vascular disease Flashcards
Types of strokes
(1. ) Ischaemia or infarction
- Reduced tissue perfusion due to inadequate blood supply
- Causes: VTE, AF , atherosclerosis, vasculitis
(2. ) Haemorrhage
- Causes: intracerebral haemorrhage, berry aneurysm, SAH
- RF: htn, anticoag, trauma
(3. ) TIA
- Syx resolve <24hrs. Within 30d there is a hi risk of CVA so secondary prevention is important
- ABCD2 = estimates the risk of stroke after suspected TIA. Although no longer used to assess risk and urgency of referral for people with TIA.
Stroke presentation + tool used to recognised in ED
FAST = for identifying stroke. In emergency room ROSIER can be used for recognising stroke.
- Sudden onset of neuro syx, typically asymmetrical
- Limb weakness
- Facial weakness
- Dysphagia
- Visual or sensory loss
Acute management of stroke
Acute management
(1. ) ABCDE, oxygen if <95% + admission to stroke unit
(2. ) CT
(3. ) Aspirin 300mg STAT, and then 75mg for 2w + PPI –> Once haemorrhage excluded
(4. ) Thrombolysis: IV alteplase –> Once haemorrhage excluded
- Given <4.5hr of syx onset
- CI: Recent surgery last 3m, active malignancy, brain aneurysms, anticoagulation, severe liver disease, clotting disorder
(5. ) Thrombectomy
- Offer if 6-24hrs of syx onset
- If confirmed ischaemic stroke with occlusion
when pt is stable -> management of stroke + TIA
(1. ) TIA: Stroke specialist referral within 24hrs
(2. ) Imaging: diffusion weighted MRI (GOLD), carotid USS
(3. ) Carotid endarterectomy or stenting if confirms carotid stenosis
(4. ) Secondary prevention
- Lifestyle: smoking cessation, reduce alcohol, physical activity, healthy diet
- Optimise comorbidities
(a. ) Antiplatelet: 75mg Aspirin, 75mg Clopidogrel
(b. ) Atorvastatin
(c. ) Antihypertensives
(d. ) Anticoagulants
(5. ) Do not offer COCP
(6. ) Notify DVLA: not drive at least 1m
(7. ) Stroke rehabilitation
RICP causes + clinical features
Causes
- SOL e.g. tumor
- Haemorrhage: subdural, extradural, SAH, intracerebral
- Hydrocephalus
- Infection: meningitis, encephalitis, brain abscess
- Cerebral oedema: from trauma, SAH, idiopathic intracranial HTN
Clinical features
(1. ) Headache worse on coughing/leaning forward
(2. ) Vomiting
(3. ) Altered GCS
(4. ) Hx of trauma
(5. ) Cushing’s triad = bradycardia, irregular respirations, widened pulse pressure
(6. ) Visual disturbance: pupil change/ diplopia/ papilledema
(7. ) CN3 palsy - due to temporal coning of brain
(8. ) CN6 palsy - due to tonsillar coning of cerbellar
RICP Ix + Mx
Ix
- Obs, BM, neuro ex
- Bloods: FBC, UE, LFT, BGL, clotting, blood cultures
- Imaging: CT (GOLD)
- LP: measure open pressure
Mx
(1. ) ABCDE
(2. ) Urgent neuro referral for definitive Rx
- Surgical decompensation of mass lesion
- Shunt procedure to relieve hydrocephalus
- Glucocorticoids to reduce vasogenic oedema
(3. ) Supportive Tx
(4. ) Intensive care may be needed
Temporal arteritis: RF, complications, presentation
- Systemic vasculitis/granulomatous inflammation of medium and large arteries
- Medical emergency
- RF = female, >50, Caucasian, PMR
- Complication = blindness, stroke, large artery complication e.g. aortic aneurysm, dissection, relapses are common
Presentation
(1. ) Severe u/l temporal headache
(2. ) Temporal artery abnormality such as tenderness/ thickening/nodularity
(3. ) Scalp tenderness - when brushing hair it may be noticed
(4. ) Jaw claudication
(5. ) Visual disturbances - vision loss /diplopia
(6. ) Systemic syx: fever, aches, fatigue, wt loss, loss of appetite
(7. ) PMR syx.
Temporal arteritis: Dx + Mx
DX: Clinical presentation, rasied ESR, biopsy
(1. ) Blood: raised CRP + ESR, anaemia, raised plt
(2. ) Temporal artery biopsy + histology shows multinucleated giant cells
(3. ) Duplex USS
Mx
(1. ) 40-60mg PO (IV steroids if vision loss) start immediately
(2. ) Aspirin
(3. ) PPI, bisphosphonates, Ca, vit D
(4. ) Referral
- Vascular surgeons - for biopsy
- Rheum - for dx and mx
- Ophthalm emergency same day - if visual syx
