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Neurology > Stroke > Flashcards

Stroke Flashcards

1
Q

Define a stroke

A

A stroke involves, usually permanent, neurological deficit lasting >24 hours

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2
Q

Define a TIA

A

A TIA involves a brief episode of neurological dysfunction without permanent effects lasting <24 hours

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3
Q

What is the proportion of stroke that is ischaemic? And what proportion is haemorrhagic?

A

15% are haemorrhagic

85% are ischaemic

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4
Q

Within ischaemic stroke, what are the different types?

A

Atherosclerosis

Cardioembolic

Other

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5
Q

Within haemorrhagic stroke, what are the different types?

A

Intracerebral

and subarachnoid

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6
Q

What do A and B represent?

A

A: Broca’s area

B: Wernicke’s area

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7
Q

Which lobes do each of the coloured areas represent?

A

Blue: frontal lobe

Yellow: parietal lobe

Green: temporal lobe

Red: occipital lobe

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8
Q

What functions is the frontal lobe responsible for?

A
  • Motor function
  • Higher cognition
    • thought processing
    • reasoning
    • intelligence
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9
Q

What functions is the parietal lobe responsible for?

A
  • Sensory function
  • Sensory association
  • Vision
    • fibres for lower quadrant visual field
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10
Q

What functions is the temporal lobe responsible for?

A

Temporal lobe

  • language
  • hearing
  • vision
    • fibres for upper quadrant visual field
  • memory and emotion
  • association
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11
Q

What functions is the occipital lobe responsible for?

A

vision

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12
Q

What functions is the cerebellum responsible for?

A

Cerebellum

  • Balance
  • Movement
  • Coordination
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13
Q

The following areas are (generally) supplied by which arteries?

  1. Red
  2. Yellow
  3. Blue
A
  1. Middle cerebral artery
  2. Anterior cerebral artery
  3. Posterior cerebral artery
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14
Q

The following areas are supplied (generally) by which arteries?

  1. Blue
  2. Red
  3. Yellow
A
  1. Posterior cerebral artery
  2. Middle cerebral artery
  3. Anterior cerebral artery
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15
Q

Why do motor and sensory deficits often occur together?

A

Because the brain regions responsible for them are beside each other

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16
Q

Label the main arteries that supply the brain in this diagram of *what*?

A

The Circle of Willis

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17
Q

Which lobe/lobes do the anterior cerebral arteries supply?

A

Frontal

Parietal

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18
Q

Which lobe/lobes do the middle cerebral arteries supply?

A

Frontal

Parietal

Temporal

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19
Q

Which lobe/lobes do the posterior cerebral arteries supply?

A

Occipital

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20
Q

What is the Oxford Classification of Stroke?

A

It categorises stroke based on the inital presenting symptoms and clinical signs

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21
Q

Does the Oxford Classification of Stroke provide a diagnosis?

A

No, it’s essentially a working diagnosis before imaging which can give an idea of where to look for the causative issue

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22
Q

What are the four different categories a stroke could fit under in the Oxford Classification of Stroke?

A

TACS (total anterior circulation stroke)

PACS (partial anterior circulation stroke)

LACS (lacunar syndrome)

POCS (posterior circulation syndrome)

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23
Q

What is a TAC?

A

A Total Anterior Circulation Stroke

a large stroke affecting a large vessel

of the anterior circulation and :.

many smaller downstream vessels

supplying various brain regions

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24
Q

In a TAC

A) Which part of the brain circulation is disrupted?

B) Which arteries are disrupted?

C) Which brain lobes are affected?

A

A) Anterior circulation

B) Anterior and middle cerebral arteries

C) Frontal, parietal and temporal

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25
Q

What clinical features are associated with a TAC?

How many of these features are required for a diagnosis?

A

Need all 3 of:

  1. Motor or sensory deficit (usually contralateral)
    • hemiplegia involving at least 2 of face, arm and leg +/- hemisensory loss
  2. Hemianopia (usually contralateral)
  3. Higher cortical dysfunction
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26
Q

What is a PAC?

A

Partial Anterior Circulation Syndrome

a smaller (compared to TAC) stroke affecting a smaller vessel of the anterior circulation

:. less downstream arteries are affected

and not all functions of the anterior circulation are disrupted

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27
Q

What clinical features are associated with PACS?

How many of these are required for a diagnosis?

A

2 of:

  1. Motor or sensory deficit
  2. Hemianopia
  3. Higher cortical dysfunction
    • dysphasia, neglect

(same as TAC but only need 2 of 3)

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28
Q

What is a LAC?

A

A Lacunar infarct

the mildest of strokes affecting the smallest vessels.

The deep perforating arteries supply specific areas and infarction results in

  • specific,
  • yet minimal symptoms

associated with the posterior or anterior circulations

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29
Q

What clinical features are associated with LACS?

How many are required for a diagnosis?

A

1 of:

  1. Pure motor deficit
  2. Pure sensory deficit
  3. Sensory and motor deficit
  4. Ataxic hemiparesis
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30
Q

There are specific features which, if present, mean you can’t diagnose someone with a LAC.

What are they?

Why?

A
  • Higher cortical dysfunction
  • Posterior circulation syndrome symptoms

because the corresponding regions are not supplied by deep perforating vessels

31
Q

What is a POCS?

A

a posterior circulation syndrome

large stroke affecting

vertebrobasilar vessels and their branches

which supply:

  • occipital lobe
  • brain stem
  • cerebellum
32
Q

as well as ……. what do vertebrobasilar vessels also supply

A

Occipital lobe

Brain stem

Cerebellum

vertebrobasilar vessels also contribute greatly to the…

Circle of Willis

33
Q

What clinical features are associated with a POCS?

A
  1. Isolated hemianopia
  2. Bilateral motor and sensory deficit
  3. Brain stem signs and symptoms
  4. Cranial nerve deficits
  5. Cerebellar signs and symptoms
34
Q

How many of the five features of a POCS are required to diagnose it?

A

Any

35
Q

Are there any specific features that mean you should rule out POCS?

A

No

36
Q

Ok, so someone presents with any of the symptoms previously discussed

What now?

A

CT SCAN!

37
Q

Pt X presents and clinically you’re very suspicious of a stroke.

You’ve CT scanned them and it looks normal.

Now what?

A

MRI them!!

CT scan shows less detail so often (esp. in more acute strokes) the ischaemic damage doesn’t show up well and an MRI is needed to locate the damage

38
Q

What colour does blood show up as on a CT scan?

A

Acutely (within 3 days) blood shows up WHITE on a CT scan

After this, it is broken down and becomes BLACK on a CT scan

39
Q

What does ischaemia look like on a CT scan?

A

Ischaemia looks darker on a CT scan

40
Q

When looking for ischaemia on a CT scan, what should you be looking for?

A
  • loss of sulci
  • loss of grey/white matter definition
  • dense MCA
    • it is common
41
Q

What can be seen on this image?

What imaging modality is this?

A

CT Scan

MCA Infarct

(this is a common cause for stroke so it’s good to look out for)

42
Q

Is there any damage?

Where is it?

A

Yes

(See circled)

There is loss of sulci definition and grey/white matter definition

This is ischaemic damage

43
Q

What are the two main types of ischaemic stroke?

Are they treated differently?

A

Atherosclerotic and Cardioembolic

In terms of acute treatment, ischaemic stroke is ischaemic stroke regardless of its underlying cause.

In the long-term, the treatment differs slightly.

44
Q

You’ve done a CT and confirmed acute ischameic stroke

How do you manage it?

A
  1. Thrombolysis (alteplase); within 4.5 hrs
  2. Antiplatelet (aspirin 300mg); start within 24 hours and continue daily for 2 weeks

Thrombectomy in some cases

45
Q

You do a CT and it confirms acute haemorrhagic stroke.

How do you manage it?

A

Less clear cut than ischaemic stroke…

  • Decompressive surgery?
  • Surgical intervention?
    • surgical clipping
    • endovascular technique
  • lower BP if high
46
Q

What is the long-term management for atherosclerotic stroke?

A
  1. Antiplatelet (clopidogrel 75mg)
    • after 2 weeks aspirin is replaced with clopidogrel for life
  2. Statin (atorvostatin)
    • start within 48 hrs of stroke symptoms and continue lifelong
    • if a patient is already on a statin then continue
47
Q

What is the long-term management for a cardioembolic stroke?

A
  1. Anticoagulant (warfarin)
    • review after 2 weeks for anticoagulant therapy
  2. Statin (atorvastatin)
    • start within 48 hours of stroke symptoms and continue lifelong
    • if patient is already on a statin then continue
48
Q

What is the long-term management of a haemorrhagic stroke?

A

Monitor B.P

49
Q

Typical example of stroke

A

Hemiplegia following infarct of MCA

50
Q

What is a completed stroke?

A

The deficit has become maximal, usually within 6 hours

51
Q

What is a stroke-in-evolution?

A

describes progression during the first 24 hours

52
Q

What is a minor stroke?

A

patients recover without significant deficit, usually within a week

53
Q

What is a Rosier score?

A

Loss of consciousness/syncope: - 1 point

Seizure: - 1 point

New, acute onset:

  • asymmetrical facial weakness + 1
  • asymmetrical arm weakness + 1
  • asymmetrical leg weakness + 1
  • speech disturbance + 1
  • visual field defect + 1

Score >0 a stroke is likely

Score < or equal to 0, stroke is not likely but not excluded

54
Q

In a TACS where is the occlusion likely to be?

A

either the internal carotid or the MCA on one side

55
Q

How might a TACS present?

A
  • Homonymous hemianopia
  • Cortical signs (dysphasia, neglect)
  • Complete hemiparesis
  • Hemisensory loss
  • Incontinence
  • Forced deviation of eye towards the side of the stroke
56
Q

How might a PACS present?

A

Isolated hemiparesis

Pure hemisensory loss

Hemiparesis with limb ataxia

57
Q

How might an POCS present?

A
  • severe truncal ataxia (midline vermis lesion)
  • limb clusminess
    • signs ipsilateral to cerebral hemisphere damage
  • gaze palsies
  • respiratory rhythm disturbance
  • hemiparesis
    • contralateral
58
Q

What are the classical symptoms of a large medullary syndrome?

A
  1. ipsilateral facial parasthesia or pain
  2. severe vertigo and vomiting
  3. dysphagia
  4. dysphonia
  5. ataxia
  6. contralateral limb sensory impairment
59
Q

You examine a patient and realise they are presenting with a Horner’s syndrome,

what might be going on?

A

Large medullary syndrome

can present with:

  • ipsilateral facial loss of pain and temp
  • contralateral limb spinothalamic sensory impairment
60
Q

What are the potential causes of a subarachnoid haemorrhage?

A

Saccular (berry) anaeurysms (70%)

Arteriovenous malformation (10%)

No arterial lesion found (15%)

61
Q

What are the different types of intracranial haemorrhage?

A
  • Intracerebral haemorrhage (10% of strokes)
  • Cerebellar haemorrhage
  • Subarachnoid haemorrhage (5% of strokes)
  • Subdural haemorrhage
  • Extradural haemorrhage
62
Q

What are the clinical features of a subarachnoid haemorrhage?

A
  • sudden, devastating headache, often occipital
    • usually followed by vomiting & often coma and death
  • survivors may remain comatose or drowsy for hours, days or longer
  • major SAH: neck stiffness & positive Kernig’s sign (meningitis)
  • papilloedema sometimes
  • CSF v bloody
63
Q

What is the first investigation in suspected subarachnoid haemorrhage?

A

Investigate immediately with non-contrast CT

Subarachnoid and/or intraventricular blood is usually seen (caused by APKD and Ehlers Danlos Syndrome)

64
Q

You suspect subarachnoid haemorrhage in a pt. You immediately do a non-contrast CT and the CT appears normal.

What next?

A

Lumbar puncture is not necessary if SAH is confirmed by CT,

but should be performed is doubt remains.

Visual inspection of CSF is usually sufficiently reliable for diagnosis

65
Q

How do you manage subarachnoid haemorrhage?

A

bed rest and supportive measures

control hypertension

dexamethasone often prescribed to reduce cerebral oedema & believed to stablise the blood-brain barrier

Nimodipine (calcium-channel blocker) reduces mortality

In selected cases, surgical (clip accessible anaeurysms) results are excellent

66
Q

What type of intracranial haemorrhage usually follows a head injury?

A

Subdural

67
Q

How might a subdural haemorrhage present?

A

Headache, drowsiness and confusion all common

Focal deficits (hemiparesis, sensory loss) develop

Epilepsy occasionally occurs

Stupor, coma and coning may follow

68
Q

What are the timings of the signs & symptoms of a subdural haemorrhage?

A

Interval between injury and symptoms can be days, weeks or months

Symptoms are indolent and can fluctuate

69
Q

What kind of subarachnoid haemorrhage is common in the elderly?

A

Chronic, apparently spontaneous SDH

Also occurs with anticoagulents

70
Q

Where does an extradural haemorrhage occur?

A

Between bone and dura

71
Q

Trauma to which area of the skull is likely to cause an extradural haemorrhage?

A

Pterion

72
Q

How does an extradural haemorrhage usually present?

A

Characteristic picture:

head injury with a brief duration of unconsciousness, followed by improvement (the lucid interval)

The patient then becomes stuporose, with an ipsilateral dilated pupil and contralateral hemiparesism with rapid transtentorial coning

Bilateral, fixed dilated pupils, tetraplegia and respiratory arrest follow

73
Q
A

Neurology (6 decks)

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