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Neurology > Strokes & haemorrhages > Flashcards

Strokes & haemorrhages Flashcards

1
Q

What is TIA

A

Definition: Acute loss of cerebral/ ocular function with sudden symptoms lasting less than 24 hours mainly due to vascular compromise (atherothromboembolism from an artery)

→Temporary focal cerebral Ischaemia due to lack of oxygen → No Infarction!

→Symptoms maximal at onset and usually last 5-15 minutes

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2
Q

Which artery are most associated with TIA

A

90% - Carotid artery affect
Hemiparesis, hemisensory loss, hemianopic visual loss aphasia, amaruosis fugax
10% - Vertebrobasilar artery

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3
Q

TIA dx

A

1st line - Diffuse weighted CT/MRI
2nd line - carotid doppler US
if + CT Angiography

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4
Q

TIA tx

A

Loading dose of aspirin 300mg + refer to speciallist within 24hrs of onset

Long term
Antiplatelet therapy: aspiring + clopidogrel
+Stating

If artery >70% stenosed - carotid endaarterectomy

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5
Q

What are the different types of strokes / haemorrhages?

A

Stroke:
Ischaemic: Embolism = reduced perfusion= ischaemia and infarction

Haemorrhage = rupture of blood vessel => Infarction

Can also have global ischaemia - whole brain Hypoperfusion ~ MI

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6
Q

STROKE RF

A

Age
IHD
Diabetes
HTN
Smoking
Male
Hyperlipidiemia
PVD
Clotting disorders
vasculitis
alcohol
Vasculities
Infective endocarditis
Carotid bruit

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7
Q

How to investigate a stroke?

A

Clinical recognition: FACT: Face, Arms, Speech, Time
**
1st line - NC-CT - differentiates betweem haemorrhage and infarction
2nd- Diffuse weighted imaging MRI
3rd - CT angiogram if going for thrombectomy (Ischaemic Stroke)**

Other
Bloods - Rule out other causes:
Glucose (Hypoglycemia)
FBC (Polycythemia)
ESR (Vasculitis)
INR (if on warfarin)
ECG - AF /MI

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8
Q

How are stroke classified

A

BAMFORD CLASSIFICATION

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9
Q

How would a stroke present if ACA was affected?

A

+ Gait, Incontinence
Drowsiness (frontal lobe affected)

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10
Q

How would a stroke present if MCA was affected?

A
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11
Q

How would a stroke present if PCA was affected?

A

MOST COMMON PX
visial agnosia - cant interpret visual info
propagnosia - inability to recognise faces

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12
Q

How would a stroke present if
Vertebrobasilar artery was affected?

A

Quadriplegia
Dysarthria & speech impairment
Vertigo, nausea, vomiting
LOC/Drowsiness

If basilar - LOCKED IN SYNDROME

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13
Q

Lacunar Infarction

A

Lacunar infarct - Small perforating artery occlusion supplying subcortical area (internal capsule, basal ganglia, thalamus, pons)

one of:
Hemiplegia
Homoyomous hemianopia
higher cortical dysfunction - dysphagia/negleect/dysarthia

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14
Q

Treating strokes?

A

If stroke is confirmed (CT excludes haemorrhage)

1st - Loading doese of aspiring 300mg aspirin / 2wks then clopidogrel 75 mg life

Definitive TX
within 4.5 hrs of sx - Thrombolysis with Alteplase

Within 6 hours
Thrombectomy with CT angiography

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15
Q

what is an intracerebral heamorahage

A

Sudden bleeding into brain tissue due to rupture of blood vessels, leading to infarction due to O2 deprivation. Pooling of blood increases ICP.

10% of strokes, 50% mortality.
MOST COMMONly due to HTN

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16
Q

What are the causes of an intra-cerebral haemorrhage

A

HTN - causes stiff brittle vessels ; prone to rupture
Secondary to ischaemic stroke, bleeding after reprefusion
vasculitis
Brain tumour

17
Q

Treating intracerbral haemorrhages?

A

Coagulation -
Stop anticoagulants immediately
Reverse with clotting factor replacement if needed (Beriplex + vitamin k if on warfarin)

AGGRESIVE BP control -
<6 hours after onset
Aim to lower below 140 mmHg systolic
(CI - Poorly, Comatosed, early surgery)
Nimodipine - CCB

Reducing ICP - (Cushing’s NX triad)
IV mannitol
Mechanical ventilation if needed

Neurosurgical referral -
Decompressive craniectomy

18
Q

TO NOTE: if stroke was in Left -MCA of right handed patient>

A

Likely to see expressive aphagia, and receptive aphagia
cant speak or understand
this is due to broca’s area and wernicke’s area

In the non-dominant side - hemisensory loss

19
Q

What are the different types of heamorrhages? and what are the global signs?

A

Subarachnoid haemorrhage
Subdural Haemorrhage
Epidural haemorrhage

Global SX: Headache, HTN, Altered mental state (confusin, syncope,seizure), HTN + Focal neruological deficit

20
Q

How would brain haemorrhages appear on a NC-CT?

A

Intra-cerebral haemorrhage - Hyperdense lesion
Subarachnoid haemorrhage - Star Shaped - blood in basal cistern
Subdural haemorrhage - Cresent shaped lesion +/- evidence of midline shift (Hyperdense then hypodense over time)
Epidural haemorrhage -Hyperdense Lens shaped lesion +/- midline shift

21
Q

Features of Subarachnoid haemorrhage?

A

Definition: Spontaneous bleeding between arachnoid and pia mater usually due to rupture of a cerebral aneurysm.
MC - Communicating branches of the circle of Willis.
35-65
Very severe - 50% dead, 50% sever disability
RF - CTD, PKD, Bleeding disorderm coartication of aorta, ^^% berrys aneurysm

22
Q

Pathophsyiology of Subarachnoid haemorrhage

A

Blood loss / hypo perfusion - ischaemia and cell death
Severe Thunderclap Headache

Raised ICP - blood into cranial space (Hydrocephalus)

Blood in SA space:
* Irritates meninges - Meningism (Photophobia, neck stiffness, Kernig’s sign, Brudzinki’s Sign, 3rd nerve palsy - fixed dilated pupil, droopy eyelid)
* Irritates arties - vasopasm - further reducing perfusion

23
Q

SAH IVx and TX

A

CT - Star shape lesion (basal cistern blood infiltration)
Lumbar puncture >12hrs = Xanthocromia
yellow CSF - from broken RBC
MR/CT Angiography - localizes source

TX:
IV mannitol
CCB nimodipine (reduces vasospasm)
Neurosurgery - Endovascular coiling

24
Q

Features of subdural haemorrhage?

A

Definition – Accumulation of blood between the arachnoid and dura mater, usually due to the rupture of a bridiging vein. Can be acute (~big trauma) or chronic (~older patients)
~~ w/ shearing forces - shaken baby syndrome / deceleration injury

Epidemiology + RFs:
More common in elderly and alcoholics (brain atrophy and increased falls)
Most due to trauma
Anticoagulation

25
Q

Pathophsyiology of subdural hematoma?

A

Bleeding from bridging veins into subdural space

=Forms a haemotoma (clot) which stops the bleeding

Weeks/months later the clot autolyses – clot draws water in and expands

Gradual increase in ICP => Midlinee shift + Herniation and coning (Uncal herniation) => Coma + Death

Cushing triad ~^ICP (Bradycardia, wide pulse pressure, irregular breathing)

26
Q

Subdural hematoma sx

A

Acutely
Fluctuating consciousness
Drowsiness
Headache
Confusion
Behavioral change
Signs of ICP – vomiting, nausea, seizure, raised BP
Coma – many present with this

Chronic - Slow onset w/ latent period

27
Q

Subdural hematoma IVx

A

CT head –
Acute: Hyperdense crescent shape
Chronic: Hypodense crescent shape

28
Q

how to treat Increased ICP?

A

Bed position - tilt head 30 degrees
intubation
O2
osmotherapy (iv mannitol/hypertonic saline)

29
Q

Subdural haematoma TX

A

Starts with basics – ABCDE, Start oxygen, Maintain systolic BP >90 mmHg

Neurosurgery:
Burr hole – irrigation + evacuation
Craniotomy – to reduce ICP acutely

IV mannitol – reduce ICP

30
Q

What is an epidural haematoma?

A
  1. Definition – Collection of blood between the dura mater and the bone usually cause by head injury resulting in the fracture of temporal/ parietal bone (ptrieon space) and subsequently rupture of middle meningeal artery

Always suspect this after a traumatic head injury with low conscious levels falls or slow to improve or lucid interval.

~ present in young adults

31
Q

How would an epidural hematoma present?

A

Head injury
Brief LOC or drowsiness
Lucid interval – haemotoma is still small, can last hours to a few days
Followed by rapid decline, severe headache, vomiting, confusion, seizures, raised ICP - cusing triad

32
Q

Epidural IVx

A

CT head – Gold standard
Shows hyperdense biconcave region that is adjacent to the skull

33
Q

Epidural TX

A

ABCDE assessment
IV Mannitol
Neurosurgery – Clot evacuation, ligation of middle meningeal artery
May need intubation and ventilation

34
Q
A

Neurology (17 decks)

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