Strokes Flashcards
Nausea + Vomiting
Headache
Seizures
Hemiplegia
Intracranial venous thrombosis
- Saggital sinus
Nausea + Vomiting Headache Periorbital oedema Opthalmoplegia Trigeminal Involvement
Intracranial venous thrombosis
- Cavernous sinus
Nausea + Vomiting
Headache
CN VI, VII palsies
Intracranial venous thrombosis
- Lateral sinus
Investigations to diagnose carotid artery stenosis
Duplex US of carotids
Management of carotid artery stenosis
if blockage > 50% = Carotid endarectomy
Stroke mimics
Migraine Post seizure focal deficits Hypoglycaemia Acute SOL presentation Demyelination Bell's Palsy Non-organic (functional)
Types of strokes
Ischaemic (85%)
Haemorrhagic (15%)
Pathophysiology of arteriosclerosis (stroke)
- Thickening of inner wall + central wall of artery
- Artery then calcifies to protect against HTN
- Calcification then crack due to increased BP on exertion and causes a haemorrhage
Causes of haemorrhage strokes
Vessel wall damage (AVAA)
- Arteriosclerosis/HTN (most common)
- Vasculitis
- Aneurysms
- Atriovenous malformations
Transient onset of focal neurological symptoms lasting <24 hours
Transient Ischaemic attack (TIA)
- transient decrease in blood flow to the brain
TIA with visual problems
Anterior TIA
TIA with dizziness
Posterior TIA
> 1 x TIA episode
Crescendo TIA
- Admit ASAP
First investigation of focal neurological symptoms
Capillary blood glucose
- to check for hypoglycaemia
Acute management of TIA
Aspirin 300mg + urgent specialist review
Secondary management (prevention) of TIA
Clopidogrel
or
Aspirin + Dipyridamole
3 features needed to diagnose a stroke
- Acute onset
- Focal signs + symptoms (you can picture what part of brain is affected)
- Disruption of blood supply to brain
1st line investigations for stroke
Non-contrast CT
- To exclude haemorrhage
secondary investigations of stroke
CT/MRI Angiography
Measures disability of daily living in stroke patients
Barthel index
Measures risk of bleeding for patients on anticoagulants
HASBLED
Used to measure requirement for anticoagulation in AF patients
- Risk of stroke in AF patients
CHA2DS2VASc Score
Used to help identify stroke early in Emergency department
ROSIER Score
- stroke is likely is score > 0
Causes of ischaemic stroke
Thrombotic
- thrombosis from large vessels e.g. carotid
Embolic
- blood clot, fat, air, bacteria
Main cause of embolic strokes
AF
Acute management of ischaemic stroke
- Aspirin 300mg (haemorrhage excluded)
< 4.5 hours after onset: Thrombolysis (Alteplase)
< 6 hours after onset: Thrombectomy
Contraindications to thrombolysis
Previous IC Haemorrhage Seizure IC neoplasm SAH Previous brain injury (within 3 months) LP (past week) GI bleed (past 3 weeks) Active bleeding Pregnancy Oesophageal varices HTN (200/120)
Long-term management for ischaemic stroke
- Aspirin (300mg) for 2 weeks
Clopidogrel (75mg)
Statin if cholesterol >3.5mmol/L - Aspiring + dipyridamole
(instead of clopidogrel)
Anti-coagulants are used for
Venous clots
Anti-platelets are used for
Arterial clots
3 examples of anticoagulants
Warfarin
Heparin
DOACs
5 examples of anti-platelets
Aspirin Clopidogrel Ticagrelor Prasugrel Dipyridamole
The 3 H’s
Hemiparesis Higher cortical dysfunction - dysphagia - visuospatial neglect Homonymous hemianopia (contralateral)
Total Anterior Circulation Syndrome (TACS)
- 15%
Vessels affected in TACS
Proximal Middle cerebral artery (MCA)
or
Internal Carotid artery (ICA)
1 or 2 of the 3 Hs
Hemiparesis Higher cortical dysfunction - dysphagia - visuospatial neglect Homonymous hemianopia (contralateral)
Partial Anterior Circulation Syndrome (PACS)
- 25%
1 or more of HBC:
Homonymous Hemianopia
Brainstem syndromes
Cerebellar syndromes
Posterior Circulation Syndrome (POCS)
- 25%
Vessels affected in PACS
Middle cerebral artery (MCA)
Vessels affected in POCS
Vertebral artery
Basilar artery
Cerebellar artery
Hemianopia in POCS =
- Posterior cerebral Artery (PCA)
1 of:
Motor loss Sensory loss Sensorimotor loss Ataxic hemiparesis Clumsy hand-dysarthria
Lacunar Syndrome (LACS)
- 25%
- associated with HTN
Vessels affected in LACS
Small penetrating artery occlusion
- lenticulostriate branches of MCA
- supply to brain stem
Used to classify stroke syndromes
Bamford (Oxford) Stroke Classification
Contralateral hemiparesis
Upper > lower
Middle Cerebral artery (MCA)
Contralateral hemiparesis
Lower > upper
Anterior Cerebral artery (ACA)
- Contralateral homonymous hemianopia with macular sparing
- Visual agnosia (can’t name object)
Posterior cerebral artery (PCA)
- Ipsilateral CNIII palsy
- Contralateral weakness of upper + lower extremities
Weber’s syndrome
Vessels affected in Weber’s syndrome
Branches of posterior cerebral artery (PCA) that supply midbrain
Amaurosis fugax is from
Retinal/ ophthalmic artery stroke
Locked in syndrome is caused by
Basilar artery stroke
Ipsilateral facial paralysis + deafness
Lateral Pontine syndrome
Vessels affected in lateral pontine syndrome
Anterior inferior cerebellar artery
- Ipsilateral facial pain + temperature loss
- Contralateral Limb/torso pain + temperature loss
- Ataxia
- Nystagmus
Lateral medullary syndrome
“Wallenberg Syndrome”
Vessels affected in Lateral medullary syndrome / “Wallenberg Syndrome”
Posterior inferior cerebellar artery
Driving: 1 episode of stroke/tia
1 month off
6 weeks off if HGV driver + notify DVLA
Driving: Multiple stroke/tia episodes
3 months off + notify DVLA
Driving: Craniotomy
Pituitary: 6 months off
Meningioma: 1 year off
