TIA and Stroke Flashcards
1
Q
TIA
- Definition
- Definition - crescendo
- Differentials (5)
Management
- Optimum BP
- Score to decide whether emergency referral necessary
- Confirmed TIA
- Antiplatelet
- Carotid endarterectomy - when, indication
- Driving
A
- Transient symptoms
- 2+ TIAs in 1 week
- Hypoglycaemia, migraine aura, focal epilepsy, hyperventilation, retinal bleed (if amaurosis fugax)
- < 140/85
- ABCD2
- Immediate aspirin, see specialist within 24 hours
- Aspirin 300mg 2 weeks, then clopidogrel
- Within 2 weeks if >70% (or >50%) stenosed
- Cannot drive until see specialist, then stop for at least 1 month if confirmed
2
Q
Lacunar stroke (LACS)
- Structures involved (4)
- Classification (1 of 5)
A
- Basal ganglia, internal capsule, thalamus, pons
2. Pure motor, pure sensory, ataxic hemiparesis, sensorimotor, dysarthria/clumsy hand
3
Q
Stroke - general
- Ischaemic stroke - suggestive features
- Haemorrhagic stroke- causes (2)
- Precipitating factors (4)
- Symptoms potentially suggestive of bleed (3)
A
- Carotid bruit, AF, past TIA, IHD
- Intracerebral, subarachnoid
- HTN, cerebral amyloid angiopathy, aneurysms, cerebral arteriovenous malformations
- Meningism, severe headache, coma
4
Q
Anterior circulation
- Arteries involved (4)
- Total AC stroke - classification
- Partial AC stroke - classification
Associated clinical deficits
- Left middle cerebral artery (2)
- Right middle cerebral artery (3)
A
- Internal carotid, anterior cerebral (frontomedial cerebrum), anterior communicating, middle cerebral (lateral hemispheres)
- Unilateral weakness, homonymous hemianopia (middle cerebral), and higher cerebral dysfunction
- 2/3 above signs
- Right sided weakness of face + arm (more than leg), dysphasia
- Left sided weakness - face + arm (more than leg), visual / sensory neglect, denial of disability
5
Q
Posterior circulation
- Arteries involved (4)
- PC stroke - classification
A
- Vertebral, basilar (branches to anterior inferior cerebellar, pontine, superior cerebellar), posterior cerebral - occipital lobe, posterior communicating
- 1 of cerebellar / brainstem syndromes, loss of consciousness, or isolated homonymous hemianopia (macular sparing)
6
Q
Lesion consequences
- Corticospinal tracts in brainstem
- Oculomotor tract in brainstem
- 5th nerve nuclei
- 7th nerve nuclei
- 9th + 10th nerve nuclei
- Brainstem sympathetic fibre
- Reticular formation
A
- Hemiparesis /Tetraparesis
- Diplopia
- Facial numbness
- Facial weakness
- Dysphagia, dysarthria
- Horner’s syndrome
- Coma/altered consciousness
7
Q
Acute management
- Maintaining homeostasis (BM, BP)
- When to give oxygen
- How to exclude haemorrhagic stroke
- Immediately given once haemorrhage excluded
Ischaemic
- Thrombolysis - 1st line drug
- Should be given within
- What to do 24 hours post-lysis, + why
- Contraindications
- Additional thrombectomy - indication
- Haemorrhagic - general
A
- BM 4-11mmol/L, BP 185/110 (ischaemic) or systolic 130-140 (haemorrhagic)
- If SpO2 <95%
- Non-enhanced CT within 1 hour
- 300mg aspirin (continue for 2 weeks)
- Alteplase
- 4.5 hours of onset of stroke symptoms
- CT to identify bleeds
- Previous/current intracranial haemorrhage, active bleeding, pregnancy, seizure during stroke, brain tumour, stroke/TBI in last 3 months, LP in last 7 days, GI haemorrhage in last 3 weeks, oesophageal varices, uncontrolled HTN (>200/120)
- Confirmed ischaemic stroke + proximal anterior circulation occlusion
- Urgently reverse anticoagulation, urgently lower BP, sometimes surgery (craniotomy)
8
Q
Stroke assessment - scale used
A
NIHSS (national institute of health stroke scale)
9
Q
Aphasia - types
- Broca’s
- Wernicke’s
A
- Expressive aphasia
2. Receptive aphasia
10
Q
Stroke - precipitating factors
- Coagulopathies (4)
- Infections to consider (3)
- Vasculitis - causing strokes secondary to (2)
- ‘Other’ causes
- Commonest genetic cause
- Inheritance
A
1, Thromboycythaemia, polycythaemia, hyperviscosity states, thrombophilia
2. HIV, neurosyphilis, hepatitis
- Infection, CTD
- Arterial dissection, venous sinus thrombosis, vasculitis, antiphospholipid syndrome, SAH
- CADASIL
- Autosomal dominant
11
Q
Intracranial venous thrombosis (IVT)
Cerebral
1. Defining features (4)
Cavernous sinus thrombosis
- Structures running through CS (5)
- Classic presentation (3)
- Associated with (6)
- CN 3 palsy - presentation
- CN 4 - innervates
- Palsy - presentation
- CN 6 - innervates
- Palsy - presentation
- Differentials
- Bloods
- Imaging
- Management
- Ideal INR
A
- Headache, altered consciousness, seizures, papilloedema
- 3rd, 4th, 5th and 6th cranial nerves, carotid artery
- Proptosis, chemosis, painful ophthalmoplegia
- Pregnancy, puerperium, COC, haematological disease, infection, CTD
- ‘Down and out’ pupil + ptosis, mydriasis, absent light reflex
- Superior oblique muscle
- Diplopia on downwards gaze when the eye is adducted
- Lacteral rectus muscle
- Failure of abduction/diplopia when trying of the affected eye
- SAH, meningitis, encephalitis, intracranial abscess, arterial infarct
- Thrombophilia screen
- CT/MRI venography
- Anticoagulation with LMWH/heparin, then warfarin
- 2-3
12
Q
Stroke due to arterial dissection
- Symptoms
- Medical management
A
- Stroke symptoms occur after trivial neck trauma
2. Offer either anticoagulants or antiplatelet agents
13
Q
Long-term prevention
- Primary - risk factors to control
- What to do if AF/prosthetic valves
- AF - score to use to calculate stroke risk
- Anticoagulation - score to use to assess bleeding risk
Secondary - post-stroke
- Antiplatelet - 1st line
- 2nd line (2)
- Anticoagulation - when to start
- Level of cholesterol post-stroke where a statin should be started
A
- HTN, DM, lipids, IHD, smoking
- Lifelong anticoagulation
- CHADSVASc
- HAS-BLED
- Clopidogrel
- Low-dose aspirin, dipyridamole
- 2 weeks if large, 7-10 if clinically/radiologically small
- 3.5 mmol/L
