Group work scenarios Flashcards Preview

Stroke week > Group work scenarios > Flashcards

Flashcards in Group work scenarios Deck (23)
Loading flashcards...
1

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)

2

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

3

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

4

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

5

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.

6

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 

7

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*

8

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

9

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

10

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

11

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

12

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)

13

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

14

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

15

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 

16

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.

2) What investigation should be performed immediately and why?

CT head- rule out haemorrhagic stroke (white)

17

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.

3) What is the likely Oxford classification (OSCP)?

TACS- right

18

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.

5) Which lobes of the brain have been affected? B) Which blood vessel has been occluded?

frontal

- internal carotid

- MCA

19

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.

6) Should thrombolysis be given?

yes if within 4.5 hours

20

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.

7) Should any further urgent imaging be considered?

CT angiogram 

21

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.

8) What investigations should be done prior to discharge from hospital?

ECG

carotid US
BP

HbA1C

cholesterol

22

h your facilitator. For each patient, address the questions (in red) in turn as they appear on the slides, and feedback to the group via the discussion on blackboard, or by writing text on the slide and as directed by you moderator.. 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? 1b) Why? 1c) Has Mrs R had a TIA or a stroke? 2a) could anything else of caused her symptoms? List common stroke mimics 2a) which lobes of the brain have been affected? 3) which blood vessel may have been occluded? 4) What further investigations should be considered and why? 5) What type of brain imaging is most useful in TIA?6) What is the likely aetiology and pathophysiology of Mrs R’s event? 7) What immediate treatments should be considered to prevent stroke? 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.

 

9) What medical treatment options should be considered prior to discharge?

thrombolysis and thrombectomy 

23