Group work scenarios Flashcards
Total Anterior Circulation Stroke - TACs
- Occlusion of a large cerebral artery (Internal carotid or middle cerebral)
- High mortality (60% at 1 year)
- All three of:
- Hemiplegia contralateral to the cerebral lesion, usually with contralateral hemi sensory loss
- Hemianopia Contralateral to cerebral lesion
- New disturbance of higher cerebral function (aphasia, visuospatial problems - neglect)
Lacunar Stroke - LACs
- Occlusion of a single deep perforating artery (lenticulatestriate)
- High recurrence rate and often missed
- Pure motor loss, OR pure sensory loss, OR ataxic hemiparesis i.e. a single deficit
Partial Anterior Circulation Stroke - PACs
Occlusion of a branch of the middle cerebral artery
High recurrence rate. 16% mortality at 1 year
Diagnosis requires 2 out of 3 TACS deficits, OR higher cerebral dysfunction alone, OR monoparesis, for example:
- Motor/sensory deficit + Hemianopia
- Motor/sensory deficit + new higher cerebral dysfunction
- New higher cerebral dysfunction alone
Posterior Circulation Stroke - POCs
- Occlusion of a posterior vessel (basilar/ vertebral/posterior cerebral) leading to cerebella/ brainstem/ occipital infarcts
- Complex presentation due if brainstem involved due to decussation of various tracts e.g.
- Ipsilateral cranial nerve palsy (single/multiple) with contralateral motor and /or sensory deficit
- Disorders of conjugate eye movement (horizontal/vertical)
- Cerebellar dysfunction without ipsilateral long tract sign
- Isolated hemianopia or cortical blindness
Causes of ischaemic stroke
- Cardioembolism (30%). Atrial fibrillation, myocardial infarction, prosthetic heart values, cardiac surgery, cardioversion, infectious endocarditis,
- Atherothrombosis in large vessels (15%). In situ (intracerebral vessels) , OR embolism from atherosclerotic plaques in extracerebral vessels (carotids, aortic arch, vertebral etc).
- Lacunar (20%). Caused by occlusion of deep penetrating arterial branches, especially the lentulastriate braches of the middle cerebral artery (MCA).
- Other ischaemic/crptogenic (15-20%). Venous sinus thrombosis, vasculitis, thrombophilia, carotid artery dissection,
- Intracerebral Haemorrhage (ICH) (10-15%). Bleeding into the brain parenchyma. Most common cause by far = hypertension. Others include cerebral amyloid angiopathy, arteriovenous malformation rupture, secondary ICH e.g. from tumours.
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
1) Are Mrs R’s symptoms likely to have an underlying vascular cause?
- risk factors
- sudden onset
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
1c) Has Mrs R had a TIA or a stroke?
probably TIA
ACA- think leg homonculus
*TIA- 24hrs symptoms*
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
2a) could anything else of caused her symptoms? List common stroke mimics
slipped disc
LMN lesion
seizure
migraine
pre-syncope
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
2a) which lobes of the brain have been affected?
frontal (motor cortex)- think medial homonculus
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
3) which blood vessel may have been occluded?
ACA–> branch of the internal carotid
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
4) What further investigations should be considered and why?
head CT, FBC, BM, ECG, cartotid US, MRI can be helpful
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
5) What type of brain imaging is most useful in TIA?
MRI (CT no longer suggested)
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
?6) What is the likely aetiology and pathophysiology of Mrs R’s event?
atherosclerotic plaque - occlusion
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker
7) What immediate treatments should be considered to prevent stroke?
- antiplatelet (aspirin, apixiban)
- carotid endarectomy
- lipid- lowering- statin
- smoking cessation
- diet advice
Case Study 2 (Mr A): 65-year-old gentleman. Keen gardener. Found collapsed by wife. Drowsy with a dense left sided weakness, left homonymous hemianopia, and a fixed gaze palsy (to the right). Not attentive to his left side. Only past medical history is of Type 2 DM.
1) What is the most likely diagnosis?
stroke - ischamia, haemorrhagic
