Strokes for finals folks Flashcards
Stroke Station
Unilateral motor loss of the face, arms or legs
Same half visual loss in both eyes
Partial anterior circulation infarct (PACI)
Two of:
Unilateral motor loss of the face, arms or legs
Same half visual loss in both eyes
Loss of higher functions (eg speech)
One sided facial weakness, homonymous hemianopia and slurred speech
Total anterior circulation stroke
All 3 of:
- One-sided motor +/- sensory loss in face, arms and leg
- Loss of same half of vision in both eyes
- Loss of higher function eg speech
Anterior and middle cerebral arteries
What symptoms indicate a lacunar stroke?
Any of
Pure sensory loss
Unilateral motor +/- sensory loss
Ataxic weakness bilaterally
An isolated homonoymous hemianopia can indicate what kind of stroke? What two other symtpoms does this present with?
Posterior infarct circulation syndrome
- Brainstem syndromes
- Loss of consciousness
- Isolated homonymous hemianopia
Supplied by vertebrobasilar arteries
Stroke by anatomy
Upper > Lower contralateral hemiparesis
+/- sensation loss
Anterior cerebral artery
Stroke by anatomy
Lower > Upper Contralateral weakness
Homonymous hemianopia
Middle Cerebral Artery
Stroke by anatomy
Visual agnosia
Contralateral homonymous hemianopia
Posterior cerebral artery
Stroke by anatomy
Contralateral extremity weakness
Ipsilateral CNIII palsy
Smaller branches of PCA
Known as Weber’s syndrome
Stroke by anatomy
Locked in Syndrome
Basilar arteries
Stroke by anatomy
Pain/temperature loss in limb/torso
IL facial pain + loss
Posterior Inferior Cerebellar Artery
CL Limb/torso pain, temp loss
IL facial pain +/- motor loss
IL deafness on same side as facial pain
Anterior inferior cerebellar artery
PICA + IL facial paralysis and or deafness
How do you investigate a stroke?
1st line: CT to determine if haemorrhagic
GS: Diffusion weighted MRI if unclear
4 hour stroke history without haemorrhage on CT.
Initial treatment?
Definitive treatment?
Alteplase as under 4.5 hours of symptom onset
thrombectomy as within 6 hours (if angiography confirms occlusion of ACA/MRA)
Which ischaemic stroke patients get thrombectomy?
Image confirmation of prox anterior (ACA/MCA) occlusion
Presenting <6 hours of onset
Presenting 6-24 hours onset + imaging evidence of salvageable tissue
When should 300mg aspirin for 14 days be given to stroke patients?
ASAP within 24 hours
BUT AFTER IMAGING + TREATMENT
Which ongoing conditions contraindicate thrombolysis in stroke?
Current: Pregnancy, oesophageal varices, uncontrolled HTN (>200/100), seizure at stroke start, IC neoplasm
What contraindicates a stroke if it occured in the past 7 days?
7 days: Lumbar puncture
When is a GI bleed a contraindication to thrombolysis?
3 weeks: GI bleeding
When is a previous stroke/TBI contraindication to thrombolysis?
3 months: Stroke/TBI
What is a contraindication to thrombolysis regardless of when it happened?
At any point: Previous IC haemorrhage
What does secondary stroke prevention entail?
HALTSS
Hypertension: Control 2 weeks post stroke
Antiplatelets: 75mg clopidogrel daily 2 weeks post stroke
Lipids: Atorvostatin 20-80mg once nightly
Tobacco: Cessation
Sugar: Diabetic screening and management
Surgery: >50% stenosis in ipsilateral carotid artery stenosis
What antiplatelet options are there for stroke if clopidogrel cannot be taken?
Aspirin + MR dipyridamole
MR dipyridamole alone if aspirin not tolerated
What are the domains of the NIHSS
- Loss of consciousness
- Gaze
- Visual fields
- Facial palsy
- Motor arm
- Motor leg
- Limb ataxia
- Sensory
- Language
- Dysarthria
- Extinction/inattention
What are the LOC questions in NIHSS
**Alertness **(spontaneous / minor stimuli / major stimuli / flaccid)
Month and age (both / one / none)
Open and close eyes, grip and release hand (both / one / none)
**
How to assess gaze in NIHSS
Ask for eyes to follow through horizontal plane
Occulocephalic reflexes can alternatively be used
0 - normal
1 - Gaze abnormal but no forced deviation or paralysis
2 - Gaze paralysis not overcome by oculocephalic manouvre
How to assess visual fields
Check quadrants as per usual cranial nerve exam
0 - No visual loss
1- Partial hemianopia
2 - Complete hemianopia
3 - bilateral hemianopia
How to assess facial paralysis
Raise eyebrows, show teeth
0 - normal
1 - flattened folds, smile assymetry)
2 - significant lower facial paralysis
3 - total paralysis of one/both sides
How to assess motor arm
Extend arms palm down at 90 deg (sitting) / 45 deg (lying) and hold for 10s, starting with non-paretic arm
0 - no drift
1 - drift but doesnt hit bed
2 - drifts to bed but some effort against gravity
3 - No effort against gravity (movement at shoulder)
4 - No movement
Motor leg
Hold leg at 30 deg while supine for 5s
0 - Holds for full 5 secs
1 - Falls to bed within 5 seconds
2 - Falls to bed immediately
3 - No movement
How to test limb ataxia
finger-nose and heel shin test
0 - No ataxia
1 - in one limb
2 - in two limbs
How to test sensation
Recall of R and L pin prick sensation / grimace to noxious stimuli
0 - No sensory loss
1 - dulling of sensation
2 - unaware of sensation
How to test language
Describe events in picture, name items, read list of sentences
0 - No aphasia
1 - Some loss of fluency and /or comprehension
2 - Cannot identify pictures (but can point to pictures)
3 - No usable speech
Score what you see not what you think the patient can do
Dysarthria
Read, repeat words from a list
0 - normal articulation
1 - slurring but understandable with some difficulty
2 - Mute / unintelligible
Extinction / inattention
Check vision and sensation bilaterally
0 - no abnormality
1 - inattention, extinction to one sensory modality
2 - profound hemi-inattention / inattention in >1 modality
