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stroke Flashcards

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1
Q

define stroke

A

cerebrovascular event caused by abnormal perfusion of cerebral tissue
- Clinical syndrome characterised by sudden onset of developing focal or neuro disturbance that lasts more than 24hr or leads to death

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2
Q

what is an ischaemic stroke?

A

occlusion of blood vessels –

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3
Q

which type of stroke is most common?

A

ischaemic - 85%
haemorrhagic - 15%

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4
Q

what is infarction?

A
  • Infarction: tissue death due to ischaemia
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5
Q

what types of haemorrhagic strokes are there?

A
  • Intracerebral haemorrhage or subarachnoid haemorrhage
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6
Q

what is the pathophysiology causing an ischaemic stroke?

A

thrombus formation
emboli
thrombosis
dissection
all resulting in occlusion to cerebral vessels

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7
Q

how can a thrombosis lead to ischaemic stroke?

A
  • Result of thrombus (atheromatous plaque) within vessel, embolus (blood clot) arising from distant site or even dissection
  • Thrombosis: blockage of vessel due to atherosclerosis (CVS RF or small vessel disease – vasculitis, sickle cell disease)
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8
Q

how can an emboli lead to a stroke?

A
  • Emboli: propagation of blood clot leading to acute obstruction and ischaemia – AF or carotid artery disease
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9
Q

how can a dissection lead to an ischaemic stroke?

A
  • Dissection: rare cause of cerebral ischaemia from tearing intimal layer of artery  leads to intramural haematoma that comprises cerebral blood flow. May be secondary to trauma
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10
Q

what is the most common cause of a haemorrhagic stroke?

A

hypertension

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11
Q

what are non traumatic causes of a haemorrhagic stroke?

A
  • Other causes of non-traumatic intracerebral haemorrhage include vascular malformations eg AV malformation, AV fistula, brain tumour, vasculitis, bleeding disorder
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12
Q

what RF are there for a stroke?

A
  • Smoking
  • DM
  • Hypertension
  • Hypercholesterolemia
  • Obesity ‘
  • AF
  • Cartodi artery disease
  • Thrombophilia disorders eg antiphopspholipid syndrome
  • Sickle cell disease
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13
Q

what symptoms are seen in a haemorrhagic stroke?

A

more likely to have global features such as headache and altered mental status
- Headache
- Altered mental status
- N+V
- Hypertension
- Seizures
- Focal neuro deficits – dependent on location of bleeding

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14
Q

what signs/ symptoms are seen with a anterior ischaemic stroke?

A

Unilateral weakness/ sensory deficits eg face/ arms/ legs
- Homonymous hemianopia: visual field loss on same side
- Higher cerebral dysfunction: dysphasia, visuospatial dysfunction eg neglect , agnosia

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15
Q

what is agnosia?

A

Agnosia: rare disorder where a patient can not recognise and identify objects, persons or sounds using one or more senses despite otherwise normally functioning senses

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16
Q

what features are seen within a posterior ischaemic stroke?

A

Posterior ischaemic stroke: affects balance, vision, cranial nerves
- Dizziness
- Diplopia
- Dysarthria and dysphagia
- Ataxia
- Visual field defects
- Brainstem syndromes

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17
Q

what assessments are required for a suspected stroke?

A
  • FAST test
  • Assessed using NIHSS score with urgent cross sectional imaging eg CT head with/without CT head angiography
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18
Q

what NIHSS score is linked to good outcomes?

A

<4

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19
Q

what NIHSS score is linked to ischaemic stroke?

A

22-26

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20
Q

what score is linked to haemorrhagic stroke and therefore contra-indicated thrombolysis?

A

> 26

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21
Q

what is the FAST test?

A

new facial weakness, new arm weakness and new speech difficulty

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22
Q

what is the acute management of a stroke?

A
  1. ABCDE
  2. NIHSS assessment
  3. capillary blood glucose measurement ‘
    4> imaging - determine ischaemic or haemorrhagic stroke
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23
Q

why would you do a capillary blood glucose?

A

remove hypoglycaemia/ hyper as differential
similar symptoms

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24
Q

what imaging can be done to differentiate between ischaemic or haemorrhagic?

A

CT angiogram
MRI FAST - assess if still perfusion and if they can have thrombolysis

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25
what is the window for thrombolysis within an ischaemic stroke?
<4.5hrs
26
what is thrombolysis?
IV infusion of altepase - clot busting drug
27
why is thrombolysis contra-indicated within haemorrhagic?
would make them bleed more - stops all clotting would turn into catastrophic event
28
if someone missed thrombolysis window, what other options are available?
mechanical thrombectomy medicinal
29
what is mechanical thrombectomy?
endovascular removal of clot from large cerebral vessel
30
when in mechanical thrombectomy indicated?
NIHSS score of >5 presenting <6hrs
31
if a patient can not have thrombolysis or surgery, what options can they have for an ischaemic stroke?
1. aspirin 200mg for 2 weeks and then clopidrogrel for life time (75mg) 2. life long anticoags eg apixaban
32
what is the management for haemorrhagic stroke?
Anticoag reversal  discuss with haemtology Blood pressure Lowering  aim for <140 systolic if <6hrs Referral to neurosurgery eg Burr Holes procedure
33
what lifelong management is required post stroke?
blood pressure control blood glucose control anti-lipid therapy anticoags antiplatelets lifestyle advice
34
why would anticoags be needed post stroke?
incase a clot cause common in those with AF
35
what anti-lipid therpay is needed, when do you start it post stroke?
start statin 48hrs post stroke
36
what lifestyle management is needed post stroke?
improve diet more exercise stop smoking reduce alcohol
37
what is the DVLA advice following a stroke?
do not drive initially if symptoms resolve 1mth post - do not need to inform inform if haemorrhagic stroke occurred inform if drive larger than car
38
what are early complications of a stroke?
- Haemorrhagic transformation of ischaemic stroke - Cerebral oedema - Seizures - Infection eg aspiration pneumonia from dysphagia - Venous thromboembolism - Death
39
what are late complications of a stroke?
- Mobility and sensory issues - Bladder and bowel dysfunction - Pain - Fatigue - Cognitive problems - Visual problems - Emotional and psychological issues - Issues with swallowing, hydration and nutrition
40
what are toxic/ metabolite stroke mimics differentials?
hypoglycaemia, drug and alcohol consumption
41
what are neurological differentials of a stroke?
- Neurological: seizure, migraine, Bell’s Palsy
42
what infection differentials are there of a stroke?
- Infection: meningitis/ encephalitis, systemic infection with decompensation of old stroke
43
how would differentiate between seizure and stroke?
Seizure: often cause loss of consciousness - EMG would reveal the surge in electrical activity
44
how would you differentiate between migraine and stroke?
Migraine: be sitting in dark room and no stimulation would improve symptoms  would not in stoke - Migraine – positive sensation  tingly, prickly, seeing spots - Stroke: absence of sensation  feeling numb or weak, having vision loss
45
how would you differentiate between bell's palsy and stroke?
Bell’s Palsy: watering from eye on affected side, changes in ability to taste, sound sensitivity and ringing in ear - Stroke: trouble finding words, eyes gazing in one direction, trouble walking and vision changes - Bells: can not move eyebrows and lower portion of face but limbs are not affected
46
how would you differentiate between stroke and meningitis?
Meningitis: systemically unwell – fever, photophobia and neck stiffness
47
how would you differentiate between stroke and encephalitis?
Encephalitis: altered consciousness, seizures and focal deficits
48
how would you differentiate between syncope and stroke?
Syncope: transient loss of consciousness with spontaneous and unaided come around and no further issues following
49
what would indicate psychogenic/ functional/ conversion therapy?
- Excessive hesitation in locomotion - Increasing swayings in rombergs test - Uneconomic postures wasting muscle energy - Small cautions steps like walking on ice - Sudden buckling of the knees emotional distress - Seen in young women most frequently
50
what is rombergs test?
positive test is inability to maintain an erect posture over 60seconds with eyes closed
51
which patients is venous sinus thrombosis most common in?
often in obese young women in hypercoagable states - Pregnant or taking OCP
52
which type of CT should be used to assess query stroke?
non contrast if it is haemorrhagic - will cause them to bleed out
53
what does dysdiadochokinesia indicate?
parkinsons - can not do fast repetitive movements
54
what is the most common cause of haemorrhagic stroke?
hypertension
55
if a CT comes back unremarkable following query stroke, what would it indicate?
ischaemic stroke- would not see for a couple weeks after needs altepase
56
how long does a TIA last?
less than 24hrs
57
what is a TIA?
transient ischaemic attack - temporary neuro dysfunction
58
what is a cresendo TIA?
2+ TIAs in a week - higher risk of stroke
59
what symptoms would indicate a posterior ischaemic stroke?
ataxia and vertigo
60
what would be seen in total anterior circulation stroke?
3/3 - unilateral weakness - homonymous hemianopia - higher cerebral dysfunction
61
what would be seen on a partial anterior stroke?
2/3 - unilateral weakness - face, arm, leg - homonymous hemianopia - higher cerebral dsyfunction
62
what is seen within a lacunar syndrome?
1/4 - pure sensory stroke - pure motor stroke - sensori- motor - ataxic hemiparesis
63
what is seen within a posterior circulation?
1/5 - cranial nerve palsy +/- contralateral motor or sensory - bilateral motor+/- sensory - conjugate eye movement - cerebellar dysfunction - isolated homonymous hemianopia
64
what
65
would an anterior cerebral artery stroke present as?
opposite side weakness (hemiparesis) sensory loss - mainly lower extremities
66
how would a middle cerebral artery stroke present as?
opposite side weakness sensory loss - mainly upper extremities contralateral homonymous hemianopia
67
how would a posterior cerebral artery stroke appear as?
contralteral homonymous hemianopia with macular sparing visual agnosia
68
what is visual agnosia?
inability to recognise and name known objects
69
where does 'weber syndrome' affect within a stroke in the brain?
branches of posterior supplying midbrain
70
how does a webber - branches of posterior supplying midbrain stroke present?
ipsilater CNIII palsy contralateral weakness of upper and lower extemity
71
how does a posterior inferior cerebellar stroke present?
ipsilateral facial pain and temp loss contralateral limb/ torso pain and temp loss ataxia, nystagmus
72
how does an anterior inferior cerebellar stroke present?
ipsilateral facial pain and temp loss contralateral limb/ torso pain and temp loss ataxia, nystagmus ipsilateral facial paralysis and deafness
73
how does a basilar artery stroke present?
locked in syndrome
74
what is a lacunar stroke?
small occlusion in a large artery
75
how does a lacunar stroke present?
isolated hemiparesis hemisensory loss linked to HTN
76

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