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Nervous System > Strokes > Flashcards

Strokes Flashcards

1
Q

Where do the majority of stroke occur?

A

Territories supplied by middle cerebral artery

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2
Q

What occurs when there is an infarct in the vertebral arteries?

A

Infarct in posterior inferior cerebellar artery (PICA - largest branch)

Lateral medullary syndrome (Wallenberg syndrome)

S&S:

  • ipsilateral facial deficit in pain and temperature sensation (spinal trigeminal nucleus lost)
  • ipsilateral cerebellar ataxia and incoordination (inferior cerebellar peduncle)
  • dysarthria/dysphagia/reduced gag reflex (nucleus ambiguous)
  • contralateral deficit in pain and temperature in trunk and limbs (spinothalamic tract)
  • vertigo (vestibular nucleus)
  • ipsilateral Horner’s syndrome
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3
Q

What areas of the brain are supplied by the anterior cerebral artery?

A

Superior and medial parts of frontal lobe

  • prefrontal cortex
  • pre-central gyrus
  • post-central gyrus
  • Broca’s area

Corpus callosum

note: no collateral circulation

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4
Q

What areas of the brain are supplied by the middle cerebral artery?

A

Majority of the lateral surface of cerebral hemisphere (apart from the superior parietal lobe and inferior temporal lobe and occipital lobe)

  • Broca’s area
  • Wernicke’s area
  • pre-central gyrus
  • post-central gyrus

+ internal capsule and basal ganglia

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5
Q

What areas of the brain are supplied by the posterior cerebral artery?

A

Midbrain
Thalamus
Inferior parts of temporal and occipital lobes

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6
Q

What areas of the brain are supplied by the basilar artery?

A

Most of the brainstem

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7
Q

What are the symptoms associated with an infarct in the posterior cerebral artery?

A

Loss of colour vision
Visual agnosia
Visual field disturbances

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8
Q

What is the definition of a stroke?

A

Clinical syndrome of abrupt loss of focal brain function lasting over 24hrs or causing death that is either due to spontaneous haemorrhage into brain substance or inadequate blood supply to a part of the brain

note: includes subarachnoid haemorrhage

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9
Q

What is the definition of a transient ischaemic attack?

A

Sudden onset of focal disturbance of brain function (occasionally global) presumed to be of vascular origin which resolves completely within 24hrs

note: the more time it takes to resolve, the more likely it is to be a stroke
note: 24hrs is a controversial definition

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10
Q

Contrast the incidence of the different types of stroke.

A

80%-85% are cerebral infarcts

10%-15% are intracerebral haemorrhages

5% are subarachnoid haemorrhages

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11
Q

What are the different types of intracerebral haemorrhages?

A

Primary = spontaneous; no structural lesion

Secondary = underlying lesion e.g. tumour, arteriovenous malformation

Haemorrhagic transformation of infarct (extensive infarct —> cerebral oedema —> fragile blood vessels —> haemorrhage)

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12
Q

What is the aetiology of cerebral infarcts?

A
  • large vessel atheroma/embolism
  • cardiac embolism
  • small vessel disease/lacunae
  • non-atheromatous arterial disease (arteritis)
  • blood disorders
  • cryptogenic (10%)
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13
Q

What is the aetiology of intracerebral haemorrhages?

A
  • hypertension microaneurysms/lipophyalinosis (vessel wall thickening and reduced lumen diameter) (40%)
  • aneurysms or arteriovenous malformations (15%)
  • amyloid angiopathy (amyloid deposits in CNS blood vessels) (10%)
  • haemostatic anticoagulant, thrombolytic thrombocytopenia (10%)
  • cocaine or amphetamines
  • tumour
  • venous thrombosis (esp. in diabetes)
  • peri-partum pregnant women
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14
Q

What are the classes within the Oxford Classification of Strokes?

A

Total anterior circulation stroke (TACS)

Partial anterior circulation stroke (PACS)

Lacunar stroke (LACS)

Posterior circulation stroke (POCS)

note: all are strokes due to cerebral infarcts

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15
Q

Outline the incidence, pathophysiology, symptoms, and outcome of total anterior circulation strokes.

A

20% of strokes

Occlusion of internal carotid artery or proximal occlusion of middle cerebral artery

Large volume infarct (superficial and deep territories)

S&S (all 3 req.):

  • contralateral hemiparesis +/- hemianaesthesia
  • contralateral hemianopia
  • higher cerebral dysfunction e.g. dysphasia, dyspraxia

50% die within 1yr

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16
Q

Outline the incidence, pathophysiology, symptoms, and outcome of partial anterior circulation strokes.

A

35% of strokes

Occlusion of a branch of middle cerebral artery

Restricted area of infarct

S&S:

  • 2 of the 3 symptoms seen in TACS (contralateral hemiparesis, contralateral hemianopia, higher cerebral dysfunction) OR
  • restricted motor deficit in face OR arm OR leg only OR
  • isolated cortical signs

High early recurrence rate

17
Q

Outline the incidence, pathophysiology, symptoms, and outcome of lacunar strokes.

A

20% of strokes

Single perforating artery occluded

Affects the basal ganglia or pons

S&S:

  • pure motor OR
  • pure sensory OR
  • sensorimotor
  • ataxic hemiparesis

Silent (therefore underdiagnosed)

18
Q

Outline the incidence, pathophysiology, symptoms, and outcome in posterior circulation strokes.

A

25% of strokes

Affects brainstem, cerebellum, or occipital lobe

Complex presentation

19
Q

Differentiate the symptoms which result from strokes affected the dominant and non-dominant hemispheres.

A

85% of people have left hemisphere as dominant (even in left-handed people)

Dominant cortex affected =

  • dysphagia
  • dysgraphia
  • dyslexia

Non-dominant cortex affected =

  • visual spatial disorder (visual association area affected)
  • neglect (visual association area affected)
20
Q

What are some important considerations when taking a stroke history, and why?

A

Stroke or non-stroke? (different management)

TIA or stroke? (different investigations)

Type of stroke? (location/pathology cause different onset time and neurological symptoms)

Cause of stroke?

Suitable for thrombolysis (time is brain)

21
Q

What are some important red flag symptoms in a stroke history?

A

Bleeding

  • headache
  • seizure

Raised intracranial pressure

  • headache
  • vomiting
  • drowsiness

Aetiology e.g. cardiac symptoms

note: atypical presentations (esp. in elderly) include delirium, confusion, collapse, and incontinence

22
Q

What might be seen on a CT head in a stroke?

A

Infarcts are grey

Blood is white

Oedema is dark grey and causes midline shift

note: if bleeding is in basal ganglia, it is too deep for neurosurgery

23
Q

Give some examples for differential diagnoses for stroke.

A
  • hypoglycaemia = difficulty speaking, floppy one side (symptoms improve when [glucose] increases)
  • migrainous aura
  • epilepsy
  • space occupying lesion
  • demyelinating disorders e.g. MS
  • labyrinthine disorders
  • retinal bleed/infarct
  • peripheral neuropathy
  • myopathies
  • delirium
  • hyperventilation (transient)
  • functional v.s. psychological
24
Q

What are some important signs seen on examination in stroke?

A

Baseline obs:

  • BP
  • pulse rate and rhythm
  • proteinuria/haematuria

?genetic/hereditary:

  • telangiectasia
  • hyperlipidaemia
  • endocarditis/stigmata of vasculitis
  • neoplastic screen

CVS:

  • ?cardiac source of embolism (arrhythmias, valvular defects)
  • ?vascular source of embolism (carotid/renal bruits, peripheral pulses)

Resp:
- dysphagia may lead to aspiration pneumonia

25
Q

What are some important investigations for stroke?

A
  • blood glucose (rule out hypoglycaemia)
  • FBC
  • INR
  • U&Es, LFTs, TFT, lipids (baseline for prescribed drugs e.g. statins)
  • ECG (look for AF which increases risk of mortality)
  • CXR (where indicated)
  • urgent CT head when thrombolysis is an option (look for bleeding which would contra-indicate thrombolysis)
    note: early normal CT does not rule out ischaemic stroke or infarct (just rules out bleeding)

+ MRI brain in certain situations
+ carotid ultrasound (?carotid embolism)
+ echocardiogram (if cause is unknown e.g. patent foramen ovale)
+ 24hr cardiac monitoring (if cause is unknown e.g. arrhythmias)

26
Q

What are some important additional investigations in cryptogenic strokes or in young patients with stroke?

A
  • full coagulation profile (e.g. if unable to conceive)
  • thrombophilia screen (e.g. family history of DVT)
  • antiphospholipid antibodies
  • autoimmune screen
  • fasting plasma homocysteine
  • blood cultures
  • thyroid function
  • syphilis serology
  • HIV serology
27
Q

What is the management for an acute stroke?

A

IV thrombolysis (alteplase) IF:

  • CT has excluded bleeding and established infarct
  • no bleeding risk e.g. not on warfarin
  • any patient within 3hrs, consider anybody
28
Q

What is the outcome of IV thrombolysis in acute stroke?

A

1/3 will improve (of those 1/10 will fully recover)

3% will be worse overall

1/14 will have intracerebral haemorrhage —> 1/20 of those will become worse

29
Q

Give some examples of how to prevent future strokes in stroke patients.

A

Anti-thrombotics

Treat hypertension, hypercholesterolaemia, diabetes

Carotid surgery in carotid stenosis

30
Q

What are the different segments of the internal carotid artery?

A

Bouthillier classification

  • cervical
  • petrous
  • lacerum
  • cavernous
  • opthalmic
  • posterior communicating (lesion causes 3rd nerve palsy)
  • anterior choroidal (supplies posterior limb of internal capsule and optic chiasm; lesion causes visual field disturbances)

Nervous System (16 decks)

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