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Stage 2: Supporting Life > Stroke + Differentials > Flashcards

Stroke + Differentials Flashcards

1
Q

What % of strokes are ischaemic and what % are haemorrhagic?

A

85% ischaemic

15% haemorrhagic

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2
Q

What anatomical factors cause intracerebral haemorrhage?

A

1) Small vessel disease
2) Amyloid angiopathy
3) AVMs

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3
Q

What haemodynamic factor causes intracerebral haemorrhage?

A

Hypertension

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4
Q

What haemostatic factors cause intracerebral haemorrhage?

A

1) Anticoagulants
2) Anti-platelets
3) Thrombolytics

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5
Q

What other factors cause intracerebral haemorrhage?

A

1) Recreational drugs

2) Vasculitis

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6
Q

Describe amyloid angiopathy related haemorrhage

A
  • Amyloid deposition in cortical artery muscle layers
  • Typically causes local intracerebral haemorrhage or ICH at grey/white matter border
  • Prone to recurrence
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7
Q

What are 8 causes of ischaemic stroke?

A

1) Intracranial atherosclerosis
2) Penetrating artery disease
3) Carotid plaque with arteriogenic emboli
4) Flow reducing carotid stenosis
5) Cardiogenic emboli
6) AF
7) Valve disease
8) Left ventricular thrombi

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8
Q

What are 4 major risk factors for ischaemic stroke?

A

1) Hypertension
2) Smoking
3) Diabetes
4) Hyperlipidaemia

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9
Q

What does a stroke examination consist of?

A

1) GCS
2) Temperature
3) Pulse (fibrillation)
4) BP
5) Heart sounds → murmurs, septal defects
6) Carotid bruits
7) Evidence of aspiration
8) Neurological deficit → visual, speech, facial, motor, sensory

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10
Q

What investigations do you need to do on someone with a stroke?

A

1) ECG

2) Blood tests → haemoglobin, platelets, clotting, biochemistry

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11
Q

In what timeframe do all patients need a brain scan?

A

< 1hr

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12
Q

Which patients need a brain scan urgently?

A

1) Unconscious
2) Deteriorating conscious level
3) On anticoagulants
4) Presentation within thrombolysis window of opportunity

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13
Q

What area is a key collateral circulation?

A

Circle of Willis

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14
Q

What are the 3 vascular territories of the cerebral hemisphere?

A

Anterior, middle and posterior cerebral

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15
Q

What are the signs of a lesion in the ACA?

A

1) Contralateral hemiparesis → leg more than arm/face

2) Cortical signs → emotional changes, dysphagia (left ACA)

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16
Q

What are the signs of a lesion in the MCA?

A

1) Contralateral hemiparesis → arm/face more than leg
2) Contralateral hemisensory loss
3) Cortical signs → contralateral heminopia, contralateral hemineglect, dysphagia (left MCA)

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17
Q

What are the signs of a lesion in the posterior cerebral artery?

A

1) Contralateral heminopia

2) Contralateral hemineglect

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18
Q

What are the signs of a lesion in the vertebrobasilar territory?

A

1) Nausea and vomiting
2) Diplopia
3) Vertigo and nystagmus (involuntary eye movement)
4) Ataxia
5) Hemi/quadriplegia
6) Visual field defect
7) Coma

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19
Q

What are the signs of a lacunar stroke (small vessel)?

A

1) Pure hemiparesis
2) Pure hemisensory loss
3) Sensorimotor stroke
4) Ataxic hemiparesis
NO CORTICAL FEATURES

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20
Q

What are the 3 steps to diagnosing the type of stroke?

A

1) Anatomy → Where is the lesion? Which side? Which territory?
2) Pathology → What is the lesion - infarct or haemorrhage?
3) Aetiology → Why has it occurred? e.g. large artery/small vessel disease, PMG, FH, SH, risk factors

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21
Q

What is a TIA?

A

An acute loss of focal cerebral or monocular function

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22
Q

How long do symptoms of a TIA last?

A

< 24h

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23
Q

Why do TIAs occur?

A
  • Inadequate cerebral/ocular blood supply

- Result of arterial thrombosis or embolism → artery, cardiac or haematological disease

24
Q

What does TIA stand for?

A

Transient ischaemic attack

25
Q

How do you diagnose a TIA?

A
  • Clinical diagnosis without a specific diagnostic test

- Rely on a constellation of clinical features

26
Q

What are non-focal neurological symptoms?

A

Symptoms which do not suggest a TIA unless accompanied by focal neurological symptoms

27
Q

What are examples of non-focal neurological symptoms

A

1) Faintness
2) Non-specific dizziness
3) Light-headedness
4) Confusion
5) Mental disorientation
6) Incontinence
7) Drop attacks
8) Syncope

28
Q

What are 6 causes of transient focal neurological attacks?

A

1) TIA (focal cerebral ischaemia)
2) Migraine with aura (with or without headache)
3) Partial (focal) epilepsy
4) Transient global amnesia (TGA)
5) Multiple sclerosis
6) Labyrinthine disturbances → Meniere’s disease, BPPV, benign recurrent vertigo, labyrinthitis/vestibular necrosis

29
Q

What 5 conditions starting with S does stroke mimic?

A

1) Syncope
2) Seizures
3) Sepsis
4) Space occupying lesion (tumour)
5) Somatisation

30
Q

In what kind of patients does migraine with aura tend to occur?

A

Younger patients (than stroke) with a family history

31
Q

What is migraine with aura?

A

A positive phenomena, usually < 60 mins that doesn’t leave any residual deficit
- Progression from one symptom to another without delay e.g. visual symptoms to parasthaesiae to dysphagia

32
Q

Describe the visual symptoms of migraine with aura

A
  • Can be homonymous, unilateral or central

- Flashes of light, zig-zag lines, scintillations, fortification spectra which usually build up or expand

33
Q

Describe the sensation symptoms of migraine with aura

A
  • Parasthaesiae or heaviness in one or other limbs

- Evolves/spreads within several minutes in marching pattern hand to elbow then face into tongue

34
Q

What is epilepsy?

A

A focal, sudden positive sensory or motor phenomena

35
Q

What are the symptoms of epilepsy?

A
  • Multiple attack of pins and needles on one side of limbs
  • Sensation will start somewhere and then spread v quickly to adjacent body parts over seconds/1 min
  • Focal jerking
  • Altered awareness
36
Q

How is epilepsy different from TIA or migraine time wise?

A
  • Epilepsy spreads over seconds
  • Migraine over minutes
  • TIA tingling arises in all affected body parts at the same time
37
Q

What is transient global amnesia (TGA)?

A

A sudden disorder of memory in middle-aged or elderly patients

38
Q

What happens in TGA?

A
  • For a period (some hours), patient cannot memorise any current/new information (anterograde amnesia)
  • They often also can’t recall events of the past few days/weeks (retrograde)
  • After a few hours, they return back to normal without any neurological signs
  • Might be asking same questions repeatedly, although orientated
39
Q

How might someone with a glioma with vasogenic oedema present?

A
  • Week history of sudden onset weakness in left hand which lasted several minutes (suspect TIA but no vascular risk factors)
  • Motor and sensory examination normal (but patient says hand doesn’t feel right)
  • History of profound weight loss for 6 months with occasional headaches for the last month
40
Q

How do you work out if neurological symptoms are due to vascular pathology (cerebral ischaemia/haemorrhage)?

A

1) If they are focal rather than non-focal
2) If the focal symptoms are negative rather than positive
3) Sudden onset
4) Maximal at onset rather than progressing over a period
IF YES to all questions, then likely to be vascular

41
Q

What is the relative risk reduction of aspirin, statins and BP lowering in most patients?

A

Aspirin = 20%
Statin = 20%
BP lowering = 30%

42
Q

What treatment will be given to a patient who had a TIA who has right internal carotid artery stenosis?

A

Carotid endarterectomy (removal of plaque) 2 days after presentation

43
Q

What are the 5 treatments for stroke?

A

1) Stroke units
2) Intravenous thrombolysis
3) Intra-arterial interventions
4) Surgery for haemorrhagic stroke
5) Preventing complications

44
Q

Why is it important to open up the blocked artery as soon as possible?

A

Time is brain → to reduce irreversible brain damage and dead infarcted tissue

45
Q

What is an example of an intra-arterial intervention?

A

Endovascular thrombectomy → removing clot from artery

46
Q

What can be used to treat severe stroke?

A

Hemicraniectomy → half of scalp removed, relieves pressure (can recover relatively well)

47
Q

Describe the patient who might need a hemicraniectomy

A
  • Aphasic (can’t speak or follow commands)
  • Gaze paresis (eyes deviate to left)
  • Right sided heminopia, neglect, hypotonia, weakness, sensory deficit, extensor plantar response
  • Normal left sided neurology
  • Right handed?
48
Q

What is used to prevent complications/stroke?

A

MRI imaging of proximal DVT and PE

49
Q

What treatment can be used to reduce risk of DVT in patients who have had a stroke?

A

Intermittent pneumatic compression

50
Q

What is hemiplegia?

A

Paralysis of one side of the body

51
Q

What may some ischaemic strokes be preceded by that act as warning signs?

A

TIAs

52
Q

What is a stroke?

A
  • Irreversible brain damage caused by a sudden interruption to the vascular supply leading to cerebral ischaemia
  • Brain cells no longer receive oxygen, become hypoxic, swell and die
53
Q

What are the two types of causes of stroke?

A

Embolic/thrombotic

54
Q

What are embolic clots?

A

Blood clots that form elsewhere, travel and lodge in end vessels

55
Q

What are thrombotic clots?

A

Blood clots that form locally, usually at an area where the wall is affected by atherosclerosis → these clots gradually increase and eventually block the vessel

Stage 2: Supporting Life (30 decks)

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