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ELM3 - integrated cases > case 14 - collapse > Flashcards

case 14 - collapse Flashcards

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1
Q

What is the clinical name for a stroke?

A

Cerebrovascular Accident (CVA)

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2
Q

What is a cerebrovascular accident/stroke?

A

A clinical term referring to cerebrovascular disease, encompassing those that cause hypoxic iscahemia and haemorrhage

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3
Q

What differentiates a CVA from a TIA?

A

A CVA causes a rapidly developing focal or global lesion that lasts longer than 24 hours often with permanent neurological damage, while a TIA causes a deficit lasting less than 24 hours with complete recovery.

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4
Q

What are the 2 broad categories of stroke?

A

Ischaemic, Haemorrhagic

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5
Q

What are the 2 subtypes of ischemic stroke?

A

Global cerebral ischaemia, focal cerebral ischaemia

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6
Q

What is global cerebral ischaemia?

A

A generalised decrease in cerebral perfusion and hypoxia.

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7
Q

What are some of the causes of global cerebral ischaemia?

A

myocardial infarction, heart failure, cardiac arrest, shock/hypotension

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8
Q

What parts of the brain are most vulnerable to damage in global cerebral ischaemia?

A

‘Watershed areas’ - areas of the brain that lie at the border/distal part of different arterial perfusion areas.

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9
Q

What is focal cerebral ischaemia?

A

An obstruction of blood supply to a localised area of the brain for long enough to cause ischaemic infarction

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10
Q

Which vessel is most commonly involved in infarcts to large vessels of the brain?

A

The MCA - middle cerebral artery

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11
Q

Which areas of the brain are usually impacted by infarcts of small penetrating vessels?

A

Basal ganglia, thalamus, internal capsule

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12
Q

What is the name of an area of vulnerable tissue around an ischaemic area in a stroke?

A

The penumbra

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13
Q

What are the 2 classifications of ischaemic infarcts/strokes?

A

Haemorrhagic infarcts, non-haemorrhagic infarcts

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14
Q

What vascular event most commonly causes a haemorrhagic ischemic infarct?

A

An embolism - a thrombus that has travelled arterially from the periphery

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15
Q

What are some of the common causes of embolism that lead to haemorrhagic ischemic infarcts?

A

Mural thrombi in MI, stasis in AF/valvular disease, thormbosis overlying atherosclerotic plaques, paradoxical emboli from a DVT passing through a septal defect.

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16
Q

What is the gross appearance of a haemorrhagic ischemic infarct in the brain?

A

Multiple petechial haemorrhages and an area of redness

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17
Q

What causes the haemorrhage associated with embolic strokes?

A

Reperfusion of damaged tissue through collateral circulation or following thrombolysis of thromboembolic material and leakage of blood through necrotic vessels.

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18
Q

What is the mechanism of neuronal damage in haemorrhagic ischemic infarcts?

A

decreased perfusion/oxygen supply, cerebral oedema raises ICP, haemorrhage causes vasospasm and neurotoxicity

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19
Q

What vascular event typically causes a non-haemorrhagic ischaemic infarct?

A

A thrombotic event in the brain, such as plaque rupture

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20
Q

What type of arteries is typically involved in thrombotic events within the brain?

A

Medium sized arteries - most prone to plaque rupture

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21
Q

What is the gross appearance of non-haemorrhagic ischaemic infarcts in the brain?

A

A pale, bland appearance, followed later by blurring of the grey-white matter interface

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22
Q

What is the mechanism of neuronal damage in non-haemorrhagic ischaemic infarcts?

A

Lack of oxygen and nutrient supply

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23
Q

What are 2 most common types of haemorrhagic stroke?

A

Hypertensive intracranial bleeding, Subarachnoid haemorrhage

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24
Q

What is hypertensive intracranial bleeding?

A

A type of hameorrahgic stroke where chronic hypertension damages arteries and arterioles causing vessel rupture and intraparenchymal haemorrhage

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25
What is the most common cause of spontaneous subarachnoid haemorrhage?
Rupture of a berry aneurysm in a cerebral artery
26
What are the symptoms of a spontaneous subarachnoid haemorrhage?
Thunderclap headache, signs of meningeal irritation (neck stiffness, photophobia, etc.)
27
Where do berry aneurysms tend to form?
Near the source of cerebral arteries in the circle of willis
28
Why do berry aneurysms form?
Generally due to congenital defects in the arterial wall, leading to the development of aneurysms in childhood, though will generally be benign until old age
29
What are the clinical signs of stroke due to anterior cerebral artery occlusion?
Contralateral hemiplegia and contralateral impaired sensation, both greatest in the lower limb
30
What are the clinical signs of stroke due to middle cerebral artery occlusion?
Contralateral hemiplegia and contralateral impaired sensation, greatest in the upper limb and face. There may be severe aphasia if stroke occurs in the dominant hemsiphere
31
What are the clinical signs of stroke due to posterior cerebral artery occlusion?
Contralateral homonymous hemianopia (loss of vision on half of each eye that is opposite to the side of the occipital lesion)
32
What are the clinical signs of stroke due to posterior inferior cerebellar artery occlusion (AKA lateral medullary syndrome)?
ipsilateral decrease in facial pain and temperature, ipsilateral cerebellar ataxia, contralateral decrease in limb pain and temperature, contralateral dysphagia/dysarthria/vocal cord paralysis/nystagmus
33
What are the lifestyle/modifiable risk factors for cardiovascular disease?
High fat diet, alcohol/drugs, smoking, socio-economic factors
34
What are the comorbidities associated with cardiovascular disease?
Hypertension, elevated LDL, diabetes mellitus, atrial fibrillation, renal disease, atherosclerosis
35
What drugs are risk factors for cardiovascular disease?
HRT, oral contraceptive pill, atypical antipsychotics, COX-2 inhibitors (e.g. diclofenac)
36
What is the total score for the Glasgow Coma Scale?
15
37
What are the 3 components of the glasgow coma scale, and what are their scores out of?
Eye opening (/4), Best verbal response (/5), Best motor response (/6)
38
What are the scores possible for Eye Opening in the glasgow coma scale?
4 = spontaneous 3 = to speech 2 = to pain 1 = none
39
What are the scores possible for Best Verbal Response in the glasgow coma scale?
5 = oriented 4 = confused 3 = inappropriate words 2 = incomprehensible sounds 1 = none
40
What are the scores possible for Best Motor Response in the glasgow coma scale?
6 = obeying 5 = localising 4 = withdrawal 3 = flexing 2 = extending 1 = none
41
What is the range for a ‘mild score’ under the Glasgow Coma Scale?
13-15
42
What is the range for a ‘moderate score’ under the Glasgow Coma Scale?
9-12
43
What is the range for a ‘severe score’ under the Glasgow Coma Scale?
3-8
44
What is the CHA2DS2-VASc score used to determine?
The risk of ischaemic stroke in an individual with Atrial Fibrillation
45
What CHA2DS2-VASc score indicates anticoagualtion therapy with warfarin, dabigatran, etc./
A score of 2 or more
46
Why is it important to establish the last known-well time in a patient presenting with symptoms of stroke?
Used to predict permanent/reversible damage to the brain. May have an effect on the prescription of thrombolytic therapy. Helps to differentiate diagnostically a TIA and CVA
47
What acute general medical care is provided to stroke patients?
Treating elevated blood glucose and elevated/depressed blood pressure
48
What blood test can be used to rule out a key cause of collapse?
Blood sugar - rules out hypoglycaemia
49
What are some things to include in an acute neurological assessment of a patient with a stroke?
Cranial nerve assessment, upper/lower limb power, tone, reflexes, coordination
50
What drugs are often used in the acute treatment of haemorrhagic stroke, and why?
Antihypertensives to reduce ICP, Anticonvulsants in the event of seizure
51
What surgical treatments are there for acute haemorrhagic stroke?
Evacuation, clip/coil of aneurysm
52
What are the key parts in acute treatment of haemorrhagic stroke?
Establishing severity and last known well time, general medical care, blood tests, neurological examination, CT and possibly MRI, surgical intervention, drug therapy (antihypertensives, anticonvulsants)
53
What secondary prevention therapy can be prescribed following haemorrhagic stroke?
Antihypertensives (e.g. calcium channel blockers, ACE inhibitors, ARBs), Antidyslipidaemics, Glycaemic control drugs
54
What are some example of antihypertensives used for secondary prevention therapy of stroke?
Verapamil, enalapril, candesartan
55
What are the parts involved in acute treatment of ischaemic stroke?
Establish last known well time, acute general medical care, blood test, neurological exam, CT to exclude intracerebral haemorrhage, IV alteplase for thrombolysis
56
What thrombolytic drug is indicated up to 9 hours after an ischaemic stroke?
IV alteplase
57
What is the dosing for IV alteplase in stroke patients?
90mg/kg up to 90mg
58
What secondary prevention therapies are prescribed for thrombotic ischaemic stroke?
Dual antiplatelet therapy (aspirin + clopidogrel), antihypertensives, antilipidaemics
59
What imaging and surgery is often required in an embolic ischaemic stroke?
Mechanical thromectomy, doppler of the carotid artery and carotid stenting
60
What secondary prevention therapies are prescribed for embolic ischaemic stroke?
dual antiplatelet therapy (aspirin + clopidogrel), anticoagulants, antihypertensives, antilipidaemics, antiarrhythmics (in AF)
61
What are the brain CT scan findings immediately after an ischaemic stroke?
May be no abnormal findings at all, but sometimes a hyperdense vessel sign is seen
62
What are the brain CT scan findings 24-48 hours after an ischaemic stroke?
Hypodensity (darkness) associated with cerebral oedema at the regions of the ischaemia. There will be a diminished boundary between grey and white matter.
63
What are the brain CT scan findings in a subarachnoid haemorrhage (haemorrhagic stroke)?
Blood in basilar cisterns (dancing man sign), blood in pericallosal cistern superior to the corpus callosim. Blood in sulci
64
What are some example of healthcare professionals involved in stroke management?
Physiotherapist, Occupational therapist, District nurse, Pharmacist, Dietician, HCA/carer, Speech-language therapist, Psychologist/counsellor, Social worker
65
What are some of the conditions that may mimic stroke symptoms, and therefore are often differential diagnoses?
Alcohol intoxication, drug overdose, cerebral infections, drug overdose, epidural hematoma, hypoglycemia, metabolic disorders, migraines, Bell’s Palsy, seizure, brain tumors
66
What are the assessment/management strategies for a paramedic/first responder to a suspected stroke patient?
Support ABC (Airway, Breathing, Circulation) providing oxygen therapy if required, perform stroke assessment, establish last known well time, check blood glucose level, identify current medications and medical conditions including history of stroke, provide advance notification to the hospital.

ELM3 - integrated cases (2 decks)

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