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Nervous System > Cerebral Infarction > Flashcards

Cerebral Infarction Flashcards

1
Q

Define stroke

A

Sudden onset of focal or global neurological symptoms cause by ischaemia or haemorrhage and lasting more than 24hrs

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2
Q

Define TIA

A

Term used if the symptoms resolve within 24 hours

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3
Q

Name six causes of an ischaemic stroke

A
  • Large artery atherosclerosis
  • Cardioembolic
  • Small artery occlusion
  • Undetermined/cryptogenic

Rare causes
• Arterial dissection
• Venous sinus thrombosis

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4
Q

Name three causes of haemorrhage stroke

A

• Primary intracerebral haemorrhage
• Secondary haemorrhage
o Subarachnoid haemorrhage
o Arteriovenous malformation

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5
Q

What are the two types of strokes?

A

Ischaemic and haemorrhagic

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6
Q

What is the incidence and impact of stroke?

A
  • 150 000 new strokes/year in UK
  • 67 000 deaths/year in UK
  • Stroke risk increases with age
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7
Q

Name four non-modifiable risk factors for stroke

A
  • Previous stroke
  • Elderly
  • Male
  • Family history
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8
Q

Name six modifiable risk factors for stroke

A

• Hypertension

  • Smoking
  • Cholesterol
  • Diet, high BMI, sedentary
  • Alcohol
  • Diabetes
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9
Q

How does hypertension impact risk of stroke?

A
  • Stroke risk is related to blood pressure level
  • Chronic hypertension worsens atheroma and affects small distal arteries
  • Hypertension is a major risk factor for haemorrhagic strokes as well
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10
Q

How does smoking impact risk of stroke?

A
  • 2-fold increase risk of cerebral infarction

* 3-fold increase risk of sub-arachnoid haemorrhage

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11
Q

How does diabetes impact risk of stroke?

A

Increases incidence of stroke up to 3-fold in both sexes.

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12
Q

How do lipids impact risk of stroke?

A
  • Increase serum lipids increase stroke risk due to blood vessel wall atheroma
  • Increase plasma level of low density lipoprotein (LDL) results in excessive amounts of LDL within the arterial wall
  • Hypertension, cigarette smoke and diabetes contribute to LDL-C deposition in arterial walls
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13
Q

How does alcohol impact risk of stroke?

A
  • Small amounts of alcohol decrease stroke risk

* Heavy drinking increase risk 25-fold

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14
Q

What are other risk factors?

A
  • Impaired cardiac function – recent heart attack, atrial fibrillation
  • Oral contraceptives (+hormone replacement therapy) with a high oestrogen content – progesterone-only are ok.
  • Hypercoagulable states – malignancy, genetic
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15
Q

Describe the pathophysiology of ischaemic stroke

A
  1. Failure of the cerebral blood flow to a part of the brain, caused by an interruption of the blood supply to the brain
    • Can be transient (as in TIA)
    • Results in varying degrees of hypoxia
  2. Hypoxia stresses the brain cell metabolism. This is especially important in the ischaemic penumbra. If prolonged, the hypoxia -> anoxia (no oxygen).
  3. Anoxia -> infarction (complete cell death, leading to necrosis). This is a stroke.
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16
Q

How does further damage occur after a stroke?

A
  • Oedema – depending on the size + location of the stroke

* Secondary haemorrhage into the stroke

17
Q

What three cerebral arteries form the anterior circulation of the brain?

A
  • Internal carotid arteries
  • Anterior cerebral artery (ACA)
  • Middle cerebral artery (MCA)
18
Q

What three cerebral arteries form the anterior circulation of the brain?

A

• 2 vertebral arteries -> 1 basilar
• 3 cerebellar arteries
Posterior cerebral artery (PCA

19
Q

What are the effects of an anterior cerebral artery occlusion?

A

Contralateral
• Paralysis of foot and leg
• Sensory loss over foot and leg
• Impairment of gait and stance

20
Q

What are the effects of a middle cerebral artery occlusion?

A

• Contralateral
o Paralysis of face/arm/leg
o Sensory loss face/arm/leg
o Homonymous hemianopia
• Gaze paralysis to the opposite side
• Aphasia if stroke on dominant (left) side
• Unilateral neglect and agnosia for half of external space if non-dominant stroke (usually right side)

21
Q

What are the effects if an occlusion of the middle cerebral artery occlusion occurs in the right hemisphere?

A

Left hemiplegia, homonymous hemianopia

Neglect syndromes (agnosia):
• Visual agnosia 
• Sensory agnosia 
• Anosagnosia (denial of hemiplegia)
• Prosopagnosia (failure to recognise faces)
22
Q

What type of stroke occurs if a branch of the MCA supplying basal ganglia is occluded?

A

Lacunar stroke

23
Q

What are the symptoms of a lacunar stroke?

A
  • Devoid of cortical signs – i.e. no dysphasia, neglect, hemianopia
  • Pure motor stroke
  • Pure sensory stroke
  • Dysarthria – clumsy hand syndrome
  • Ataxic hemiparesis
24
Q

What structures are supplied by the posterior circulation?

A
  • Brainstem
  • Cerebellum
  • Thalamus
  • Occipital lobe
  • Medial temporal lobe
25
Q

What are the symptoms of brainstem dysfunction?

A
  • Coma, vertigo, nausea, vomiting, cranial nerve palsies, ataxia
  • Hemiparesis, hemisensory loss
  • Crossed sensori-motor deficits
  • Visual field deficits
26
Q

What are the investigation for stroke?

A
  • Bloods - FBC, glucose, lipids, ESR
  • CT or MRI - infarct vs haemorrhage
  • ECG
  • Echo
  • Carotid doppler USS - stenosis
  • Cerebral angiogram/venogram - vasculitis
  • Hypercoagulable blood screen
27
Q

What are three aims of therapies for acute ischaemia?

A
  • Restore blood supply
  • Prevent extension of ischaemic damage
  • Protect vulnerable brain tissue
28
Q

What is the acute treatment for stroke?

A
  1. Thrombolysis (Tissue Plasminogen Activator – TPA)

But, if they have contraindications, they should be offered:

  1. Aspirin
  2. Intra-arterial therapy/thrombectomy
29
Q

What are five different treatments for secondary prevention of stroke?

A
  • Antihypertensives
  • Anti-platelet
  • Lipid lowering agents
  • Warfarin for AF
  • Carotid endarectomy NNT of 3
30
Q

What does management strategies for stroke after an episode involve?

A
  • Prevention of stroke recurrence
  • Prevention of complication related to stroke
  • Rehabilitation
  • Re-integration into community
31
Q

Name five objectives of stroke care

A
  • Reduce mortality
  • Reduce residual disability amongst survivors
  • Improve psychological status of patients and care-givers
  • Improve patient/care giver knowledge
  • Maximise quality of life
32
Q

What is the criteria for TPA use?

A
  • < 4.5hrs from symptoms onset
  • Disabling neurological deficit
  • Symptoms present > 60 mins
  • Consent obtained
33
Q

What is the exclusion criteria for IV TPA?

A 
Anything that increases the possibility of haemorrhage:
   • Blood on CT scan 
   • Recent surgery 
   • Recent episodes of bleeding 
   • Ataxic hemiparesis 
   • Coagulation problems 
• BP > 185 systolic or > 110 diastolic 
• Glucose < 2.8 or > 22mmol/L
34
Q

Name different staff on a stroke unit

A
  • Clinical staff
  • Stroke nurses
  • Physiotherapists
  • Speech and language therapists
  • Occupational therapists
  • Dietitian
  • Psychologist
  • Orthoptist

Nervous System (47 decks)

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