Stroke/TIA Flashcards
What are the dizzy plus syndromes in relation to arterial events?
Superior cerebellar artery occlusion = dizzy. Anterior inferior cerebellar artery = dizzy and deaf. Posterior inferior cerebellar artery = dizzy, dysphagic and dysphonic
What are the signs of a vertebrobasilar circulation occlusion/stroke?
hemianopia, cortical blindness, diplopia, vertigo, nystagmus, ataxia, dysarthria, dyphasia, hemi or quadraplegia, unlateral or bilateral sensory symptoms, hiccups, coma. DANISH - dysdiadokinesis, dysmetria, ataxia (towards side of lesion), nystagmus, intention tremor, slurred speech, hypotonia
What are the signs/symptoms of lateral medullary syndrome? Occlusion of what arteries may cause lateral medullary syndrome?
vertigo, vomiting, dysphagia, ipsilateral ataxia, soft palate paralysis, ipsilateral horner’s syndrome and cross-pattern sensory loss - analgesia to pinprick on ipsilateral face and contralateral trunk and limbs. Occlusion of vertebral artery or posterior inferior cerebellar artery
What are the modifiable risk factors for stroke?
Hypertension, smoking, DM, heart disease (valvular, ischaemic, AF), peripheral vascular disease, past TIA, raised PCV, carotid bruit, the Pill, raised lipids, high alcohol use, raised clotting, increased homocysteine, syphilis
What are the signs of stroke?
sudden onset, with potential progression over hours
focal signs of infarct area
suggests bleeding - meningism, severe headache and coma within hours
suggests ischaemia - carotid bruit, AF, past TIA, IHD
What are the signs of a cerebral infarct?
contralateral hemiplegia - initially flaccid then becomes spastic Contralateral sensory loss dysphasia homonymous hemianopia visuo-spatial deficit
What are some of the signs of a brainstem infarct?
Quadraplegia
disturbances to gait
disturbances to vision
locked-in syndrome
Where are lacunar infarcts found anatomically? What are the signs of a lacunar infarct?
basal ganglia, internal capsule, thalamus and pons.
Produces 5 syndromes - ataxic hemiparesis, pure motor, pure sensory, sensorimotor and dysarthria/clumsy hand.
Cognition/consciousness intact except thalamic strokes
What are some of the differentials to a diagnosis of stroke?
Head injury, hyper/hypoglycaemia, subdural haemorrhage, intracranial tumours, hemiplegic migraine, Epilepsy (Todd’s palsy), CNS lymphoma, pneumocephalus (air entry), Wernicke’s encephalopathy, Drug overdose, Hepatic encephalopathy, Mitochondrial cytopathies, herpes encephalitis, HIV, HTLV-1, Toxoplasmosis, Abscesses, (extras - mycotic aneurysm, Coccidioides immitis, Acanthamoedba/naegleria)
What should the management be within 1 hour of presentation to hospital?
ABCD:
Protect the airway
pulse, BP and ECG - look for AF, maintain high blood pressures
Blood glucose - aim for 4-11 mmol/L
Urgent CT/MRI - CT to rule out haemorrhage if thrombolysis possible, and in cerebellar stroke (cerebellar haematoma requires urgent evacuation)
Thrombolysis - if symptoms <4.5 hours ago
NBM until swallowing assessment done, hydrate with IVF but beware cerebral oedema risk
Antiplatelet agents - once haemorrhagic stroke excluded, give Aspirin 300mg
Refer to stroke unit urgently
What are the most common causes for a stroke?
Small vessel occlusion cerebral microangiopathy thrombosis in situ cardiac emboli - AF, endocarditis, MI atherothromboembolism - eg from carotids CNS bleeds - HTN, trauma, aneurysm rupture, anticoagulation, thrombolysis
What demographic of patient should the less common causes of stroke be considered? What are some of the other causes?
Younger patients
Sudden BP drop >40mmHg (watershed stroke) carotid artery dissection vasculitis subarachnoid haemorrhage venous sinus thrombosis antiphospholipid syndrome thrombophilia Fabry's disease CADASIL/CARASIL
What is the primary prevention’s used for stroke?
look for and control: HTN, DM, hyperlipidaemia and cardiac disease. Smoking cessation
Increase exercise - increased HDL’s and increased glucose tolerance
Lifelong anticoagulation if rheumatic or prosthetic heart valve
What is the secondary prevention’s used for stroke?
controlling risk factors as for primary prevention
Antiplatelet agents - clopidogrel monotherapy
Anticoagulation - start warfarin if indicated (non-valvular AF or ischaemic stroke, prosthetic valves, acute MI) 2 weeks after the stroke (if clinically and radiologically small then 7-10 days)
What is the CHA2DS2-Vasc score?
Represents the risk of stroke in the next year in a patient with a diagnosis of AF
C - congestive heart failure H - hypertension A2 - age >75 = 2 D - diabetes mellitus S2 - stroke/tia/thrombo-embolism = 2 V - vascular disease A - age 65-74 Sc - sex category female
What is the HASBLED score?
assesses 1 year risk of major bleeding in patients taking anticoagulants with AF
H - hypertension A - abnormal liver function A - abnormal renal function S - stroke B - bleeding L - labile INRs E - elderly >65yrs D - drugs A - alcohol
What are some of the complications of a stroke?
aspiration pneumonia pressure sores contractures depression stress in spouse
What is the definition of a TIA?
sudden onset of focal CNS phenomena due to temporary occlusion of part of the cerebral circulation with symptoms resolving within 24 hours of onset.
What are the signs of a TIA?
attacks can be single or many. They should mimic strokes of the same arterial territory.
Global event (dizziness, syncope) are not typical of TIAs
Multiple highly stereotyped attacks suggests critical intracranial stenosis
Can present as amaurosis fugas= (one eye’s vision progressively lost like a curtain descending)
What are the common causes of TIA?
atherothromboembolism from the carotid if most common
Cardioembolism - mural thrombus post-MI or in AF, valve disease or prosthetic valve
Hyperviscosity - polycythaemia, sickle-cell anaemia, leukostasis (very high WCC), myeloma
Vasculitis is a rare cause - cranial arteritis, PAN, SLE, syphilis
What is the differential diagnosis to a TIA?
hypoglycaemia
migraine aura - symptoms spread and intensify over minutes, often with visual scintillations
focal epilepsy - symptoms spread over seconds and often include twitching and jerking
hyperventilation
retinal b leeds
Rare mimics: malignant hypertension, MS (paroxysmal dysarthia), intracranial tumours, peripheral neuropathy, phaeochromocytoma, somatization
What is the treatment for TIA?
control CV risk factors: HTN (cautiously lowe BP, aim for <140/85), hyperlipidaemia, DM, smoking cessation
Antiplatelet drugs: clopidogrel 75mg/d
warfarin indications: cardiac emboli
carotid endarterectomy: if >70% stenosis
What are the rules regarding driving after a TIA?
avoid for 1 month and inform the DVLA only if multiple attacks in a short period or residual deficit
What is the score used to determine the risk of stroke following a TIA?
ABCD2 which predicts the short-term risk of a stroke after TIA (up to 90 days, but optimised for 2 days post TIA)
A: age >60
B: BP>140/90
C: clinical features - unilateral weakness = 2, speech disturbance w/o weakness = 1
D: duration of symptoms - >1h = 2, 10-59mins = 1
D: diabetes
