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Y6 Neuro > Stroke > Flashcards

Stroke Flashcards

1
Q

Define stroke

A

A stroke is a rapidly developing acute focal neurological deficit that lasts more than 24 hours, caused by cerebrovascular aetiology.

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2
Q

Aetiology of stroke

A

ischaemic (85%)
Vascular occlusion or stenosis → reduced cerebral blood flow
- Thrombosis/embolism
- Atherosclerosis (carotid, vertebral)
- Vessel disease e.g. dissection, vasculitis, venous thrombosis
- Haem disease e.g. SCD, antiphospholipid syndrome

Haemorrhagic (15%)
Vascular rupture → leaking of blood → raised ICP + toxic metabolites

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3
Q

Risk factors for a stroke

A

Older age
FHx or Hx of stroke
HTN, DM, dyslipidaemia
Smoking
Atrial fibrillation, carotid artery stenosis
SCD

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4
Q

General symptoms of a stroke

A

Sudden onset (deteriorates within seconds)
Weakness, sensory or visual cognitive impairment
Impaired coordination or consciousness
Head or neck pain (in carotid or vertebral artery dissection)
Aphasia
Diplopia
Dysarthria
Vertigo
Nausea/vomiting
Altered consciousness or coma

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5
Q

What is the Bamford classification for stroke

A

Total anterior circulation stroke (TACS)
Partial anterior circulation stroke (PACS)
Lacunar syndrome (LACS)
Posterior circulation stroke (POCS)

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6
Q

What constitutes a total anterior circulation stroke

A

ALL 3:
- Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- Higher cortical dysfunction (dysphasia)

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7
Q

What constitutes a partial anterior circulation stroke

A

2 of 3 of:
- Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- Higher cortical dysfunction (dysphasia)

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8
Q

What constitutes a lacunar syndrome

A

Involves perforating arteries around the internal capsule, thalamus and basal ganglia

Presents with 1 of the following:
- Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
- Pure sensory stroke.
- Ataxic hemiparesis

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9
Q

What constitutes a posterior circulation stroke

A

Involves vertebrobasilar arteries

1 of:
- Cerebellar or brainstem syndromes
- Cranial nerve palsy + contralateral motor/sensory deficit
- Conjugate eye movement disorder (gaze palsy)
- Bilateral motor/sensory deficit
- Loss of consciousness
- Isolated homonymous hemianopia

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10
Q

General signs of stroke on examination

A

UMN lesion:
- Hypertonia and spasticity
- Hyperreflexia
- Clonus
- Pronator drift

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11
Q

What differs anterior from middle cerebral artery stroke

A

Anterior: legs > arms > face
- Personality/behavioural change
- Confusion

Middle: Face > arms > legs
- Facial weakness
- Aphasia (Broca’s: expressive | Wernicke’s: receptive)
- Apraxia
- Hemineglect
- Quadrantanopia

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12
Q

What vessels of the posterior circulation can be affected in stroke and what differs between their presentations

A

Cerebral: hemianopia
Anterior inferior cerebellar: vertigo, ipsilateral ataxia, deafness, tinitus, facial weakness
L Posterior inferior cerebellar artery (Wallenberg’s/lateral medullary): ipsilateral ataxia, nystagmus, dysphagia, facial numbness, CN palsy (Horner’s), contralateral sensory loss
Basilar: CN pathology + impaired consciousness

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13
Q

Investigations for stroke

A

ECG, BM

FBC: ?thrombocytopenia, thrombocytosis, polycythaemia
U&Es: ?renal failure, electrolyte disturbance
CRP
Clotting
Glucose, lipids
X match, G&S

CT non-contrast: ?haemorrhagic or ischaemic stroke
Echo: ?cardiac thrombus
Carotid doppler: ?carotid artery dissection/stenosis
MRI brain: ischaemic infarct = bright
CT-angiogram: ?artery dissection

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14
Q

What will show on CT head for stroke

A

Non-contrast CT ± perfusion CT ± CTA
Hyperdense (white) = acute clotted blood (haemorrhage, hyperdense artery sign)
Isodense = hyperacute active bleeding (rarely imaged; often swirling / mixed density)
Hypodense (dark) = ischaemic infarct, chronic clotted blood

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15
Q

How are stroke changes on CT classified according to time

A

Early hyperacute (0 to 6h): Hyperdense artery, loss of grey-white matter interface
Late hyperacute (6 to 24h): Hyperdense artery, loss of grey-white matter interface
Acute: (24h-1w): Hypodense (denser than CSF density), swelling
Subacute (1-3w): Normal density appearance (‘fogging’), reduced swelling
Chronic (>3w): ‘Encephalomalacia’ and CSF density achieved

Sub-acute infarcts : Poorly demarcated, Hypodense, Mass effect
Chronic infarct: Well demarcated, CSF density

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16
Q

What scoring is used for stroke

A

Scoring:
NIHSS (on admission): severity, guide treatment, predict outcomes (>21 = major)
Rosier (on admission): assess symptoms
CT ASPECT: assess early CT ischaemic changes

17
Q

Management for stroke

A
  1. A-E assessment
  2. Urgent CT head
    • Haemorrhagic: normalise INR
    • Ischaemic: Aspirin 300mg PO/PR → follow ischaemic pathway
  4. Transfer to stroke unit
  5. Furhter Ix, SALT assessment, nutritional assessment, thromboprophylaxis, pressure sore prevention
  6. Reduce any risk factors
  7. Drug prophylaxis (Statin, ACEi/thiazide ± clopidogrel)

Supportive
Fluid: Oral > IV (0.9% day 1, 5% dextrose day 2)
Glycaemic control
BP control: HTN emergency (encephalopathy/HF/MI/PET) → IV labetalol/nicardipine
Cholesterol control: >3.5 → Statin (After 48h)
SALT assessment: consider NG tube, nasal bridle tube, gastrostomy
Disability assessment: Barthel index (functional status + improvement)
DO NOT DRIVE FOR 1 MONTH

18
Q

Management for haemorrhagic stroke

A

Neurosurgery referral → consider surgery or external ventricular drainage
Airway protection
Aspiration precautions
Control BP with IV labetalol (When SBP >180)
DVT prophylaxis

19
Q

Management for ischaemic stroke

A
  1. Aspirin (300mg), OD/PR 2w
  2. AF?
    - No: Clopidogrel 75mg OD (Lifelong)
    — Clopidogrel CI → aspirin + dipyrimadole
    - Yes: Apixaban (Xai)/warfarin in 2 weeks
  3. Statin 48hrs later

<4.5 hours: thrombolysis (IV Alteplase)
<4.5 hours with occluded proximal anterior circulation: thrombolysis + thrombectomy
<6 hours: thrombectomy

2 weeks of aspirin → clopidogrel OR warfarin/DOAC (AF)

20
Q

Complications of stroke

A

Cerebral oedema (Raised intracranial pressure and local compression)
Immobility
Infection e.g. pneumonia, UTI, from pressure sores
DVT
Cardiovascular events (arrhythmias, MI, cardiac failure)
Death
Depression
Aspiration pneumonia

21
Q

Prognosis of stroke

A

1-year mortality is 25%
Leading cause of long term disability in the US
Prognosis of functional outcome can be performed by prognostic scores like ASTRAL scores or the iScore
IV thrombolysis and dedicated stroke units are the only interventions shown to improve stroke outcome
Patients receiving alteplase are more likely to have a better outcome than those who are not.
8-12% mortality following ischaemic stroke
15-30% suffer long term significant disability

22
Q

When is carotid endarterectomy considered

A

carotid stenosis > 70% according ECST** criteria or > 50% according to NASCET*** criteria

23
Q

When is thrombectomy considered

A

NIHSS >5
Anterior circulation stokre (<6h)
Anterior circulation + potential to salvage brain tissue (CT perfusion/diffusion weighted MRI) (6-24h)
Posterior circulation + potential to salvage (<4.5h, consider only)

24
Q

What are the contraindications to thrombolysis

A

Absolute:
Previous/suspected haemorrhage
Stroke/TBI in preceding 2 months
LP in the preceding 7 days
GI haemorrhage in the alst 3 weeks
Active bleeding
Varices
Pregnancy
Seizure at onset
Intracranial neoplasm
Uncontrolled HTN >200/120

Relative: anticoagulation, diathesis, active diabetic retinopathy, suspected intracardiac thrombus, major surgery/trauma last 2 weeks

Y6 Neuro (32 decks)

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