Week 202 - Stroke Flashcards
0
Q
What is silent aspiration?
A
No external clinical signs, but still aspirating.
1
Q
What % of stroke ptx have signs of dysphagia?
A
40%
2
Q
HOw many muscles and cranial nerves are involved in swallowing?
A
30 + 5
3
Q
Which cranial nerves are involved in the swallow?
A
Glossopharyngeal V Hypoglossal VII Vagus X Facial VII Trigeminal V Cortex and Brainstem
4
Q
What is dysphagia?
A
DIFFICULTY in swallowing. Behavioural, sensory, preliminary, motor acts, cognitive awareness, visual recognition, and physiological responses to food.
5
Q
What is the diff. between dysphagia and dysphasia?
A
PhaGIA = Gut PhaSIA = speech (think expressive)
6
Q
Aetiologies of dysphagia?
A
CVA, Brain injury, PD, MND, Dementia. Head/neck cancer, cleft palate, bad dentures, Pharangeal pouch Accident, surgery COPD Cardic, UTI, Trachi, Systemic weakness Anti-Pyschotics, Sedatives, Xerostomia
7
Q
What is xerostomia?
A
Dry mouth
8
Q
How Many stages are there in the swallow? Can you describe the first two stages?
A
There are 4 main stages in the swallowing process:
Oral Preparatory Stage, in which the food is chewed (masticated), mixed with saliva, and formed into a cohesive ball (bolus)
Oral Stage, in which the food is moved back through the mouth with a front-to-back squeezing action, performed primarily by the tongue
Pharyngeal Stage, which begins with the pharyngeal swallowing response:
The food enters the upper throat area (above the voice box)The soft palate elevates
The epiglottis closes off the trachea, as the tongue moves backwards and the pharyngeal wall moves forward
These actions help force the food downward to the esophagus.
Esophageal Stage, in which the food bolus enters the esophagus (the tube that transports food directly to the stomach). The bolus is moved to the stomach by a squeezing action of the throat muscles.
9
Q
An absent cough reflex or the absence of a swallow could indicate what?
A
Larynx insensate, or vocal cord palsy.
10
Q
define aspiration
A
Fluid entering into the trachea past thep oint of the epiglottis
11
Q
Where woukd you expect aspiration consolidation?
A
Right lower lobe
12
Q
The olfactory nerve conveys the sense of ____
A
smell
13
Q
Which four cranial nerves are related to the eye?
A
Optic (II) Oculomotor (III) Trochlear (IV) Abducens (VI)
14
Q
Lesion of the optic nerve causes
A
total loss of vision in the affected eye
15
Q
Bitemporal hemianopia is caused by?
A
Compression of the optic chiasm
16
Q
Right homonymous hemianopia is caused from
A
a lesion of the optic tract
17
Q
Upper right quadrantanopia is caused by
A
lesion of the lower fibres of the optic radiation in the temporal lobe
18
Q
Lower quadrantanopia occurs from a
A
lesion of the upper fibres of the optic radiation in the anterior part of the parietal lobe.
19
Q
Right homonymous hemianopia with sparing of the macula is due to
A
lesion of the optic radiation in the posterior part of the parietal lobe
20
Q
Nystagmus is what?
A
Involuntary rhythmic oscillation of the eyes
21
Q
Inferior rectus draws eye
A
out and down
22
Q
Superior oblique draws eye
A
nasal and down
23
Q
bilateral ataxic nystagmus is characteristic of demyelinationdue to ___ ______.
A
Multiple sclerosis.
24
Examination of vision often involves the assessment of cranial nerves ___ to ___ and their central connections.
II to VIII
25
During examination of vision you should inspect
inspection visual acuity fields ocular alignment pupillary exam colour vision opthalmoscopy
26
What is a cardinal feature of thyroid eye disease?
Lid lag - upper lid fails to cover the sclera above the iris
27
Reduced visual acuity indicates a \_\_\_\_
central visual field defect
28
Lesions of the macula cause what?
/central scotomas. May be incomplete, allowing px to see through them, but not clearly.
29
Lesions of peripheral retina will cause what?
Ring scotomas
30
Lesions of the optic disk will cause what?
arcuate scotomas
31
Weak eyelid closure indicates an issue with which cranial nerve?
VII
32
Red desaturation is an early indicator of pathology affecting the \_\_\_\_\_
Optic nerve
33
What is the function of the Trigeminal nerve?
Sensation to the face, mouth and part of the dura and motor supply to the muscles of the jaw involved in chewing.
34
What are the 3 branches of the trigeminal?
Opthalmic Maxillary Mandibular
35
Unilateral loss of sensation in one or more branches of the V nerve may result from
Facial fracture or local invasion by cancer
36
Loss of corneal reflex and V1 cutaneous sensory loss are often associated with
Invasion of cancer
37
which virus can affect the trigeminal ganglion and result in loss of all sensory modalities?
Herpes Zoster
38
A brisk jaw Jerk occurs when...?
You have bilateral upper motor neurone lesions above the level of the pons.
39
In unilateral LMN lesion of VII there is ___ of both \_\_\_\_.
weakness of both upper and lower facial muscles.
40
In unilateral upper motor neurone lesions, facial paresis spares \_\_\_\_
the forehead
41
Female, 27 yo 34/40. Fit and well. No DG. Transient LOC: Rapid + complete recovery [h/o similar x3 when a teenager]. O/E NAD BP 95/65mmHg. What is this? Which type? Diff diagnoses?
Stroke? Highly unlikely. SYNCOPE - Global TLOC. No risk factors.
42
Male 78 y/o. HT, NIDDM, Smoker, HD. Sudden onset R hemiparesis with dysphasia. Normal CT [4hr post-event]. O/E h/p + dysphasia. Irregular pulse.
Stroke. L Hemisphere of the brain involved. Pot/Cardiac arrrhythmia, ischaemic affecting middle cerebral artery territory as language functions affected. AF may be a causal factor. Cardio-Embolic potentially.
43
Female, 52 y/o. 6 weeks evolving HA + personality change. Slowly progressive Lt hemianopia and then Lt Hemiparesis. O/E Lt h/p + Lt VF (visual field) deficit. Swollen optic disks. Abnormal CT scan. Non Smoker BP 130-80 mmHg.
Focal -ve No vascular risk factors Raised disks - unusual. Slow development - most likely a brain tumour. Might be venous stroke - but unlikely as most would have had catastrophe by now.
44
TAC stroke?
Total anterior circulation stroke Middle and anterior cerebral arteries have been knocked out. Quite extensive hemisphere damage (one side). Terminal arteries of the internal carotid system. 15%
45
LAC stroke?
Lacunar stroke Lacune = " a hole". A pathological term to describe what you see if a small perforating vessel has locked off. These perforating vessels go into the brain substance. You end up with a small hole in the brain (deep). The descending fibres in the internal capsule are very densely located in the white matter. This means that there will be descending fibres affected by localised ischaemia due to a lacunae stroke. Leads to weaknesses. 25% of ischaemic strokes.
46
PAC stroke?
Partial anterior circulation stroke. Less severe ( better prognosis). Likely in middle cH. 35%
47
POC stroke?
Posterior circulation stroke. 25% of ischaemic strokes.
48
What % of strokes are Ischaemic strokes?
85%
49
What is hemiparesis?
Weakness on a named side of the face
50
What is a cardio-embolic event?
?
51
Define Dysarthria.
?
52
Define dysphasia.
?
53
What are the main differences identified between monocular and binocular abnormalities?
bASICALLY REFERS TO REGION OF LESION.
54
Define Dysarthria.
Difficult or unclear articulation of speech that is otherwise linguistically normal.
55
Define Dysphasia
A language disorder marked by a deficiency in the generation of speech and sometimes also in its comprehension. This is usually due to brain disease, or damage (i.e as a result of a stroke)
56
Define: Hemiparesis
Weakness or paralysis (var.) of one side of the body
57
What is meant by the term Cardio-embolic?
With or of reference to cardiogenic embolism, which accounts for approximately 20% of ischaemic stroke cases annually. This is stroke due to cardiac embolism (likely as the result of a vardiac abonrmalities, i.e. arrythmia or AF), and is largely preventable in primary care if risk factors are accounted for appropriately.
58
What % of ischaemic Middle cerebral artery strokes are the result of total anterior circulation infarct?
85%
59
A tumour, or inflammatory presentation usually presents with which type of Oedema?
Vasogenic oedema, a type of cerebral oedema in which the blood brain barrier is disrupted. This differs from cytotoxic cerebral oedema, which leaves the bbb intact.
60
What is a cytotoxic oedema?
An intracellular oedema which mainly affects grey matter, caused from lack of ATP that is typically seen in regions of cerebral hypoxia or ischaemia.
61
What is Amaurosis fugax?
Loss of vision in one eye due to a temporary lack of blood flow to the retina.It may be a sign of an impending stroke.
62
What is the difference between cerebral hypoxia and cerebral ischaemia?
Hypoxia - lack of o2 Ischaemia - lack of perfusion
63
ACA's and MCA's are linked to disruption of the ______ (of the ___ \_\_\_\_\_ artery)
Anterior cerebral circulation (of the internal carotid artery)
64
The visual cortex is most affected (usually) by ischaemia or disruption to which cerebral arteries?
Posterior
65
A Major L MCA infarct is likely to present as?
Contralateral hemiparesis and dysphasia.
66
When are anti-coagulants used in stroke?
For cardioembolic or cerebral venous sinus thrombosis (clears the veins!)
67
IS the optimisation of the bp always relevant in the mgx of stroke patients?
YES
68
If a young healthy person has a stroke - why is this a red flag?
Likely major haemorrhage - no age related damage (wear and tear)
69
IS an early CT sensitive to a brain bleed?
YES - VERY. Shows as dense as bone matter!
70
Patient with inter cranial haemorrhage 1 hour ago. Normal clotting and platelets. Are they a candidate for Iv TPA (tissue plasminogen acivator?)
NO. This was a haemorrhagic stroke - you'll probably make it a lot worse!
71
Is lumbar puncture a CORE element of ivx for stroke?
NO. Used occasionally but not common practice.
72
A CT scan will rule out a \_\_\_. An MR will allow for you to look for \_\_\_\_, and 3d imagery will allow an assessment of \_\_\_\_.
Bleed Damage Vascular capability
73
The occasion of a binocular vs a monocular stroke is dependant on the \_\_\_.
Loci of the ischaemic event/haemorrhage. LOOK THIS UP MORE.
74
Px with norma Rt carotid art. , Lt Hem symptoms (Rt side) - Candidate for CEA (Carotid Endarterectomy)?
No. Only used when carotid artery disease - not appropriate in this case.
75
TIA signs ABCDE?
Age BP c? Diabetes D?
76
Do you conduct brain imaging for all TIA's?
YES
77
Are there ever any positive clinical features occurring in stroke?
YEs
78
Hemisphere (non global) strokes produce crossed deficits?
YES
79
What is the Rosier shceme?
Recognition of stroke in the emergency room
80
LOC with signs and symptoms of stroke. Ma or SR?
NO idea!
81
The centaur score for handing out AB refers to what?
Glands swollen = 1 Absence of cough = 1 Tamp \>38 =1 Pus on tonsils =1
82
Duloxetine inhibits the reuptake of which two things\>
Serotonin and noradrenaline.
83
CTA and CTV stand for what respectively?
Computed tomographic angiography and venous-phase imaging. These are imaging techniques that can assist in diagnosis of clots i.e. PE.
84
In under fives, the ladder of treatment (drug therapy) goes 1 ____ 2\_\_\_\_ 3\_\_\_\_\_
Ventolin Steroid Inhaler Lucatrine
85
Pathophysiological symptoms of asthma?
Htpersensitivity Mucous production (excess) Constriction of bronchiole
86
What is the Guthre test?
Performed when 7/7 old. A test for cystic fibrosis.
87
How can you quantifiably diagnose asthma in an adult?
1.) PEAK FLOW diary. Assess for diurnal variation. MINIMUM 15% required for diagnosis. 2.) Spirometry. FEV1/FVC = 0.7 MINIMUM 0.7 = Restrictive
88
Treatment ladder for Those \> 5 YO with asthma?
1 Ventolin 2 Steroid Inhaler 3 Lucatrine/LABA
89
Describe grades 1-4 of COPD
FEV1/FVC \>80 = mild (1) FEV1/FVC 50-80 = Moderate (2) FEV1/FVC \<30 = V. Severe - clost to NCWL
91
20 YO F Acute Wheeze & SOB. OE Polyphonic wheeze globally. RR \< & accessory muscles in use. Wheeze starts to fade as condition worsens. Likely cause?
Acute asthma attack.
92
CBF accounts for ___ % of resting cardiac output
20%
93
Brain uses \_\_% of total body O2 consumption
15%
94
Average CBF is \_\_mls/\_\_g/min
50mls/100g/min
95
Autoregulationof CBF is achieved by ___ in ___ \_\_\_\_\_
variation in arteriolar tone
96
With profound hypotension…
CBF inadequate for metabolic demands Impaired cellular metabolism Decreased neuronal activity Symptoms
97
With profound hypertension…
Hyperaemia Cerebral oedema Hypertensive encephalopathy
98
Autoregulation may be impaired by
Increasing age Head trauma SAH Ischaemic stroke Cerebral hypoxia High pCO2
99
What is the result of a failure of autoregulation?
CBF varies with blood pressure Increased stroke risk, especially with hypotension
100
Glia- can metabolise _______ aerobically and anaerobically
glucose
101
Neurons- can metabolise ______ but chief substrate is normally \_\_\_\_\_
glucose but chief substrate is normally lactate
102
Neurons- are obligatory a\_\_\_\_\_, suffer irreversible damage after approx _____ mins of hypoxia
obligatory aerobes, suffer irreversible damage after approx 5-7 mins of hypoxia
103
Hypoxia - main causes?
Low O2 tension in inspired air Airway obstruction Lung disease Reduced O2 carrying capacity of blood Inhibition of aerobic respiration Loss of blood supply – ischaemia
104
Global Cerebral Ischaemia is? Generalised reduction in cerebral perfusion
Generalised reduction in cerebral perfusion i.e cardiac arrest severe hypotension - “shock”
105
Severity of outcome in Ischaemia depends on
degree of ischaemia duration of ischaemia temperature blood glucose
106
What is a Watershed Infarction?
Areas of acute infarction lying at the watershed between the middle and posterior cerebral artery territories following a hypotensive episode
107
Clinical outcome of global ischaemia?
Transient confusion Focal deficit Diffuse neuronal hypoxia Non-perfused brain
108
Outcome of severe global cerebral ischaemia?
In severe global cerebral ischaemia widespread neuronal death occurs irrespective of regional vulnerability. Patients in this state are severely impaired neurologically and deeply comatose – persistant vegatative state. These patients’ brains undergo profound atrophy Some patients meet criteria for brain death with absent basic reflexes and respiratory drive. If the patient is ventilated, the brain undergoes a process of autolysis – “respirator brain”.
109
Global Cerebral Ischaemia is?
Severe loss of brain volume due to profound neuronal (and axonal) loss with compensatory expansion of cerebral ventricles.
110
Non–Perfused Brain causes?
Raised ICP (trauma, ischaemia, etc) -ICP\>arterial BP -No cerebral perfusion Medulla may continue to be perfused in some cases with preservation of spontaneous circulation and respiration. Others require ventilation -”Respirator Brain”
111
Focal Cerebral Ischaemia is what?
Cerebral arterial occlusion leading to focal ischaemia in the territory of the affected vessel
112
Transient Ischaemic Attacks are?
Transient neurological signs of rapid onset with complete recovery Are of short duration \< 24hrs Assumed to cause no structural brain damage May affect the carotid or V-B territories Pathogenesis: mostly athero- or thromboembolism – cardiac or carotid Post TIA: risk of stroke 7-10% per annum (x7 times risk) risk of myocardial infarction 7% per annum
113
Main Causes of Stroke?
Cerebral Infarction 70-85% Haemorrhage 15-30%
114
Causes of Cerebral Infarction
Large vessel thrombosis Lacunar Embolism Undetermined
115
Causes of cerebral HAemorrhage?
Intracerebral haemorrhage Sub-arachnoid haemorrhage Other
116
Risk factors for stroke
Age, ethnicity Smoking, alcohol Hypertension, atrial fibrillation, other heart diseases Carotid stenosis Hyperlipidaemia, diabetes Cardiac surgery
117
most common by far cause of cerebral infarction?
Atherosclerosis
118
Causes of cerebral embolism?
Cardiac mural thrombi – myocardial infarct valvular disease atrial fibrillation Carotid athero/thromoemboli Cardiac surgery Tumour, fat and air emboli
119
Lacunar infarction results from?
Atherosclerosis of lenticulostriate arteries (end arteries)
120
What is Cerebral Vasculitis?
Blood vessels are inflamed leading to thrombosis and hence infarction
121
What is Binswanger’s Disease (Leukariosis)
Multi-infarct Dementia Consequence of multiple cerebral infarcts Combination of atherosclerosis, embolism, arteriolosclerosis, chronic hypertension Clinical Features: dementia, abnormal gait, focal neurological deficits
122
Venous Infarction Risk Factors:
Dehydration Infection Heart Failure Malignancy Thrombophilia Pregnancy/OC Pill
123
Primary Intracerebral Haemorrhage main causes?
hypertension (50%) tumours, angiomas amyloid angiopathy illicit drugs anticoagulants
124
Hypertensive Intracerebral haemorrhage results from?
Bleeding from small diameter arterioles due to…. Arteriolosclerosis Charcot-Bouchard aneurysms
125
Primary Subarachnoid Haemorrhage causes \_\_\_% of strokes
5%
126
Complications of aneurysmal rupture
Immediate subarachnoid haemorrhage intracerebral haemorrhage vasospasm - cerebral infarction Later hydrocephalus haemosiderosis Outcome immediate mortality 10% death within 1 week 30% death within 1 year 65%
127
Pathology associated with venous drainage :
Venous sinus thrombosis • Subdural haemorrhage
128
what is a Sub dural haematoma
Rupture of bridging veins Venous blood within dural space Can cause mass effect
129
Venous Sinus Thrombosis is?
Rare but serious and treatable Hypercoaguable states (sometimes infection) Variable onset of symptoms (headache, visual symptoms, other neuro defecits) Can get venous haemorrhage Treatment = anticoagulation
130
What does this image show?
Skull fracture with small Subdural HAematoma
131
What is shown in this image?
extradural haematoma
132
What does this image show?
Venous sinus thrombosis
133
Anterior circulation of brain is supplied by?
Internal Carotid Artery
• Anterior Cerebral Artery
• Middle Cerebral Artery
– Anterior Communicating Artery
– Posterior Communicating Artery
134
Posterior Circulation ofbrain is supplied by?
Vertebral Arteries
– Basilar Artery
– Posterior Cerebral Artery
135
What does this image show?
ACA infarction
136
What does this image show?
MCA infarct
137
What does this image show?
PCS infarct
138
What does this image show?
Left MCA Infarct
with Haemorrhagic Transformation
139
What does this image show?
Left Cerebellar Infarct
140
What does this image show?
Basilar Tip Thrombus
141
What does this image show?
Basilar Tip Thrombus cta
142
DWI stands for\_\_\_ and images \_\_\_\_ better
Diffusion weighted imaging
Blood
143
Define penetration
Food into trachea, stays above vocal chords
144
Define residue (swallow radiology)
Residue of material in the valleculae post swallow
145
Define backflow (swallow radiology)
nASOPHARYNGEAL BACKFLOW OF FLUID
