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Year 4 OPIC > Stroke > Flashcards

Stroke Flashcards

(53 cards)

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1
Q

What is a stroke?

A

A sudden onset of rapidly developing focal or neurological disturbance which lasts >24 hours or leads to death

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2
Q

What are the types of ischaemic stroke?

A

Embolus (think AF)
Thrombus
Lacunar (basal ganglia due to hypertension)
Hypoperfusion

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3
Q

What is an example of a prothrombotic state?

A

Cancer
Pregnancy
Immobility
Antiphospholipid

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4
Q

What are the subtypes of haemorrhagic strokes?

A

Intracerebral- due to trauma, HTN, cerebral, amyloid

Subarachnoid haemorrhage- due to trauma, berry aneurysm or arterio venous malformation

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5
Q

What are the risk factors for stroke?

A 
Hypertension 
Age 
Smoking 
Alcohol
Hypercholesterolaemia 
Prothrombotic state 
Diabetes
Carotid artery stenosis
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6
Q

What is the bamford/oxford classification of a total anterior cerebral artery stroke?

A

Contralateral hemiparesis and sensory loss (lower limbs are more affected than upper)

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7
Q

What are the signs of middle cerebral artery stroke?

A

Contralateral hemiparesis and sensory loss (upper limbs are more affected than the lower)

Contralateral homonymous hemianopia

Aphasia (if it affects dominant hemisphere)

Hemispatial neglect (if it affects non dominant hemisphere)

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8
Q

What is the blood supply of the cerebrum?

A

The anterior, middle and posterior cerebral arteries each supply a specific territory of the brain…

The anteror cerebral arteries supply the anteromedial area of the cerebrum

The middle cerebral arteries supply the majority of the lateral cerebrum

The posterior cerebral artery supply a mixture of the medial and lateral areas of the posterior cerebrum

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9
Q

What is the classification system which is used for ischaemic stroke?

A

Bamford classification, it is also known as Bamford
This system categorises the stroke based on the initial presenting symptoms and clinical signs, this system does mot require imaging to classify the stroke, instead it is based on clinical findings alone.

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10
Q

What is atotal anteror circulation stroke?

A

This is a large cortical stroke which affects the area of the brain supplied by both the middle snd anterior cerebral arteries
All three of the following need to be present for a diagnosis of TACS….

1) unilateral weakness (and/or sensory deficit) of the face, arm and leg
2) homonymous hemianopia
3) higher cerebral dysfunction (dysphasia, visuospatial disorder)

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11
Q

What is a partial anterior circulation stroke?

A

A less severe form of TACS, in which only part of the anterior circulation has been compromised

Two of the following need to be present for a diagnosis of PACs…

1) unilateral weakness (and/or sensory deficit) of the face, arm and leg
2) homonymous hemianopia
3) higher cerebral dysfunction (dysphasia, visuospatial disorder)

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12
Q

What does the posterior circulation syndrome involve?

A

Damage to the area of the brain supplied by the posterior circulation (cerebellum and brainstem)

One of the following needs to be present for a diagnosis of POCS…

1) cranial nerve palsy and a contralateral motor/ sensory deficit
2) bilateral motor/sensory deficit
3) conjugate eye movement disorder (horizontal gaze palsy)
4) cerebellar dysfunction (vertigo, nystagmus, ataxia)
5) isolated homonymous hemianopia

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13
Q

What is a lacunar stroke?

A

A subcortical stroke secondary to small vessel disease, there is no loss of higher cerebral functions (dysphasia)
One of the following need to be present for a diagnosis of LACS…

Pure sensory
Pure motor
Sensori motor
Ataxic hemiparesis

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14
Q

What is PACS normally aused by?

A

Cardiac emboli

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15
Q

When would you predict stroke to be because of emboli.

A

AF patients
Or strongly suspected in pts with clinical evidence of cardiomegaly, valvular heart disease, heart failure endocarditis,

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16
Q

What are common post stroke complications?

A

Recurrent stroke and extension of stroke

Raised ICP
Infections (either chest due to aspiration or UTI due to incomplete bladder emptying from either constipation or supine/bed bound posture)

Immobility complications- VTE, constipation, bed sores

Mood and cognitive dysfunction

Post stroke pain and fatigue

Spasticity, contractures and secondary epilepsy (you get increase tone)

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17
Q

What does a stroke patients journey involve?

A

Admission to stroke unit

Revascularisation

Optimising physiology (surveillance, prevention, esrly intervention of complicstions, nutritional support

Secondary prevention

Rehabilitation and reablement

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18
Q

Recovery of a stroke continues until a patient resches their functional plateau, how can the plateaus be divided?

A

• Early, high functioning plateau – the extreme version of this is a TIA or minor stroke,
signifying excellent functional prognosis.
• Early, low functioning plateau – the extreme version of this is a TACS with no
meaningful improvement in function as time passes, signifying poor functional
prognosis.
• Delayed and medium functioning plateau – this will likely define recovery in most
moderate strokes. These patients will benefit from a chance at sustained rehabilitation
efforts until a functional plateau is achieved

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19
Q

When is thrombolysis given?

A

Non contraindicated patients with disabling stroke presenting within 4.5hrs
IV ALTEPLASE

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20
Q

When is thrombectomy given?

A

Patients with large vessel occlusion, should be executed within 6hrs of symptom onset

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21
Q

What assesment tools can be used in a stroke assesment?

A

FAST test
NIHSS
mRS
ASPECTS score

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22
Q

When do you use decompressive hemicraniectomy?

Study These Flashcards
A

Indicated for the manahement of malignant oedema in younger (<60 years old)
But can be considered in otherwise biologically fit stroke patients above thos cit off
Referall to neurosurgical units should be made within 24 hours and surgery compLeted within 48 hours

23
Q

What is the most worrisome concern in Intra cerebral haemorrhage?

Study These Flashcards
A

Development of raised ICP is the most worrisome concern in ICH (and the reason for the higher early mortality relative to ischaemic stroke

This can be due to haematoma expansion or hydrocephalus

24
Q

What are the non surgical strategies to address intra cerebral haemorrhage?

Study These Flashcards
A

Blood pressure control and correction of clotting abnormalities

25
What are the surgical options for intracerebral haemorrhage?
Evacuation of haematoma and ventricular drains in selected patients
26
What are the anticoagulation options for a stroke and when do you use them?
They include IV or subcut heparin Warfarin DOACS Applies in patients with AF, severe left ventricular dysfunction, thrombophilia and venous sinus thrombosis
27
What investigations can be done for antithrombotic therapy?
``` ECG MR /CTV Holter monitor Echocardiogram Thrombophilia scfeening ```
28
What are the risk stratification scores for primary prevention in AF?
CHA2DSVASc and HASBLED, patients with high HASBLED scores whose impact can be modified re usually the most to gain from angicoag
29
When do you use anti platelet agents as standard practise?
TIAs, confirmation of ischaemic stroke and 24 hrs after thrombolysis
30
When is carotid endarterectomy (CEA) used?
Mainstay intevention for managing symptomatic carotid disease after a TIA or stroke with good recovery of more than 50% (NASCET method) lumen reduction on carotid ultrasound Surgery is scheduled as soon as possible
31
How can reduction of recurrent strole be optimised?
Aggressive medical therapy- blood pressure control <130/80 High dose statin therapy Dual antiplatelet therapy before surgery or if surgery is not an option (plaque stabilisayion)
32
How an you optimise vascular risk factors in stroke?
``` Smoking cessation Maintaining average blood pressure <130/80 Glycaemic control to HbA1c <7 Total cholesterol <4 LDL cholesterol <2 Weight loss towards BMI 25 Promotion of exercise ```
33
What could be used in patients with AF in whom anticoagulation is contra indicated?
Left atrial appendage closure
34
What can you do in terms of nutritional support for patients?
Nutritional support is important for recovering stroke patients In the majority of patients with unsafe swallow function, tube assisted enteral feeding is temporary pending return of safe swallow function In addition to bedside assessments,swallowing can be assessed instrumentally with video fluoroscopy and flexible endoscopic evaluation of swallowing (FEES)
35
What does stroke rehabilitation involve?
Mobility Activities of daily living Speech and cognitive therapy Managing spasticity (orthotic prostheses and botulinum toxin therapy)
36
What is the NIHSS?
National institutes of health stroke scale This is a systematic assessment tool which provides a quantitative measurement of stroke related neurologic deficit This is used in assessing stroke severity, patient selection for various acute therapies, estimating prognosis and charting stroke recovery
37
What is ASPECTS?
The Alberta stroke programme early CT score 10 point quantitative topographic CT scan score used in patients with middle cerebral artery stroke Segmental assessment of the MCA vascular territory is made and 1 point is deducted from the initial score of 10 for every region involved Used in revascularisation therapies for patient selection and outcome prediction
38
What is modified rankin scale?
This is used to measure of global disability used to assess baseline function and evaluate outcomes and treatment impact after interventions It is a scale from 0-6 0= no symptoms 1= no signficsnt disability, able to carry out all usual activities, despite some symptoms 2= slight disability, able to look after own affairs without assistance, but unable to carry out all previous activities 3= moderare disability, requires some help, but unable to walk unassisted 4= moderately severe disability, unable to attend to own bodily needs without assistance and unable to walk without assistance 5= severe disability, requires constant nursing cafe and attention, bedridden, incontient 6= dead
39
What is the rosier scale?
The aim is to enable medical and nursing staff to differentiate patients with stroke and stroke mimics
40
What does CHA2DS2- VASC invole?
CHA2DS2VASc Congenstive heart failure/ LV dysfunction = 1 Hypertension = 1 Aged > or equal to 75 years =2 D= diabetes mellitus = 1 S= stroke/TIA/ TE = 2 V= vascular disease= prior MI, PAD or aortic plaque High risk is equal to or greater than 2 A= aged 65-74 years = 1 S= sex (female) = 1
41
What does HASBLED involve?
Hypertension ‘= 1 Abnormal renal/liver function = 1 each Bleeding fendency/predisposition = 1 Labile INR = 1 Age (>65) =1 Drugs (aspirin/NSAIDS) or alcohol = 1
42
What is the TOAST classification?
Used for ischaemic strokes to give the specific cause of ischaemic stroke… - large artery atherosclerosis - cardio embolic - small vessel disease - other determined - undetermined
43
What is a scoring system which can be used after TIA?
ABCD2 for stroke risk assesment ``` Age > or greater than 60 years Blood pressure (systolic >or equal to 140, diastolic > pr equal to 90mmHg) = 1 Clinical features of TIA (unilateral weakness with or without speech impairment = 2 OR speech impairment without unilateral weakness = 1) ``` Duration TIA duration > or equal to 60 mins = 2 or TIA duration 10-59 mons= 1 Diabetes = 1 High risk groups (ABCD2 >4, multiple TIAS (>2 in previous 7 days), patients in AF or on anticoagulants will require urgent review ie: within 24hrs but in principle all TIA patients should be seen urgently wherever possible
44
What are stroke mimics?
They can be categorised into 1) readily recognised on brain imaging- brain space occupying lesions, MS, subdural haematoma etc 2) distinct non stroke syndrome features which allow a secure diagnosis on clinical grounds, early recongnition will allow appropriate interventions, reassurance about stroke/TIA, putting a stop to uneccesary interventions, examples of this group- Benign positional vertigo, vestibular neuronitis, syncope syndrome, transient global amnesia 3) condition where recognition is clinical but features can be subtle and justify specialist assessment- clinical opinion and additional ix eg: MRI scan for prolonged (>1 hr) episodes, EEG. Included here are complicated migraine with aura, focal seizures, functional syndrome, amyloid spells
45
What is apparent neurological deficit?
Neurological dysfunction in patients with chronic stroke (but seemingly good recovery) and residual areas of scar tissue (gliosis) at the site of previous brain damage Symptoms can return (become apparent) due to underperformance of the gliotic tissue in the context of suboptimal phsyiology as in infection, low BP, hypoglycaemia, hypoxia, fatigue etc…
46
What imaging is done in stroke medicine?
Non contrast CT and MRI scanning are the mainstays of assessing the brain in stroke patients Comprehensive ‘multi modal’ brain imaging may also involve angiography and perfusion studies
47
What would you see on a CT with someone with early cerebral ischaemia?
The consequent intracellellar fluid wnd electrolyte shift results in brain cell swelling, This explains “ effacement” and loss of grey/white matter distinction , which, in addition to increased density of the relevant blood vessel (due to the presence of clotted blood) are the hallmarks of early cerebral ischaemia on CT scan.
48
What is the feature of intracerebral haemorrhage on CT?
Increased attenuation
49
Why is hypertension worrying in thrombolysis and what can you do about it?
it is a contra-indication for thrombolysis What you can do- Make sure you reverse any underlying causes for their hypertension for example: pain
50
What should you worry about in thrombolysis?
Blood pressure control Neurological deterioration Intracranial and extracranial haemorrhage Angio oedema
51
What is malignant MCA syndrome?
Happens early after ischaemic stroke, after large MCA infarct stroke Tends to happen in the young ‘Malignant MCA infarction’ is the term used to describe rapid neurological deterioration due to the effects of space occupying cerebral oedema following middle cerebral artery (MCA) territory stroke. Early neurological decline and symptoms such as headache and vomiting should alert the clinician to this syndrome, supported by radiological evidence of cerebral oedema and mass effect in the context of large hemispheric infarction.
52
What is a cerebral venous thrombosis?
Rare cause of an acute stroke Headache, seizures and focal neurological deficit More likely in those with prothrombotic tendency ie: malignancy, pregnancy They are often misdiagnosed
53
why do you have to be wary of GCS in stroke?
The speech isn't always because they are unconscious, sometimes it is because they have dysphagia

Year 4 OPIC (15 decks)

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