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NEURO > Cerebral infarction (CLINICAL) > Flashcards

Cerebral infarction (CLINICAL) Flashcards

1
Q

at what age do the majority of strokes occur

A

~75% in >65 yr olds

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2
Q

define stroke

A

the sudden onset of focal or global neurological symptoms caused by ischemia or hemorrhage and lasting more than 24 hours

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3
Q

define transient ischaemic attack (TIA)

A

the term used if the symptoms resolve within 24 hours

most resolve within 1-60 mins

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4
Q

what is more common - ischaemic or haemorrhagic stroke

A

ischaemic - 85%

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5
Q

what are the most common causes of ischaemic stroke

A
  1. Large artery atherosclerosis (e.g. Carotid - 35%
  2. Cardioembolic (e.g. atrial fibrillation) - 25%
  3. Small artery occlusion (Lacune) - 25%
  4. Undetermined/Cryptogenic 10-15%
  5. Rare causes - <5%
    - Arterial dissection
    - Venous sinus thrombosis
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6
Q

what are the causes of haemorrhagic stroke

A
  1. Primary intracerebral haemorrhage - 70%
  2. Secondary haemorrhage - 30%
    - Subarachnoid hemorrhage
    - Arteriovenous malformation
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7
Q

what are the investigations for stroke

A

blood tests - FBC, glucose, lipids, ESR

CT or MRI head - infarct vs haemorrhage

ECG - ?AF, LVH

Echocardiogram - valves, ASD, VSD, PFO

carotid doppler US - ?stenosis

Cerebral angiogram/venogram - ?vasculitis

hyper-coagulable blood scan

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8
Q

what can conditions can present like stroke but are not stroke

A

Post-ictal states (e.g. Todd’s paralysis)

Hypoglycemia

Intracranial masses

Vestibular disease

Bell’s palsy

Functional hemiparesis

Migraine

Demented patients with UTIs

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9
Q

what is the incidence and impact of stroke

A

2nd, 3rd cause of death in developed countries

number 1 cause of disability in adults

150,000 new stroked/year in the UK

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10
Q

what is the public awareness campaign for stroke

A

act FAST

F- facial weakness
A - arm weakness
S - speech problems
T - time to call 999

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11
Q

what are the 4 basic steps in the pathophysiology of stroke

A
  1. ischaemia develops
  2. results in hypoxia
  3. leads to anoxia
  4. leads to infarction
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12
Q

explain the ischaemic stage of stroke pathophysiology

A

ischaemia:

  • 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 (decreased oxygen)
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13
Q

explain the hypoxic stage of stroke pathophysiology

A

hypoxia:

  • stresses the brain cell metabolism (especially important in the ischameic penumbra)
  • if prolonged hypoxia - leads to anoxia (no oxygen)
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14
Q

explain the anoxic and infarction stages of stroke pathophysiology

A

anoxia:
- leas to infarction

infarction:

  • complete cell death leading to necrosis
  • this is a stroke
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15
Q

what can further damage result from in stroke

A

edema - depending on size and location of stroke

secondary haemorrhage into the stroke

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16
Q

what is the penumbra

A

the area surrounding an ischemic event such as thrombotic or embolic stroke - oxygen supply to this area is also disrupted - leads to hypoxia in the surrounding area

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17
Q

how can total arterial occlusion develop in ischaemic stroke

A
  1. disruption/injury to a plaque surface
  2. platelet adhesion/aggregation and fibrin formation on plaque
  3. thrombus formation
  4. leads to total arterial occlusion due to thrombus

if parts of the thrombus break off and block further areas = embolus

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18
Q

what are the two groups of risk factors for stoke and give examples of each

A

modifiable

  • hypertension
  • smoking
  • cholesterol
  • diet
  • high BMI
  • alcohol

non-modifiable

  • previous stroke
  • age
  • male
  • family history

diabetes

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19
Q

what is the most important modifiable risk factor for stroke and why

A

HYPERTENSION
- stroke related to blood pressure level

  • chronic worsens atheroma and affect small distal arteries
  • reach elderly populations
  • majority poorly treated

**major risk factor for haemorrhagic stroke as well

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20
Q

how can increased serum lipids, hypertension, smoking and diabetes increase the risk of stroke

A

all contribute to LDL-C deposition in arterial walls

increased plasma level LDL = excessive amounts of LDL in the arterial walls

= blood vessel wall atheroma

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21
Q

what are three other risk factors for stroke not already mentioned

A

impaired cardiac function
- recent MI, AF

OCP (+HRT)

  • high oestrogen bad
  • progesterone only ok

hyper-coagulable states

  • malignancy
  • gentic
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22
Q

what is the anterior blood supply to the brain

A

2 x Internal carotid arteries

2 x Anterior Cerebral Artery (ACA)

2 x Middle Cerebral Artery (MCA)

2 x Posterior Communicating Artery (PComA)

23
Q

what is the posterior circulation to the brain

A

2 Vertebral arteries →1 basilar

3 pairs of cerebellar arteries (ant/post inferior, superior)

2 Posterior cerebral artery (PCA)

24
Q

what do the anterior and posterior circulation join to form

A

the circle of willis

25
Q

what are symptoms of ACA occlusion

A

CONTRA-LATERAL

  • paralysis of foot and leg
  • sensory loss over foot and leg
  • impairment of gate and stance
26
Q

what are the symptoms of MCA occlusion

A

CONTRA=LATERAL

  • paralysis of face/arm/leg
  • sensory loss face/arm/leg
  • homonymous hemianopia

gaze deviation to same side from paralysis to the opposite side

e.g. left MCA occlusion
= gaze deviation to left BUT muscles on right paralysed

27
Q

what other symptoms would be seen if there was MCA occlusion on the dominant side

A

if stroke on dominant side (usually left) =

dys/aphasia (difficulty with language or speech)

28
Q

what other symptoms would be seen if there was MCA occlusion on the non- dominant side

A

if stroke on non-dominant side (usually right) =

unilateral neglect

visual and sensory agnosia (inability to recognise things) for half of external space

anosagnosia - denial of hemiplegia

prosopagnosia - failure to recognise faces

29
Q

what is the arterial supply of the basal ganglia

A

the small penetrating (lacunar) arteries of the MCA

30
Q

what does loss of circulation to the basal ganglia cause

A

lacunar ischaemic stroke

31
Q

what are lacunar stroke syndromes

A

devoid of “cortical” signs
- eg no dysphasia, neglect, hemianopia

  • pure motor stroke
  • pure sensory stroke
  • dysarthria - clumsy hand syndrome
  • ataxic hemiparesis
32
Q

what structures are involved in posterior circulation symptoms

A 
brainstem
cerebellum
thalamus
occipital lobe
medial temporal lobe
33
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

34
Q

what should the treatment for acute ischaemic stroke aim to do

A

restore blood supply

prevent extension of ischaemic damage

protect vulnerable brain tissue

35
Q

what are the first line treatments for stroke

A

Aspirin

Heparin

Neuroprotectant

Tissue Plasminogen Activator (TPA) - thrombolysis

Intra-arterial therapy - thrombectomy

36
Q

what additional support can improve good outcome of stroke

A

stroke units

37
Q

who makes up a stroke unit

A 
Clinical staff
Stroke nurses
Physiotherapists
Speech and Language therapists
Occupational therapists
Dietitian
Psychologist
Orthoptist
38
Q

what are the 4 main types of stroke

A

TACS - total anterior circulation stroke

PACS - partial anterior circulation stroke

LACS - lacunar stroke

POCS - posterior circulation stroke

39
Q

how would you identify LACS

A

pure motor >2/3

pure sensory >2/3

40
Q

how would you identify PACS

A

pure motor >2/3
pure sensory >2/3

1 of hemaniopia, dysphasia, neglect

41
Q

how would you identify TACS

A

pure motor >2/3
pure sensory >2/3

MUST HAVE HEMIANOPIA
+ dysphasia or neglect

42
Q

how would you identify POCS

A

all other symptoms

BRAINSTEM and or CEREBELLAR SIGNS

43
Q

of the 4 strokes, which has the highest death or dependency level at 6 months

A

TACS - 96%

44
Q

what is the criteria for tissue plasminogen activator (TPA) use

A

<4.5 hours from symptom onset

disabling neurological deficit

symptoms present >60 mins

CONSENT

45
Q

what is the exclusion criteria for IV TPA

A

anything that increases the possibility of haemorrhage

  • blod on CT
  • recent surgery
  • recurrent bleeding
  • coagulation problems

BP >185/>110

glucose <2.8 or >22mmolL

46
Q

what happens to the benefit of TPA as time passes

A

decreases - if started too late can actually cause harm

47
Q

what are the two types of thrombectomy

A

MERCI-corkscrew

solitaire thrombectomy

48
Q

why are TIAs like angina

A

warning sign

as angina is to MI - TIAs are to stroke

49
Q

what is the recurrence rate of stroke with TIA

A

10% stroke recurrence rate in the first 2 weeks after TIA

50
Q

what treatment is effective in symptomatic internal carotid artery stenosis

A

carotid endarterectomy

51
Q

after initial treatment, what should the follow management of stroke include

A

Prevention of stroke recurrence.

Prevention of complications related to stroke.

Rehabilitation.

Re-integration into the community

52
Q

what are some preventative second line treatments for stroke

A
  1. anti-hypertensives
  2. anti-plateletes
  3. lipid lowering agents
  4. warfarin for AF
  5. carotid endarterectomy
53
Q

what are the overall objective of stroke care

A

Reduce mortality.

Reduce residual disability amongst survivors.

Improve psychological status of patients and care-givers.

Improve patient / care giver knowledge.

Maximize quality of life

NEURO (51 decks)

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