Thrombotic Diseases Flashcards

1
Q

Define stroke

A

/Is a neurological deficit of cerebrovascular cause that persists beyond 24 hours or interrupted by death within 24 hours

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2
Q

When does stroke occur

A

when there is a rapid death of brain tissue due to a disturbance in blood supply

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3
Q

What is a major differentiating factor between a stroke and a TIA

A

Time frame - 24 hours
Stroke beyond 24hrs
Tia resolved within 24 hrs

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4
Q

Risk factors for stroke

A
Inactivity
Previous stroke and tia 
Obesity/unhealthy etc 
Heart disease / high Bp
Smoking
Diabetes 
Age/ family history 
Oral contraception
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5
Q

What are the carotid arteries

A

Anterior supply for front and middle regions of brain

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6
Q

What are vertebral arteries

A

Posterior supply for brain stem and rear regions of brain

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7
Q

What are the 2 types of stroke

A

Ischamic

Haemorrhagic

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8
Q

Subtypes of ischaemic stroke?

A
  • thrombosis
  • embolism
  • atrial fibrillation
  • endocarditis
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9
Q

What is thrombosis cause ischaemic stroke?

A

Associated with the large and small arteries - carotid, vertebral, basilar

Damages caused by an atherosclerotic plaque rupture leading to thrombosis, this interrupts the blood supply and then nutrients such as oxygen and glucose cannot get to the neurons. There is a rapid death of brain tissue leading to loss of function

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10
Q

What is the embolism cause of ischaemic stroke ?

A

Caused by conditions that form clots in the left ventricle of the heart such as a heart attack or congestive heart failure.

The heart is the most common source of embolism to the brain so then these clots break off and go to the brain from upstream arteries

It is basically as a result of a low ejection fraction in the heart in these conditions which activate a clotting cascade and therefore clot —> embolism

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11
Q

Most common type of stroke

A

Ischaemic

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12
Q

What is the atrial fibrillation cause of ischaemic stroke?

A

During atrial fib -the left atrium is less effective in the ejection of blood which then lead to blood stasis in the left atrial Appendage which leads to clots and therefore the Emboli can break off and cause a stroke in the brain

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13
Q

What is the endocarditis cause of stroke?

A

There can be fungal or bacterial growth in the heart valves which then form clumps or vegetation which can break off into emboli and travel to the brain

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14
Q

2 types of haemorrhagic stroke?

A

Intracerebral

Subarachnoid

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15
Q

What is intracerebral stroke and it’s cause?

A

Bleeding Within brain - due to hypertension, trauma, bleeding disorders or vascular defects

Arteriovenous malformation - the feeder artery to NIDUS lead to collection vein

There is a highBP in AVM which causes rupture and bleeding - causes haematoma which can compress, rupture and damage neurone - irreversible damage

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16
Q

What is subarachnoid stroke and risk factors

A

On surface of brain - mainly due to aneurism rupture mainly occurring in circle of Willis

Risk factors are smoking,alcohol, hypertension, genetics, drug abuse and drugs eg anticoagulants

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17
Q

How does subarachnoid stroke damage the brain?

A
  • compression of tissue From expanding haematoma

there is also toxic affects due to free iron

there’s also interruption of blood supply to neutrons

18
Q

2 types of aneurism?

A

Saccular (berry) - protrude our of artery

Fusiform- elongates within artery

19
Q

Which area is highly susceptible for aneurism in the brain stem?

A

Subarachnoid space

20
Q

Define transient ischaemic attack

A

Temporary blockage of the blood supply due to small blood clot. It can be overcome within 24 hours.

It’s occur repeatedly or in multiple regions of the brain. And it can lead to a major stroke I’m so we need to treat it as soon as possible to prevent this

21
Q

How do we assess the risk of a stroke following a patient having a TIA?

A

ABCD2 model

22
Q

Describe ABCD2 model

A
  • age - 60 or over 1 point
  • blood pressure on presentation 140/90 or higher -1 point
  • clinical features eg
    If have unilateral weakness 2 points
    Speech disturbance but no weakness-1 point
  • duration of symptoms
    30-59 min 1 point
    60 min or over 2 points
    Presence of diabetes is 1 point
23
Q

According to ABCD2- what score would place the patient at high risk?

A

A score of 4 or more (but beware that in crescendo stroke -(2 or more TIA/ week) -would be higher risk regardless of the score

24
Q

If a patient has ABCD2 score of 4 or more what action is taken

A

High risk of having a major stroke so

300 mg aspirin daily immediately
Specialist assessment within 24 hrs of TIA symptoms

25
Q

What are limitations of ABCD2 model

A

It cannot be used in people who have had multiple recurrent TIAS, or those on anticoagulants

26
Q

How can we recognise stroke?

A

FAST
F- face- is their face dropping/can they smile/ eye drop

A- arms - can the lift both arms up and keep them there?

S- speech- can they speak clearly, slurred? Can they understand what you say?

T- time to call 999 if see any features

27
Q

What scale is used to recognise stroke in A&E

A

Rosier scale

28
Q

Action taken with an ABCD2 score of less than 4?

A

Specialist assessment within a week of onset, refer to brain Imaging if need

29
Q

What are the Symptoms of stroke and how do these link to areas of the brain affected?

A
  • numbness or face arm leg on one side (sensory cortex)
  • weakness of face arm leg on one side (motor cortex)
  • loss of coordination and balance- cerebellum
  • loss of consciousness
  • worse headache of life
  • double vision/blurred - occipital lobe
  • slurred speech or loss of speech- broad or wernickes area
30
Q

What are the aims of pharmacological treatment in stroke

A
  1. To prevent further strokes
  2. Prevent further neuronal loss neuro protection
  3. Repair or replace damaged neurons called neuro restoration

All done within 4.5 hrs

31
Q

What is the main drug given within 4.5 hrs ofischaemic stroke

A

Thrombolytic agent - tissue plasminogen activator (tPA) eg alteplase 900 microgram/kg/hr (IV)

32
Q

What does tissue plasminogen activator do?

A

Activated plasminogen into plasmin which binds to the clot and dissolved it so thrombus broken down into proteolytic degradation products

33
Q

What is overall pharmacological treatment of ischaemic stroke ? - INITIAL

A
  • alteplase 900 microgram/kg/hr in specialist stroke centre or trained staff
  • aspirin 300 mg OD for 2 weeks - oral or via recital/enteral tube IF- dysphagia, history of Dyspepsia/ given a PPI

if intolerance to aspirin then can give clopidogrel 75 mg OD. But if clopidogrel contraindicated or not tolerated - give MR dipyridamole in Combo with aspirin

also give statins, antihypertnesives etc and surgery to remove plaque (endarterectomy) or stent insertion in angioplasty

34
Q

Long term pharmacological management of stroke (ischaemic)?

A

Long term clopidogrel 75 mg OD

If patient has:

  • TIA
  • ischaemic stroke but clopidogrel contraindicated- then use

MR dipyridamole 200 mg BD in combo with aspirin 75 mg OD

35
Q

What is the Pharmacological treatment for haemorrhagic stroke?

A

Removal or clip of aneurism

  • reverse any anti coagulants
  • start on anti hypertensive

Can also do surgieries to-

  • remove blood/haematoma
  • remove CSF - hydrocephalus treatment
36
Q

What is the non pharmacological long term management of stroke?

A

Restoration of functions eg physio, speech and language therapy, OT, psychologist

Also learning new skills
Adapting to some limitations caused by stroke eg smaller meals to avoid choking, physical changes to home, In continence pads, communications and mobility aids

Support networks - patience, positivity

37
Q

What is DVT

A

A blood clot occurring in the deep veins of the legs

There is no movement which reduces bloodflow in the veins leading to an accumulation of platelets and plasma proteins which cause clotting

Dislodged clots can travel to the heart and then into the lungs which causes a pulmonary embolism

38
Q

Causes of DVT?

A
  • inactivity eg immobile for long time
  • hospital stays
  • blood vessel damage eg injury - vasculitis/varicose vein
  • medical conditions
  • genetics eg thrombophilia/Hughes syndrome
  • pregnancy
  • combined contraceptive pills

Sedentary lifestyle, age, obesity, dehydration

39
Q

Symptoms of DVT

A

Sometimes asymptomatic

  • pain, tenderness swelling in area - 1 leg
    Heavy pain
    Warm skin in area
    Redness at back of leg below knee
    Swelling and fluid congestion as blood not moving

If untreated can lead to PE leading to breathlessness, chest pain, collapse

40
Q

How is DVT diagnoses?

A

Blood test for d- dimer levels

D dimers are usually released into the plasma during a clot as a result of a cross linked fibrin mesh

Also use ultrasound and venogram

41
Q

Treatments for DVT?

A

Anticoagulants to prevent clots. Getting bigger

  1. Heparin - usually low mwt or unfractionated- inhibits thrombin- IV of s/c
  2. Warfarin sodium - oral tab- start at same time as heparin - but not used in pregnancy
    (Also use apixaban and rivaroxaban)
  3. Compression stockings
  4. Inferior vena cava filters when anticoagulants not suitable

And exercise eg walking, raising legs when sitting d