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Neuro > Stroke + TIA > Flashcards

Stroke + TIA Flashcards

1
Q

What are generalised causes of interrupted O2 supply

A

Low O2 in blood
Inability to use O2
Inadequate supply of blood

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2
Q

What causes low O2 in blood

A

CO poisoning
Drowning
Respiratory arrest

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3
Q

What causes Inability to use O2

A

Cyanide poisoning

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4
Q

What causes inadequate blood supply

A

MI

Hypotension

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5
Q

What causes a zonal / watershed patter of infarction

A

Hypotension
Central arteries will be perfused
Other areas poorly perfused

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6
Q

What causes cortical necrosis

A

MI

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7
Q

What causes localised / focal interruption to 02 supply

A

Atheroma
Thromboembolism
Ruptured aneursym
Arterial dissection / venous sinus thrombosis = rare

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8
Q

What is a stroke

A

Focal neuro deficit of sudden onset due to disruption of blood supply to the brain
>24 hours
Causes infarction as brain = aerobic metabolism

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9
Q

What are two types of stroke

A

Ischaemic (85%)
Haemorrhagic
- ICH = most common
- SAH can cause 5%

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10
Q

ANATOMY OF CIRCULATION

A 
ICA 
Gives of Retinal 
Then ACA then MCA
MCA most affected atherosclerosis 
Retinal if embolic 
2 vertebral arteries (posterior brain) 
Give of basilar and cerebellar
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11
Q

What causes ischaemic stroke

A

Large atherothromboembolism or small vessel
Cardioembolic - AF / IE / MI

Rare
Carotid dissection / trauma 
Venous sinus thrombosis
Hypercoagulable state
Sickle cell
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12
Q

What causes haemorrhage stroke

A 
HYPERRTENSION 
Ruptured aneurysm 
Vessel spasm
AV malformation 
Tumour 
Anti-coagulation / thrombolysis
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13
Q

What are causes of stroke in the young

A 
Carotid artery dissection = always consider 
Vasculitis
SAH
Venous sinus thrombosis 
Anti-phospholipid syndrome
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14
Q

DDX of stroke

A 
Head injury
Severe migraine 
Hypo or hyperglycaemia - always exclude 
Metabolic - hyponatraemia 
Facial nerve palsy 
Subdural
Tumour 
Weirnecke's encephalopathy
Hepatic encephalopathy
Encephalitis
Abscess
Drug overdose
Vestibular disorder
Transient global amnesia
Demyelination
Neuropathy 
Functional Sx
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15
Q

What are RF for ischaemic stroke

A 
Age
Male
Hypertension = most important modifiable RF
Previous stroke or TIA 
Smoking
High cholesterol
DM 
Hypercoagulable 
Vasculitis 
OCP
FH
Alcohol 
Obesity 
Poor cardiac / established CVD disease 
AF for cardioembolic
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16
Q

What are RF for haemorrhagic stroke

A 
Age
Hypertension
AV malformation
Anti-coagulant
Thrombolysis
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17
Q

Atheroma RF

A

High BP
High cholesterol
Smoking
DM

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18
Q

What causes thrombosis

A

Change in vessel wall
Change in blood constituents
Stasis of blood flow

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19
Q

RF for AF

A 
P - pulmonary disease / pheochromocytoma 
I - IHD
R - rheumatic fever / MS / MR
A - anaemia / age
T - thyrotoxicosis
E - elevated BP / ethanol
S - sepsis / sleep apnoea
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20
Q

When are signs of stroke worse

A

At onset

Then begin to improve

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21
Q

What investigations do you do in all patients presenting with stroke to ED

A

Vitals inc BP (often high)
Neuro exam
Bloods
ECG
CXR
Non-contrast CT = 1st line imaging to exclude haemorrhage ASAP
MRI = better at showing infant (but not in 1st stages)

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22
Q

What bloods

A

FBC, U+E, LFT, lipids, glucose, ESR, coagulation

Preg test, LFT and toxicology in selected patient

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23
Q

Why do you do ECG

A

Look for AF / ischaemic changes

If AF - may want to do ECHO

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24
Q

Why do you do imaging and when

A 
EXLUDE BLEED
To see if suitable for thrombolysis
CT if 
- Thrombolysis indicated
- On anti-coagulant
- Bleeding tendency
- GCS <13
- Unexplained progressive / fluctuating symptoms 
- Papilloedema / stiff neck / fever 
- Severe headache at onset
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25
Q

What is FAST

A 
Face
Arms / legs - loss of power./ sensation
Speech - lost / disturbed 
Loss of vision 
Loss of coordination / balance
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26
Q

What are common visual problems in stroke

A

Hemianopia or diplopia
If whole eye affected tends to be retinal problem
Vertical nystagmus if cerebellar

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27
Q

What score is used for assessment

A

ROSIER

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28
Q

What must you do before ROSIER

A

Exclude hypoglycaemia

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29
Q

What does ROSIER Include

A
  • ve 1
  • LOC
  • Seizure at onset
  • Syncope

+1

  • Asymmetric arm weakness
  • Asymmetric leg weakness
  • Speech disturbance
  • Visual field defect
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30
Q

When is a stroke likely

A

If >0

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31
Q

What do you do if patient presents 6 weeks after event

A 
Carotid doppler of both carotids 
Put on secondary prevention
Endarectomy if >70% stenosis 
If 100% then no chance of emboli
Can do CTA or MRA to look for aneurysm
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32
Q

What are the guidelines for TIA / non-disabling stroke

A

BMT

Carotid imaging within 1 week

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33
Q

If not significant stenosis

A

Continue BMT

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34
Q

If significant >70% + symptomatic (TIA / stroke / amuorosis fujax)

A

Refer for endarectomy
If no operation 1 in 5 = stroke
1 in 100 chance if operation

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35
Q

What other tests can be done after stroke to look for cause

A 
Carotid dopper = 1st line 
CXR
24 hour ECG to look for AF
ECHO
Hyper-coagulable blood screen
Cerebral angiogram
36
Q

What is the immediate Rx of stroke

A

ABCDE management
- Dehydration common and should be treated with bolus
- Avoid overload as will exacerbate cerebral oedema
Immediate CT to exclude haemorrhage
Aspirin 300mg once haemorrhagic excluded with CT (withhold if getting thrombosis)
Continue anti-platelet
Maintain BP, fluid, O2 and temp
Only treat BP if hypertensive emergency as may impair perfusion e.g. encephalopathy, MI or dissection, PET or thrombolysis - want <185 as may impair perfusion or haemorrhage with BP >200
Protect airway as risk of hypoxia + aspiration
Avoid hyperglycaemia as poor prognosis
Screen swallow - NBM till assessed
Involve stroke team = very important

37
Q

What is 1st line in ischaemic stroke

A

Thromboylsis + Thrombectomy If within 4.5 hours

38
Q

When do you do thrombosis

A

If admitted within 4.5 hours of ischaemic stroke
Must do CT first to exclude haemorrhage
If >4.5 = stroke team as tissue dead

39
Q

What is 1st line thrombosis agent

A

Alteplase (tisse plasminogen activator which breaks down plasminogen to plasmin which breaks down clot)

40
Q

What do you do post thromboylsis

A

CT to look for bleed

41
Q

When can you offer thrombectomy

A

If within 6 hours
Confirmed anterior circulation stroke by CTA or MRA
Possibly if posterior
Can extend 6-24 hours if imaging shows can salvage tissue

42
Q

What are absolute CI to thrombolysis

A 
Symptoms improving 
Symptoms >4.5 hours 
Haemorrhage on brain imaging 
Previous ICH
Seizure at onset
Intracranial neoplasm
Minor neuro deficit or rapid improvement e.g TIA
Prior stroke or traumatic brain injury within 3 months
Symptoms suggesting SAH even if CT normal
LP within 7 days
Active bleeding
Varices
GI haemorrhage within 3 week
Pregnancy
Uncontrolled BP >185 
Platelet <100
INR >
Blood glucose <50 or >400
43
Q

What are relative CI

A 
Patient on anti-coagulant - Warfarin / heparin
Bleeding disorder
Low platelet
Low or high BG
<16 or >80
44
Q

What is given as secondary prevention after stroke

A 
Aspirin 300mg for 2 weeks 
Then start anti-platlet 
Carotid endarectomy >70% stenosis
Anti-hypertensive
Statin if cholesterol
45
Q

What is 1st line anti-platelet

A

Clopidogrel (ADP antagonist)

46
Q

What is given if clopidogrel CI

A

Aspirin (thoromboxane A2 inhibitor) high dose +

Dipyramidole inhibitor

47
Q

What do you do if AF post stroke

A

DO NOT restart anti-coagulation until CT excluded haemorrhagic and 14+ days since ischaemic
Warfarin or DOAC

48
Q

Do you go on anti-platelet if on anti-coagulant

A

No

Only if needed for other co-morbid

49
Q

What do you do for haemorrhagic stroke

A

Neurosurgeon
Craniotomy to give space
Stop and reverse anti-coagulant
Lower BP

50
Q

What is the Oxford classification of stroke

A 
Assess for initial signs of 
Unilateral hemiparesis 
Unilateral sensory loss
Of face / arm or leg 
Homonymous hemianopia
Higher cognitive dysfunction e.g. dysphasia
51
Q

What are the types of stroke

A

TACS - total anterior
PACS - partial anterior
LACS - lacunar
POCS - posterior

52
Q

What artery affected in TACS

A

MCA and ACA

53
Q

What part of criteria fulfilled

A 
ALL 4
Motor loss in 2 / 3
Sensory loss 
Must have hemianopia 
\+ cognition - dysphagia / neglect
NO BRAIN STEM
54
Q

What artery affects in PACS

A

Smaller arteries of anterior circulation / MCA

55
Q

What part of criteria filled

A 
At least 2+ 
Motor loss
Sensory loss 
One of hemianopia or cognition - dysphasia / neglect
No brain stem
56
Q

What artery affected in lacunar

A

Arteries around basal ganglia / thalamus

57
Q

What criteria fulfilled

A

1+ of
Motor / sensory loss
Can be pure sensory
Ataxia hemiparesis

NO hemianopia / dysphasia / neglect or brains stem

58
Q

What arteries in posterior stroke

A

Vertebrobasillar

59
Q

What part of criteria filled

A

1+ of cerebellar or brain stem Sx
Motor loss
Sensory loss
Hemianopia +- dysphasia + -neglect

60
Q

What is a TIA

A

Ischaemic stroke <24 hours
New definition = tissue based
Due to reversible ischaemia so not permanent
NO INFARCTION

61
Q

What causes TIA

A

Main causes
Atherothrombembolism
Cardiombolism post MI / AF

Other 
Dissection
Hyperviscosity e.g. polycytheaemia / myeloma 
Sickle cell
Vasculitis
62
Q

What is the DDx

A

Hypoglycaemia
Migraine + aura
Focal epilepsy
Retinal bleed

63
Q

What does crescendo TIA suggest

A

Critical stenosis of artery

64
Q

What do you do if suspected TIA

A 
Neuro exam
Vital signs
FBC, ESR, U+E, glucose, lipids
Imaging to exclude haemorrhage
- MRI better for TIA - images posterior better and acute ischaemia
65
Q

What do you do for cause

A

CXR
ECG
ECHO
Hyper-coagulbale screen

66
Q

What are the guidelines TIA / non-disabling stroke

A

Same

67
Q

What do you do if suspected TIA

A

Aspirin 300mg unless CI
- Anti-coagulant
- Bleeding disorder
- Already on aspirin 75mg - continue until review
Risk of stroke = highest first 48 Horus
Admit for CT and to exclude haemorrhage if on anti-coagulant
Stroke specialist within 24 hours

68
Q

If TIA suspected within last 7 days

A

Urgent assessment within 24 hours

Give aspirin 300mg if symptoms fully resolved

69
Q

If >7

A

Still refer within 7 days

70
Q

If 1+ or severe stenosis

A

Discuss need for admission with specialist as crescendo

71
Q

What do you post

A

Control CVS RF - BP / cholesterol / DM / smoking
Same as stroke
Aspirin 300mg 2 weeks - If already on non benefit
Clopidogrel 75mg
Control BP
Anti-coagulant if suspect AF
Perform ABCD2 score

72
Q

What does TIA suggest

A

Increased risk of stroke

73
Q

What is important to remember for stroke

A 
Rapid onset
Depends on part of brain affected
Abnormal movement unusual
\+ve visual Sx more likely to be migraine
Severe headache is unusual
74
Q

If a stroke in <55 what investigations for cause

A

Thrombophilia and autoimmune screen
MRI outpatient
Holter for AF

75
Q

What score is used in TIA to estimate risk of stroke

A 
ABCD2
Age >60
BP >140/90
Clinical features
Duration
DM

If score >4 = aspirin 300mg + specialist within 24 Horus

76
Q

What do you give with Aspirin

A

PPI if indicated

77
Q

How may carotid stenosis present

A

Carotid bruit
1st line = doppler USS in all patients with TIA
If >70% stenosis = endarectomy within 7 days unilateral unless both >70%

78
Q

What is a penumbra

A

Area around infarcted tissue which is hypo-perfused

May be saved if reperfused

79
Q

Common cause of stroke in the young

A

Carotid artery dissection

80
Q

What is known precipitating factor

A

Head or neck trauma

Aneurysm / HTN and atherosclerosis also indicated but consider dissection if no known CVS RF

81
Q

How does it present

A

Ipsilateral headache
Face or neck pain
Horner’s
25% can have neck pain alone - sudden severe and persistent

82
Q

How do you Dx

A

CTA OR MRA

83
Q

How do you Rx

A

Usually resolves

84
Q

If posterior bleed noticed on CT what is needed

A

Neurosurgery

85
Q

Why can posterior strokes be difficult to Dx

A

Similar to benign
BPPV
Labrynthitis

86
Q

What are important symptoms to distinguish

A

Vertical nystagmus
Vomiting
Diplopia

87
Q

Who always gets a CT gif TIA

A

If on anti-coagulant to exclude haemorrhage

Neuro (19 decks)

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