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Overview of stroke Flashcards

1
Q

WHO definition of a stroke is what?

A

“Clinical syndrome consisting of rapidly developing clinical signs of focal [or global in case of coma] disturbance of cerebral function lasting more than 24 hours or leading to death with no other apparent cause other than vascular origin.” WHO

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2
Q

Common Sx of carotid territory stroke

A

Weakness of face, leg, arm
Amaurosis fugax
Impaired language

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3
Q

Common Sx of posterior circulation problems

A

Dysarthria, dysphagia, diplopia, dizziness, ataxia, diplegia

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4
Q

Three main types of stroke

A

ischemic [clots], hemorrhagic [bleeds], TIA

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5
Q

Which most common, ischaemic or hemorrhagic?

A

Ischaemic in 85%, hemorrhagic in 15%

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6
Q

Causes of ischemic stroke and interruption cerebral blood supply

A

embolism, thrombosis, systemic hypoperfusion

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7
Q

Early signs of a stroke

A

Face, Arms, Speech, Time to call 999

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8
Q

Vascular supply and Circle of Willis summarise

A

slide

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9
Q

What are the cerebral vascular territories?

A

slide

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10
Q

What is the Oxford Stroke [Bamford] classification for strokes?

A

Clinical classification of patterns of neurological deficit in acute ischaemic stroke
- anterior circulation infarction [partial and total]
- posterior circulation infarction
lacurnar infarction

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11
Q

What is anterior circulation infarction?

A

Anterior and middle cerebral arteries

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12
Q

Sx of anterior circulation infarction?

A 
Contralateral weakness
Contralateral sensory loss/sensory inattnetion
Dysarthria
Dysphasia [receptive, expressive]
Homonymous hemianopia/visual inattnetion
higher cortical dysfunction
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13
Q

posterior circulation infarction

A
  • Cranial nerve palsy and a contralteral motor/sensory deficit [‘crossed signs’]
  • Conjugate eye movement disorder [e.g. horizontal gaze palsy]
  • Cerebellar dysfunnction [e.g. vertigo, nystagmus, ataxia, dysarhria]
    isolated homonymous hemianopia
  • bilateral events can cause reduced GCS
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14
Q

What is a lacunar infarction?

A

Occlusion of deep penetrating arteries
Affects small volume of subcortical white matter [therefore do not present with cortical features e.g. dysphasia, apraxia, neglect, visual field loss]
Underlying process is often referred to as small vessel disease [arterial wall, disorganisatioin, microatheroma, lipohyalinosis]

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15
Q

Give examples of Lacunar syndromes

A
  • Pure motor hemiparesis
  • Ataxic hemiparesis
  • ‘Clumsy hand’ and dysarthria
  • Pure hemisensory
  • Mixed sensorimotor
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16
Q

Go through Bamford stroke classification of each main type of stroke [TACS, PACS, LACS, POCS]

A

see slides

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17
Q

After recognition of stroke [FAST], what should be done immediately?

A

ABCDE assessment + bloods, BM
brief Hx and exam [time of onset, RFs, CI to thrombolysis], BP [permit moderate HTN], NIHSS [grade severity of the stroke]

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18
Q

What is the second stage of stroke Mx

A

urgent head CT [+/- CT angiography]

19
Q

What is the third stage of stroke Mx?

A

Thromblysis +/- mechanical thrombectomy if indicted or aspirin 300mg

20
Q

What is the final stage in stroke Mx?

A

investigate the cause [history, examination, bloods, imaging]
screen and prevent Cx [dehydration, aspiration, VTEs, pressure sores, infection, depression]
Establish secondary prevnetion [lifestyle, medical, surgical]
Rehabilitation [physio, OT, SALT]

21
Q

What is the NIHSS?

A

Grade and track the severity of stroke

Monitor response to acute Tx

22
Q

Utility of CT in acute stroke pros and cons

A

pros

  • quick
  • readily available 24/7
  • sensitive for haemorrhage
  • may see a ‘hyperdense vessel’

cons

  • cannot usually Dx an infarct in the acute phase
  • less sensitive than MRI for picking up other abnormalities [demyelination, mass lesions, microhaemorrhages] and for lacunar and posterior circulation infarcts
23
Q

What is thrombolysis?

A

breaking down acute clot

24
Q

how is thrombolysis given?

A

IV plasminogen activator e.g. altepase 0.9mg/kg
Given within 4.5hrs of Sx onset [or time they were ‘last seen well’]
Diagnostic uncertainty
Potentially life-saving

25
What are the contraindications for thrombylsis?
slides
26
post thrombolysis care
- more aggressive BP - monitoring - vigilance for Cx [bleeding] - 24 hour CT head [haemorrhagic transformation]
27
What is mechanical thrombectomy and when is it used?
Mechanical recanilsation of the culprit vessel Proximal stenosis 6 hour time-window for anterior circulation stroke [later for basilar thrombosis] can be used alongside IV thrombolysis Limited resource
28
What is the time window for mechanical thrombectomy?
6 hour time-window for anterior circulation stroke [later fo basilar thromosis]
29
Describe an ischaemic penumbra
``` Penumbra: - blood flow: 10-17 ml/100g/min - electrical silence - spreading depression - reversible damage in case of recirculation Ischaemic core: - blood flow permanently under <7-7.14 ml/100g/min - irreversible membrane damage - damaged brain tissue ```
30
4 simple stages for the management of stroke
1. investigate the cause [history, examination, bloods, imaging] 2. Screen and prevent complications [dehydration, aspiration, VTEs, pressure sores, infection, depression] 3. Establish secondary prevention [lifestyle, medical, surgical] 4. Rehab [physio, OT, SALT]
31
Purposes of the investigations
- Diagnosis - R/o 'stroke mimics' - identify aetiology - Guide RF modification - Prevent and treat complications
32
Investigations done for a stroke
- Blood tests [look up slides for more detail]: FBC, ESR, U&Es, lipid profile, LFTs, CRP, clotting screen, glucose and HbA1C - ECG [MI, AF] +/- 72 hour tape - carotid doppler USS [carotid stenosis] - ECG [endocarditis/thrombus] - MRI [confirm Dx, look for multi-territory infarcts]; delayed CT head if MRI is CI
33
Clues from the MRI: - acute/subacute infarcts [up to 2 weeks] - multiple infarcts same territory - multi-territory infarcts - absent flow void in vessels
- same territory ?cuplrit vessel - multiterritory infarcts ? cardioembolic - absent flow void vessels: arterial occlusion/dissection
34
In the young patient/atypical stroke patient, what should you consider?
Bloods: - HIV and vasculitic screen - Thrombophilia screen - Homocysteine Cardiac investigations - 7 day holter recorder/implantabel loop recorder - transcranial dopplers - transoesophageal echo Vascular imaging - CT angiography - MR angiography
35
MDT approach to treatment of a stroke
Nursing - analysing clinical status and progress; blood pressure management - administration of medications - nasogastric feeding - preventing pressure sores Physio - strength, balancing, function - preventing spasticity - chest physiotherapy in infections and sputum clearance Occupational therapy - functional assessments and future needs planning - cognitive and mood screening Speech and language therapy - swallowing impairment and prognosis - communicating rehabilitation in dysphasias Dieticians Orthoptics
36
Lifestyle management of a stroke
``` Smoking cessation Drug and alcohol cessation Dietary modifications Exercise Driving advice ```
37
Medical management [preventing complications]
VTE assessment - intermittent pneumatic compression devices ``` Hydration NG feeding +/- PEG feeding Spasticity - physiotherapy - botox Monitoring for infection ```
38
Medical management [secondary prevention]
Antiplatelets - aspirin 300mg PO/PR for 2 weeks [small ARR]; clopidogrel lifelong Anticoagulation - if in AF or evidence of pAF, may need to wait up to 2 weeks - HASBLED and CHADSVASC scores Hypertension - acute: risk of hypoperfusion - chronic: long term blood pressure target of< 130/80 Cholesterol - statin therapy: aim for 40% reduction in non-HDL cholsterol
39
Surgical management of stroke
Extra-cranial carotid stenosis - USS carotid dopplers +/- CTA/MRA - ipsilateral [symptomatic] carotid stenosis: 70-99% carotid endarterectomy [CEA] recommended, 50-69% consdier CEA - alternative: carotid artery stenting Malignant MCA syndrome: - decompressive hemicraniectomy Posterior circulation infarct - risk of hydrocephalus - EVD/posterior fossa decompression
40
55-year-old right handed man, sudden severe headache, weakness of right arm and leg, drowsy and confused. PMHx: HTNB, AF, DM, PKA DHx: Apixaban, Ramipril, Metformin Dx, and then Mx?
Management of haemorrhagic stroke 5 aspects: 1. ABCDE - monitoring environment, regular neuro-observations [incl. GCS and pupils] 2. Blood pressure? [140-160 systolic acutely, <130/80 long term] 3. Bleeding tendency? [coagulation/low platelets/medication-related] 4. underlying malformation? [tumour aneurysm, amyloid angioapthy, AVM, cavernoma] 5. Need for neurosurgery? [useful for superficial clots, CSF obstruction causes, hydrocephalus, posterior fossa decompression]
41
What is the minimum, and what is the maximum GCS score?
3, 15
42
What GCS should you strongly consider airway protection at?
At, or below 8
43
Ways of reversing anticoagulation
``` Warfarin [beriplex and vitamin K] Heparin [Protamine] LMWH [partially reversed with protamine] Apixaban/Rivaroxaban/Edoxaban [Beriplex is possibly effective] Dabigatran [Idarucizumab] ```
44
Name disorders that stroke can mimic
Seizures, tumours/abscess, migraine, metabolic [e.g. hypoglycaemia, hyponatraemia], functional, spinal cord/peripheral nerve/cranial nerve

Neurology (13 decks)

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