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Flashcards in 5. Stroke Deck (44):
1

Define stroke

Interruption of the blood supply to a focal part of the brain causing loss of neurological function

Symptoms last >24 hours or lead to death with no apparent cause other than that of vascular origin

2

Define a TIA (transient ischaemic attack)

Same cause as a stroke i.e. blockage to blood supply to brain leading to loss of neuro function
However, symptoms lasting <24 hours

3

3 different types of stroke?

• Ischaemic: 80-85%
• Haemorrhagic: 15%
• Subarachnoid haemorrhage: 5%

4

Causes of haemorrhagic stroke?

Hypertension
Tumour
Bleeding disorder
Vascular malformation
Amyloid angiopathy

5

Causes of ischaemic stroke?

Cardioembolism
Large vessel artherothrombosis
Cardiac course: Small vessel disease, carotid/vertebral dissection, watershed areas
Hypoperfusion

6

What is the progression of the brain tissue in an ischaemic stroke?

In the CORE zone, which is an area of severe ischemia (blood flow below 10% to 25%), the loss of oxygen and glucose results in rapid depletion of energy stores. Severe ischemia can result in necrosis of neurons and also of supporting cellular elements (glial cells) within the severely ischemic area.

Brain cells within the PENUMBRA, a rim of mild to moderately ischemic tissue lying between tissue that is normally perfused and the area in which infarction is evolving, may remain viable for several hours. That is because the penumbral zone is supplied with blood by collateral arteries anastomosing with branches of the occluded vascular tree (see inset). However, even cells in this region will die if reperfusion is not established during the early hours since collateral circulation is inadequate to maintain the neuronal demand for oxygen and glucose indefinitely.

7

How many neurones are lost per year due to aging?

30 million neuron loss per year in normal ageing

8

How can cerebral autoregulation be impacked by bp and age?

In cerebral autoregulation alter diameter in order to maintain cerebral perfusion
-Impeded if bp too high as there is force dilation, increased flow and vadogenic Oedema
- If bp too low leads to impaired dilation, artery collapse and then ischemia
-Older arteries are stiffer which is a problem

9

What is the anterior circulation supply to the brain?

From the internal carotids. Supply the:
--> Anterior 3/5 of the cerebrum
--> Diencephalon

Main branches:
-Middle cerebral artery (MCA)
-Anterior cerebral artery (ACA)
-Striate arteries

10

What is the posterior circulation supply to the brain?

Via the vertebrobasilar arteries
Supplies:
-Posterior 2/5 of the cerebrum
-Diencephalon
-Cerebellum
-Brainstem
Main branches:
-Posterior cerebral arteries
-Striate and thalamus
-Pontine
-Cerebellar

11

S&S of stroke and TIA?

Diplopia
Ataxia
Hemianopia (Stroke > TIA)
Speech loss (TIA> stroke)
Sensory loss (stroke > TIA)
Motor loss (Stroke > TIA)

12

What is diplopia?

Double vision

13

What is hemianopia?

Blindness over half the field of vision

14

Key things to look for in examination in vascular neurology?

• BP and pulse measurement in 2 arms
• Conscious level (GCS; document breakdown)
• Cardiac and carotid bruits
• BM/blood glucose value
• Neck stiffness/meningism (Kernig’s/Brudzinski signs)
• Abnormal or involuntary movements
• Any seizure-like activity
• Skin rash/infarcts e.g. vasculitic, papular rash
• Specific neurological
- eye movements (gaze preference,fixed deviation)
- speech, visual fields, inattention, motor & sensory
- gait assessment

15

Name 3 different ways to classify a stroke?

Oxford Community Stroke Project (OCSP)
- Clinical classification

TOAST classification
-Mechanism classification (e.g. large or small vessel, cardioembolic)

Carotid or vertebrobasilar territory
-Location classification

16

What are the 4 subtypes in the OCSP classifications of stroke?

1. Total Anterior Circulation Syndrome (TACS)
2. Partial Anterior Circulation Syndrome (PACS)
3. Lacunar Syndrome (LACS)
4. Posterior Circulation Syndrome (POCS)

17

What is seen/affected in LACS in the OCSP classification of strokes?

Pure motor
Pure sensory
Sensorimotor
Ataxic hemiparesis (paralysis on half body)

18

What is seen/affected in POCS in the OCSP classification of strokes?

Brainstem
Cerebellar
and/or
Isolated homonymous hemianopia

19

What is seen in TACS in the OCSP classification of strokes?

Triad of hemiparesis (or hemisensory loss)
Dysphasia (or other higher cortical function)
Homonymous hemianopia

20

What is seen in PACS in the OCSP classification of strokes?

2 features of TACS
or
Isolated dysphasia
or
Parietal lobe signs (e.g. inattention, agnosia, apraxia, agraphesthesia, alexia)

21

What is agnosia

Inability to interpret sensation hence unable to recognise things

22

What is apraxia

Inability to perform particular purposive actions due to brain damage

23

What is agraphaesthesia

Agraphesthesia is a disorder of directional cutaneous kinesthesia or a disorientation of the skin's sensation across its space. It is a difficulty recognizing a written number or letter traced on the skin after parietal damage.

24

What is alexia?

Inability to recognise or read certain words or letter (often due to brain damage)

25

What is the ABCD2 assessment in TIA and risk of stroke?


7 points score to predict early stroke risk post TIA

• Age [60 or above;=1]
• Blood pressure [systolic > 140 and/or diastolic =/> 90; =1]
• Clinical features [unilateral weakness = 2; speech disturbance w/o weakness = 1; other = 0]
• Duration of Symptoms in mins [=/> 60 =2; 10-59 =1; < 10 = 0)
• Diabetes = 1

2-day strokes scores/risk: 0-3 (1%), 4-5 (4%), 6-7 (8%)

26

Name 5 stroke mimics

(Hint: S S S S S)

1. Seizures
2. Sepsis
3. Syncope
4. SpaceOccupyingLesion (e.g. tumour, subdural)
5. Somatisation

27

What is somatisation?

The manifestation of psychological distress by the presentation of bodily symptoms

28

What are the red flags when dealing with a stroke stroke for a more sinister diagnosis?

No history
No risk factors
No imaging abnormality
Young age
Seizers
Unusual headache

29

When doing the clinical assessment for a stroke what are your 3 initial questions?

Localisation of the lesions
Likely vascular or non-vascular aetiology
Mechanism of vascular event e.g. small vessel disease, cardioembolism, hypoperfusion

30

Name the 6 investigations that should be done after a stroke?

GOOD history and exam
ECH/Holter (24hr ECG) and Echo
Cholesterol/autoimmune and thrombophilia screen
Carotid dippler
CT brain / MRI brain
Cerebral angiography

31

Indications for urgent head imaging

• Depressed level of consciousness
• Unexplained progressive or fluctuating symptoms
• Papilloedema, neck stiffness or fever
• Severe headache at onset
• History of trauma prior to onset
• Indication for thrombolysis or anticoagulation
• History of anticoagulant treatment or known bleeding tendency

32

In a CT what feature of the sulci suggests stroke?

If they are NOT VISIBLE

33

As a stroke progresses how does the CT presentation look?

Loss of normal grey/white differentiation

34

Difference between DWI and ADC MRI imaging?

DWI is mixture of T2 and diffusion weighting

ADC is pure diffusion of water

35

DWI/ADC MRI image changes after stroke?


Initially:
High signal- DWI
Low signal- ADC

After 1-2 weeks:
-DWI stays high
-ADC signal increases to normal

After 2 weeks +
-DWI becomes lower
-ADC becomes high and stays high

36

Advantages and disadvantages of CT scanning in a stroke?

Advantages:
- Can detect bleed
- Available 24/7
- Quick

Disadvantages:
- Lacks sensitivity

37

Advantages and disadvantages of MRI scanning in a stroke?

Advantages:
-Sensitive
-Diagnostic
- Management
- Prognostic

Disadvantages:
- Limited availability
- Precautions
- Slow

38

management of an acute stroke?

• Aspirin (300 mg/d) in ischaemic stroke
• Thrombolytic treatment with IV r-tPA if onset < 4.5 hrs, haemorrhage excluded by imaging, considered suitable for treatment, administered in a specialist centre
• Endovascular treatment/ mechanical thrombectomy with clot-retrieval device in selected patients
• Aggressive early BP Rx in ICH; SBP < 140
• Neurosurgical opinion for secondary hydrocephalus especially in cerebellar stroke
• Anticoagulation in atrial fibrillation- oncebleed excluded and usually after 10-14 days of stroke
• In ischaemic stroke, avoid antihypertensive medications unless MAP* (mean arterial pressure) > 130 mm Hg. In haemorrhagic stroke, aim for SBP < 140 mm Hg especially in the first 6 hours.
• If BP persistently elevated, treat with IV Labetolol. Important: avoid abrupt falls in BP
• In raised ICP: hyperventilate mechanically (PC02:25-30 mm Hg/20 breath per min), mannitol, decompressive hemicraniectomy

39

Management of SAH?

• CT brain/ lumbar puncture if CT normal looking for bilirubin & xanthochromia. Cerebral angiogram
• Management:
- airway: intubate if severe hypoxaemia
- fluid: 3L of 0.9% NaCl per 24 hrs
- BP: keep MAP < 130 mm Hg. If higher: IV labetolol or esmolol or enalapril
- Nimodipine 60 mg 6X/day (for 3 weeks)
- Codeine or tramadol for pain (Avoid NSAID) - Phenytoin if seizures have occurred

40

In secondary prevention of stroke, what is the drug treatment used?

• Anti-thombotics: Clopidogrel or Aspirin + Dipyridamole. In atrial fibrillation: Warfarin or NOAC (dabigatran, rixaroxaban, apixaban)

• Blood Pressure: Target BP < 130/80 with calcium channel blocker, thiazide diuretic (e.g. bendroflumethiazide or indapamide), ACE inhibitor (e.g. Perindopril)

• Anti-lipids: If total cholesterol > 4.0 mmol/l (or LDL-C > 2.5mmol/l [100 mg/dl], treat with statin e.g. Simvastatin (but caution in ICH or history of cerebral haemorrhage)

41

What is the MRS assessment?

Modified Rankin Scale (MRS) from 0-6. O= No symptoms, 6= Dead

Measures disability level

42

When should carotid surgery be considered in secondary prevention of stroke?

• Carotid endarterectomy (CEA) should be
considered for all symptomatic stroke/TIA
patients (without severe disability; MRS<3) and with
50-99% stenosis (by NASCET method) or 70-99% (by ECST method)
• CEA should be performed as soon as patient is stable and fit for surgery, ideally within 1 week
• CEA reasonable for asymptomatic stenosis > 60% provided > 5 yr life-expectancy & peri- operative stroke/death rate < 3%

43

What is the long term management of strokes?
Potential issues?

6 mths after stroke, over 50% survivors need some help with their ADL; 15% communication impairment and 53% motor weakness
• Psychosocial and support needs reviewed on regular basis


Potential issues: Communication, mobility, driving, depression, pressure sores, sepsis, nutrition, post-stroke seizure, shoulder pain, cognitive impairment & behavioural problem

44

What is a watershed area?
Name the 3 of the brain?

Areas with dual blood supply, key in limiting damage during an ischaemic stroke

3 watershed areas:
1. Cortical border zone: ACA + MCA
2. Internal border zone: LCA + MCA
3. Cortical border zone: MCA + PCA