFs: (HTN, ↑ lipids, DM, smoking, cardiac disease)
  • Consider life-long anticoagulation in AF (use CHADS2) - Carotid endarterectomy if symptomatic with 70% stenosis
  • Exercise
34
Q

Secondary prevention of stroke (after)?

A

I. Start a statin after 48hII. Aspirin / clopi 300mg for 2wks after stroke then either
a. Clopidogrel 75mg OD (preferred option)
b. Aspirin 75mg OD + dipyridamole MR 200mg BD
III. Warfarin instead of aspirin/clopi if Cardioembolic stroke or chronic AFb.
Start from 2wks post-stroke (INR 2-3)
IV. Carotid endarterectomy if good recovery + ipsilat stenosis ≥70%

35
Q

Rehabilitation for stroke?

A

MENDSI.
MDT: SALT (Speech and Lang Therapist) , dietician, OT, PTII.
Eating
a. Screen swallowing: refer to specialist
b. Screen for malnutrition
III. Neurorehab: physio and speech therapy
IV. DVT Prophylaxis
V. Sores: must be avoided @ all costs

36
Q

PACS stroke mortality?

A
  • 20% mortality at 1 year- 33% independent at 1 yr
37
Q

RFs for impaired swallowing

A 
Reduced consciousness
Inability to sit upright/ to hold head upright
Impaired or absent communication
Neglect or visual feed defect
Acute confusion or dementia
Facial weakness
Poor/absent voluntary cough
38
Q

Investigations of swallowing

A
  • gold standard = video fluoroscopy.

- also Fibreoptic Endoscopic examination of the Swallow (FEES).

39
Q

FEES test

A

An ENT endoscope is put through the nose into the upper airway to examine whether food (which can be coloured with blue dye pre-swallowing) is visible where it should not be.

40
Q

Definition of TIA?

A
  • Sudden onset focal neurology lasting 24h due to temporary occlusion of part of the cerebral circulation
  • ~15% of 1st strokes are preceded by TIAs.
41
Q

Causes of TIA?

A

I. Atherothromboembolism from carotids (MAINLY)II. Cardioembolism: post-MI, AF, valve diseaseIII. Hyperviscosity: polycythaemia, SCD, myeloma

42
Q

Investigations for TIA?

A
  • Aim to find cause and define vascular risk
    I. Bloods: FBC, U + Es , ESR glucose, lipids
    II. CXR
    III. ECG
    IV. Echo
    V. Carotid doppler ± angiography
    VI. Consider Diffusion weighted MRI
43
Q

Timing of management of TIA and risk of another stroke?

A
  • Intervention w/i 72hrs → 2% strokes @ 90d - Intervention w/i 3wks → 10% strokes @ 90d
44
Q

Management of TIA?

A

ACAS

  1. Antiplatelet/coagulate:
    - aspirin/clop 300mg/d for 2 wks, then 75mg/d
    - or warfarin if AF, MI
  2. Cadiac RFs control
  3. Assess risk of future stroke (ABCD2 score)
  4. specialist referral
    - ABCD2 ≥4: w/i 24hrs
    - ABCD2 <4: w/i 1wk
45
Q

Prognosis for TIA patients?

A

3x ↑ in mortality cf TIA-free populations

46
Q

ABCD2 score components

A 
Predicts stroke risk following TIA
1. Age≥60
2. BP ≥ 140/90
3. Clinical features 
a. Unilateral weakness (2 points)
b. Speech disturbance w/o weakness
4. Duration
a. ≥ 1h (2 points)
b. 10-59min
5. DM
Max score: 7
47
Q

What is ABCD2 score used for?

A

Predicts stroke risk following TIA

- Score ≥6 = 8% risk w/i 2d, 35% risk w/i 1wk

MS4 - Geriatrics (10 decks)

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