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Medicine Phase 2a Neuro > Cerebrovascular accident > Flashcards

Cerebrovascular accident Flashcards

(51 cards)

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1
Q

Examples

A

(TIA)

Stroke

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2
Q

Types of stroke

A

Ischaemic

Haemorrhagic

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3
Q

Define cerebrovascular accident

A

Syndrome of rapid onset of neurological deficit caused by focal, cerebral, spinal or retinal INFARCTION
Characterised by rapidly developing signs of focal or global disturbance of cerebral functions, lasting >24 hours or leading to death

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4
Q

Epidemiology

A

3rd most common cause of death in high-income countries (11% of UK deaths)
Leading cause of adult disability worldwide
Incidence increases with age
More common in males

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5
Q

Aetiology

A

Ischaemic/infarction account for 80% of strokes
Haemorrhagic account for 17% of strokes
Others causes 3%

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6
Q

What can cause Ischaemic/infarction that can result in stroke

A
  • Small vessel occlusion/ thrombosis in situ
  • Cardiac emboli from AF, MI or infective endocarditis
  • Large artery stenosis
  • Atherothromboembolism e.g. from carotid
  • Hypoperfusion, Vasculitis, Hyperviscosity (polycythaemia + sickle cell)
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7
Q

Causes of haemorrhages that can result in stroke

A 
Trauma
Aneurysm rupture
Anticoagulation
Thrombolysis
Carotid artery dissection
Subarachnoid haemorrhage
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8
Q

Causes in young people

A
  • Vasculitis
  • Thrombophilia
  • Subarachnoid haemorrhage
  • Carotid artery dissection - spontaneous, or from neck trauma
  • Venous sinus thrombosis
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9
Q

Causes in elderly

A
  • Thrombosis in situ
  • Athero-thromboembolism
  • Heart emboli e.g. AF, infective endocarditis or MI
  • CNS bleed
  • Sudden BP drop by more than 40mmHg
  • Vasculitis
  • Venous sinus thrombosis
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10
Q

Risk factors

A 
Male
Black/Asian
Hypertension
Past TIA
Smoking 
DM
Old age
Heart disease (valvular, ischaemic)
Alcohol
[Imagine patient with all of this]
Polycythaemia, thrombophilia; AF; hypercholestrolaemia; combine oral contraceptive pill; Vasculitis; Infective endocarditis
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11
Q

What % of strokes are ischaemic

A

70%

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12
Q

Aetiology of ischaemic stroke

A

Atherosclerosis is main pathological process.
Thrombosis occurs at site of athermatous plaque in carotid/vertebral/cerebral arteries.
Large artery stenosis acts as a source for embolism rather than occluding the vessel.
An occlusive vasculopathy known as lipohyalinosis that is a consequence of hypertension results in small infarcts known as ‘lacunes’ and/or the gradual accumulation of diffuse ischaemic change in deep white matter.

Ischaemic infarction due to occlusion of a vessel, usually by an embolism of a thrombus.

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13
Q

Pathophysiology of ischaemic stroke

A

Ischaemic -> infarct -> Death of neural tissue -> Loss of functionality

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14
Q

What is the name of the occlusive vasculopathy that results from hypertension and results in the gradual accumulation of diffuse ischaemic change in deep white matter

A

Lipohyalinosis

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15
Q

What is the name for the gradual accumulation of diffuse ischaemic change in deep white matter

A

Lacunes

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16
Q

Describe venous sinus thrombosis

A

Rare
Thrombosis within intracranial venous sinuses, such as the superior sagittal sinus, or in cortical veins
May occur in pregnancy, hypercoaguable states and thrombotic disorders or with dehydration or malignancy

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17
Q

What can result from venous sinus thrombosis

A

Cortical infarction
Seizures
Raised intracranial pressure

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18
Q

What % of strokes are haemorrhagic

A

17%

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19
Q

Risk factors of haemorrhagic stroke

A

Hypertension, excess alcohol, smoking and age

Space occupying lesion e.g. tumour - rare

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20
Q

Pathophysiology of haemorrhagic stroke

A

Primarily intracerebral haemorrhage
Risk factors -> small vessel disease and aneurysms -> rupture and haemorrhage
Hypertension resulting in micro aneurysm rupture

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21
Q

Aetiology of lobar intercerebral haemorrhage

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A

Deposition of amyloid-B in the walls of small and medium-seized arteries in normotensive patients - particularly over 60

22
Q

Example of a cause of haemorrhagic stroke in young adults

Study These Flashcards
A

1/5th strokes are due to carotid/vertebral artery dissection - can occur due to recent neck pain, trauma or neck manipulation

23
Q

General clinical presentation of ischaemic stroke

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A

Depends on the location of the infarct. Cerebal hemisphere (most common):
Signs contralateral to the affected side. Hemiplegia, hemisensory loss, upper motor neurone facial weakness and hemianopia
Brainstem:
Complex, depending on location
Multi-infarct:
Multiple steps progressing to dementia

24
Q

Clinical presentation of haemorrhagic stroke

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A

Severe headache, nausea/vomiting.
Sudden loss of consciousness -> Stroke
(similar to ischaemic)

25
Clinical presentation of stroke of Anterior Cerebral Artery (ACA) Territory
``` Leg weakness and leg sensory disturbances Gait apraxia Truncal ataxia Incontinence Drowsiness Akinetic mutism ```
26
What is apraxia and ataxia
(Gait) Apraxia = Loss of ability to have normal function of lower limbs such as walking (Truncal) Ataxia = patients cant sit or stand unsupported and tend to fall backwards
27
Why does stroke affecting the ACA cause drowsiness
since part of consciousness is in the frontal lobe (which the ACA supplies)
28
What is akinetic mutism
Decrease in spontaneous speech | Stuporous state
29
Clinical presentation of stroke of Middle Cerebral Artery (MCA) Territory
``` CONTRALATERAL ARM & LEG WEAKNESS CONTRALATERAL sensory loss Hemianopia Aphasia Dysphasia Facial droop ```
30
What are aphasia and dysphasia
Aphasia - inability to understand or produce speech | Dysphasia - deficiency in speech generation
31
Clinical presentation of stroke of Posterior Cerebral Artery (PCA) Territory
``` CONTRALATERAL HOMONYMOUS HEMIANOPIA Cortical blindness Visual agnosia Prosopagnosia Colour naming and discriminate problems Unilateral headache (*RARE in ischaemic stroke, so if you see headache then think PCA) ```
32
Describe contralateral homonymous hemianopia
loss of half the vision of the same side in both eyes
33
What is meant by cortical blindness
eye healthy, but brain issue causing blindness
34
What are: Visual agnosia Prosopagnosia
Visual agnosia - cannot interpret visual information, but can see Prosopagnosia - cannot see faces
35
Clinical presentation of stroke of Posterior circulation territory such as vertebrobasilar artery
Motor deficits such as hemiparesis or tetraparesis and facial paralysis Dysarthria (unclear speech articulation) & speech impairment Vertigo, nausea & vomiting Visual disturbance Altered consciousness
36
Why are posterior circulation stroke more catastrophic
Due to wide region supplied by it
37
Describe lacunar stroke
Small subcortical strokes e.g. midbrain, internal capsule
38
Clinical presentation of lacunar stroke
``` Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three Pure sensory loss Ataxic hemiparesis (cerebellar and motor symptoms) ``` In general only 1 modality tends to be affected
39
True or False: No reliable way of distinguishing between haemorrhage and ischaemic infarcts When could you assume otherwise
True - Intracerebral haemorrhage is more often associated with severe headache or coma (signs of raised intracranial pressure (ICP) i.e. due to blood forming space-occupying lesion) - Patients on oral anticoagulants should be assumed to have had a haemorrhage unless it is proved otherwise
40
Differential diagnosis
Always EXCLUDE hypoglycaemia as a cause of sudden onset neurological syndrome Hypoglycaemia Migraine aura (symptoms spread and intensify over minutes, often with visual scintillations (sparkling/blinking)) Focal epilepsy Intracranial lesion - tumour or subdural haemotoma Syncope due to arrhythmia
41
What is syncope
Temporary loss of consciousness usually related to insufficient blood flow to the brain (AKA fainting)
42
Diagnosis
Urgent CT head/MRI head BEFORE TREATMENT (CT to confirm ischaemic) Pulse, BP and ECG - look for AF Bloods - FBC, Glucose
43
Why is it important to be careful in treating high BP
Even a 20% fall in BP may compromise cerebral perfusion
44
Why are bloods done in diagnosis (FBC and glucose)
FBC - look for thrombocytopenia and polycythaemia | Blood glucose - to rule out hypoglycaemia
45
When is CT head/MRI urgent
If suspected cerebellar stroke, unusual presentation (i.e. alternative diagnosis likely), high risk of haemorrhage (low GCS and signs of raised ICP) Rule out haemorrhagic stroke before starting thrombolysis
46
Treatment
Aspirin IV alteplase in at least 4.5 hours (thrombolytic; IV tissue plasminogen activator) Antiplatelet (aspirin -> Lifelong Clopidogrel) Maintain glucose NBM (Nil By Mouth) Ensure hydration and keep O2 stats > 95% Stop anticoagulants (Haemorrhagic)
47
Describe risk factor management for stroke prevention
Platelet treatment (lifelong if already had stroke) e.g. ASPIRIN + DIPYRIDAMOLE or CLOPIDOGREL Cholesterol treatment like statins e.g. SIMVASTATIN Atrial fibrillation treatment e.g. WARFARIN or new oral anticoagulants e.g. PIXIBAN Blood pressure treatment e.g. ACE-inhibitor e.g. RAMIPRIL
48
Why is it important to ensure hydration and keep O2 stats > 95%
Maximise reversible ischaemic tissue
49
Haemorrhagic treatment
Frequent GCS monitoring Antiplatelets contraindicated Any anticoagulants should be reversed for Warfarin reversal use BERIPLEX and VITAMIN K Control hypertension Manual decompression of raised ICP, can also reduce ICP by giving diuretic e.g. MANNITOL Surgery may be required
50
Called by paramedics to inform you there is a 65 yr old RIGHT HANDED man who presents with a RIGHT SIDED WEAKNESS of BOTH ARMS & LEGS, DYSARTHRIA, LOSS OF VISION and DIFFICULTY SPEAKING - Paramedics say symptoms came on SUDDENLY at 13:30 - Time is now 15:00 Diagnosis and treatment?
Diagnosis: Likely to be MCA stroke since BOTH arms & legs involved Treatment: Within the 4.5 hour time frame for thrombolysis (alteplase) as long as CT head confirms ischaemic and no contraindications
51
What is Clopidogrel
P2Y12 inhibitor | Antiplatelet drug

Medicine Phase 2a Neuro (28 decks)

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