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Ischaemic Stroke Flashcards

1
Q

what is the stroke classification system?

A

bamford/oxford classification

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2
Q

what is a total anterior infarct (TACI) defined by?

A

contralateral hemiplegia or hemiparesis
AND
contralateral homoymous hemianopia
AND
higher cerebral dysfunction (e.g. asphasia, neglect)

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3
Q

what does a total anterior circulation infarct (TACI) involve?

A

anterior and middle cerebral arteries

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4
Q

what is a partial anterior circulation infarct (PACI) defined by?

A

2 of:
contralateral hemiplegia or hemiparesis
contralateral homonymous hemianopia
higher cerebral dysfunction (e.g. asphaia, neglect)

OR
higher cerebral dysfunction alone

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5
Q

what does a partial anterior circulation infarct (PACI) involve?

A

anterior or middle cerebral artery

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6
Q

what is a lacunar infarct (LACI) defined by?

A
  • pure motor stroke
  • pure sensory stroke
  • sensorimotor stroke
  • ataxic hemiparesis

NO visual field defect, higher cerebral dysfunction or brainstem dysfunction

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7
Q

what does a lacunar infarct (LACI) involve?

A

small deep perforating arteries, typically supplying internal capsule or thalamus

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8
Q

what is a posterior circulation infarct (POCI) defined by?

A
  • cerebellar dysfunction
  • conjugate eye movement disorder
  • bilateral motor/sensory deficit
  • ipsilateral cranial nerve palsy with contralateral motor/sensory deficit
  • cortical blindness/isolated hemianopia
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9
Q

what does a posterior circulation infarct (POCI) involve?

A

vertebrobasilar arteries and associated branches (supplying the cerebrellum, brainstem and occipital lobe)

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10
Q

what area of the brain do the anterior cerebral arteries supply?

A

medial and supero-medial edge of the cortex, along the falx cerebri

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11
Q

what area of the brain does the middle cerebral artery supply?

A

hemisphere (cortex and white matter)

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12
Q

what is the typical presentation of the occulsion of the left middle cerebral artery?

A

dysphasia

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13
Q

what are the clinical features of an acute basilar artery occulsion?

A

‘locked-in syndrome

  • quadriparesis (complete loss of movement)
  • preserved consciousness
  • preserved ocular movements - typically only vertical gaze
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14
Q

name posterior stroke syndromes

A
  • locked-in syndrome
  • lateral pontine syndrome
  • lateral medullary syndrome/wallenberg’s syndrome
  • medial midbrain syndrome/weber’s syndrome
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15
Q

what artery occlusion leads to locked-in syndrome?

A

basilar artery

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16
Q

what artery occulsion leads to lateral pontine syndrome?

A

anterior inferior cerebellar artery

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17
Q

what artery occlusion leads to weber’s syndrome (medial midbrain syndrome)?

A

branches of the posterior cerebral artery that supply the midbrain

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18
Q

what are the clinical features of the wallenberg’s syndrome (lateral medullary syndrome)?

A

DANVAH
* Dysphasia
* ipsilateral Ataxia
* ipsilateral Nystagmus
* Vertigo
* Anaesthesia (ispilateral facial numbness and contralateral pain loss on the body)
* ipsilateral Horner’s syndrome

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19
Q

what are the clinical features of weber’s syndrome (medial midbrain syndrome)?

A
  • ipsilateral oculomotor nerve (CN III) palsy
  • contralateral hemiparesis
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20
Q

what is the scoring system used to recognise stroke in the emergency setting?

A

ROSIER

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21
Q

what is the most common artery infarct in thromboembolic strokes?

A

middle cerebral artery territory

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22
Q

what artery occulsion leads to wallenberg’s syndrome (lateral medullary syndrome)?

A

posterior inferior cerebral artery

23
Q

what are the clinical features of lateral pontine syndrome?

A
  • ataxia
  • dysarthria
  • dysphagia
  • ipsilateral horner’s syndrome
  • ipsilateral loss of pain and temperature sensation on the face
  • contralateral loss of pain and temperature sensation over the contralateral body

AND ipsilateral facial paralysis (CN VII) OR hearing loss (CN VIII)

wallenberg’s syndrome + facial paralysis or deafness

24
Q

what is wernicke’s area responsible for?

A

understanding of speech

25
what is broca's area responsible for?
fluent speech
26
what type of dysphasia would an infarct in wernicke's area lead to?
**receptive dysphasia** typically present with a patient speaking in 'word salad' as a result of their impaired understanding | patient can express but not understand
27
what type of dysphasia would an infarct in broca's area lead to?
**expressive dysphasia** patient retains their understanding of speech but is having difficulty producing words of their own | patient can understand but not express
28
what is the definition of an ischaemic stroke?
sudden onset focal neurological deficit of vascular aetiology, with symptoms last >24 hours (or with evidence of infarction on imaging)
29
what precentage of strokes are ischaemic?
85%
30
what are the causes of an ischaemic stroke?
* intracranial small vessel atherosclerosis * large vessel atherosclerosis (e.g. carotid artery stenosis) * cardio-embolic pathology (e.g. AF) * primary vascular causes (e.g. vasculitis and arterial dissection) * haematological causes (e.g. prothrombotic states)
31
what are the risk factors for ischaemic stroke?
* age * male sex * family history of ischaemic stroke * hypertension * smoking * diabetes mellitus * atrial fibrillation * weaker risk factors = hypercholesterolaemia, obesity, poor diet, oestrogen-containing therapy, migraine
32
what is the mnemonic for acute management of ischaemic stroke?
DR ABCDE airway protection and aspiration precautions are very important
33
what should be performed with suspected stroke?
CT head should be performed on arrival to distinguish ischaemic from haemorrhagic stroke
34
what is the most sensitive test for confirming ischaemic infarct?
diffusion weighted MRI - used if the diagnosis is unclear
35
what is the medical management of acute stroke?
alteplase (tissue plasminogen activator)
36
what is the criteria for giving alteplase?
**within 4.5 hours of symptoms onset** with no contraindications to thrombolysis
37
what are the contraindications to thrombolysis?
* recent head trauma * GI or intracranial haemorrhage * recent surgery * acceptable BP * platelet count * INR
38
when can mechanical thromboectomy be performed?
* **within 6 hours** of symptom onset in **anterior** circulation strokes * **within 12 hours** of symptom onset in **posterior** circulation strokes
39
what is the recommended aspirin dosing?
* no hyperacute treatment = aspirin **300mg OD for 2 weeks** * hyperacute treatment = aspirin **started 24 hours post-treatment following repeat CT head**
40
what investigations are commenced post-acute ischaemic stroke?
* carotid ultrasound * CT/MRI angiography * echocariogram * serum glucose * serum lipids
41
what is the mneumonic for chronic ischaemic stroke management?
HALTSS
42
what is the management of chronic ischaemic stroke?
**H** = hypertension -initiate **antihypertensives 2 weeks post-stroke** **A** = antiplatelet therapy - **clopidogrel 75mg OD** **L** = lipid-lowering therapy - **atorvastatin 20-80mg OD** **T** = tobacco - **smoking cessation** **S** = sugar - **screened for diabetes** **S** = surgery - ipsilateral carotid artery stensosi requires **carotid endarterectomy**
43
what is an embolus?
anything that moves through the blood vessels until it reaches a vessel that is too small to let it pass
44
what is a thrombus?
blood clot that forms in a vein
45
what type of clot typically occurs in a large blood vessel occlusion?
embolus as to have a clinical stroke event, occlusion has to be sudden and almost complete which is unlikely if it is a thrombotic occlusion ## Footnote if a large artery occludes slowly with thrombosis, collaterals form and the acute occlusion goes unrecognised
46
where does large vessel infarcts typically occur?
cortex - produces cortical signs
47
what are cortical signs?
* left hemisphere (usually the dominant hemisphere) * dysphasia * agnosia
48
what conditions mimic strokes?
* migraine * post seizure focal deficits * hypoglycaemia * acute presentations of subacute/chronic pathology like SOL * demylination * bell's palsy * non-organic states
49
what is amaurosis fugax?
form of stroke that affects the retinal/ophthalmic artery
50
what adverse side-effect do antipsychotics increase the risk of in elderly patients?
increased risk of stroke and VTE
51
what blood tests should be performed in patients >55 years who have no obvious cause of stroke?
* thrombophilia * autoimmune screening
52
anterior cerebral artery stroke presentation
* contralateral hemiparesis and sensory loss * lower extremities > upper
53
middle cerebral artery stroke presentation
* contralateral hemiparesis and sensory loss * upper extremities > lower * contralateral homonymous hemianopia * aphasia
54
posterior cerebral artery stroke presentation
* contralateral homonymous hemianopia with macular sparing * visual agnosia

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