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Stroke Flashcards

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1
Q

what is the definition of stroke?

A

the sudden onset of focal or global neurological symptoms caused by ischemia or hemorrhage and lasting more than 24 hours.

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2
Q

what percentage of strokes are ischaemic and haemorrhagic?

A

85% are ischaemic strokes

15% haemorrhagic strokes

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3
Q

what is a TIA?

A

is the term used if the symptoms resolve within 24 hours.

Most TIAs resolve within 1-60 min.

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4
Q

what is a hemorragic stroke?

A

hemorrhage/blood leaks into brain tissue

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5
Q

what is an ischemic stroke?

A

clot stops blood supply to an area of the brain

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6
Q

what are the different causes of an ischaemic stroke?

A

Large artery atherosclerosis (e.g. Carotid) 35%
Cardioembolic (e.g. atrial fibrillation) 25%
Small artery occlusion (Lacune) 25%
Undetermined/Cryptogenic 10-15%
Rare causes <5%
Arterial dissection
Venous sinus thrombosis

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7
Q

what are the different causes of a hemorrhagic stroke?

A

Primary intracerebral hemorrhage 70%
Secondary hemorrhage 30%
Subarachnoid hemorrhage
Arteriovenous malformation

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8
Q

what are modifiable stroke risk factors?

A

oestrogenic pills or even HRT prothrombotic

Drugs of abuse like cocaine can be damaging to cerebral blood vessels

Smoking

heart disease, atherothrombosis, risk of subarachnoid haemorrhage,

Bad diet because of high cholesterol and increased risk of atheroma

centripetal obesity

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9
Q

what are non-modifyable risk factors?

A

Previous stroke
Age
Male
Family history

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10
Q

what is the most important modifyable risk factor?

A

hypertension

The risk of stroke is related to the level of blood pressure

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11
Q

what does chronic hypertension exacerbate?

A

atheroma and increases involvement of smaller distal arteries

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12
Q

which arteries experience the most pressure?

A

Small end arteries coming directly off large arteries experience higher pressure and are at risk of lipohyalinosis

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13
Q

what does lipohyalinosis of small arteries cause?

A

Lacunar ischaemic stroke

Small vessel haemorrahges

Especially in
Brainstem
Basal ganglia
Subcortical areas

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14
Q

what are smokers at increased risk of?

A

2x increased risk of cerebral infarction

3x increased risk for sub-arachnoid hemorrhage

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15
Q

how does diabetes affect the likelyhood of suffering from a stroke?

A

Diabetes mellitus increases the incidence of strokes 3x

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16
Q

how do lipids impact the likelyhood of suffering from a stroke?

A

The relationship between serum lipids and stroke is established.

Risk related to development of atheroma in blood vessel walls.

A high plasma level of low density lipoprotein (LDL) results in excessive amounts of LDL within the arterial wall.

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17
Q

how does atrial fibrillation increase the risk of a stroke?

A

Prevalence doubles with age : 9% at 80-90 years

5x increased risk embolic stroke

More severe strokes

Higher mortality and morbidity, longer hospital stays, and lower rates of discharge to patients’ own homes

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18
Q

what has no benefit in patients with AF in reducing chance of ischaemic stroke?

A

antiplatelets (e.g. Aspirin)

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19
Q

what reduces the risk of ischaemic stroke by 2/3?

A

Anticoagulants (warfarin and DOACS)

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20
Q

what has less of a risk of causing bleeding than warfarin?

A

DOACS (e.g. Edoxaban and Apixaban)

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21
Q

what are other risk factors for suffering from a stroke?

A

Other cardiac causes (recent heart attack, myxoma, PFO).

Oral contraceptives (+ HRT) with a high estrogen content. Progesterone-only OK

Hyper-coagulable states:
- malignancy
- genetic

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22
Q

what is the anterior arterial supply to the brain?

A

2 x Internal carotid arteries
2 x Anterior Cerebral Artery (ACA)
2 x Middle Cerebral Artery (MCA)

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23
Q

what is the posterior arterial supply to the brain?

A

2 Vertebral arteries →1 basilar

3 pairs of cerebellar arteries
2 Posterior cerebral arteries (PCA)

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24
Q

what parts of the brain does the carotid system supply?

A

The carotid system supplies most of the hemispheres and cortical deep white matter

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25
what parts of the brain does the vertebrobasilar system supply?
the vertebro-basilar system supplies the brain stem, cerebellum and occipital lobes
26
which questions should you ask when making diagnosis of a stroke?
What is the neurological deficit? Where is the lesion? What is the lesion? Why has the lesion occurred? What are the potential complications and prognosis?
27
what are functions of the frontal lobe?
High level cognitive functions ie. abstraction, concentration, reasoning Memory Control of voluntary eye movement Motor control of speech (dominant hemisphere) Motor cortex Urinary continence Emotion and personality
28
what aspect of speech is within the frontal lobe, and what happens if this area is affected?
motor control of speech Broca's aphasia or expressive aphasia is when people find it very difficult to find and say the right words, although they probably know exactly what they want to say.
29
what are functions of the parietal lobe?
Sensory cortex Sensation (identify modalities of touch, pressure, position) Awareness of parts of the body Spatial orientation and visuospatial information (non dominant hemisphere) Ability to perform learned motor tasks (dominant)
30
what are functions of the temporal lobe?
Primary auditory receptive area Comprehension of speech (dominant) – Wernicke’s Visual, auditory and olfactory perception Important role in learning, memory and emotional affect
31
what aspect of speech is within the temporal lobe, and what happens if this area is affected?
Wernicke’s aphasia – usually left hemisphere. Deficit in language comprehension. Can speak fluently but has semantic errors and may sound nonsensical/jargon
32
what is the homonculus?
The sensory homunculus is a topographic representation of the sensory distribution of the body found in the cerebral cortex. This topograph usually has body parts illustrated along the surface of the postcentral and precentral gyrus of the parietal lobe.
33
what would infarct of the anterior cerebral artery cause weakness of, (supplies part of the precentral gyrus)?
leg>arm weakness
34
what would infarct of the middle cerebral artery cause weakness of, (supplies part of the precentral gyrus)?
face and arm> leg weakness
35
what will a small stroke in deep white matter/corticospinal tract result in?
A small stroke here (or there) will result in a major deficit as the fibres are packed close together
36
what function is controlled by the cerebellum?
Balance and coordination
37
what makes up the brainstem?
Midbrain, pons and medulla
38
which cranial nerves arise from the brainstem?
10 of 12 cranial nerves arise in brainstem (ipsilateral signs)
39
what would a stroke in brainstem result in?
Contralateral hemiparesis due to crossing of cortical tracts in lower medulla Some major functions: eye movement, breathing, swallowing, heart beat, consciousness
40
what are functions of occipital lobe?
Primary visual cortex Visual perception Involuntary smooth eye movement
41
what are clinical presentations of stroke?
Motor (clumsy or weak limb) Sensory (loss of feeling) Speech: Dysarthria/Dysphasia Neglect / visuospatial problems Vision: loss in one eye (amaurosis fugax) or hemianopia Gaze palsy Ataxia/ vertigo / incoordination / nystagmus
42
do symptoms of stroke have a rapid onset?
yes
43
what do symptoms depend on?
which part of the brain is affected
44
how can strokes be classified?
according to Oxford Community Stroke Project Classification (OCSP)
45
what are the four different clinical classifications of stroke?
Total Anterior Circulation Stroke (TACS) Partial Anterior Circulation Stroke (PACS) Lacunar Stroke (LACS) Posterior Circulation Stroke (POCS)
46
describe OCSP classification of LACS?
small vessel anterior +/- weakness (>2/3 face arm leg) +/- numbness (>2/3 face arm leg) - hemianopia/dysphagia/neglect - cerebellar signs
47
describe OCSP classification of PACS?
large / partial vessel anterior +/- weakness (>2/3 face arm leg) +/- numbness (>2/3 face arm leg) 1 of hemianopia/dysphagia/neglect - cerebellar signs
48
describe OCSP classification of TACS?
large / total vessel anterior +/- weakness (>2/3 face arm leg) +/- numbness (>2/3 face arm leg) 2 of hemianopia/dysphagia/neglect (must have hemianopia) - cerebellar signs
49
describe OCSP classification of POCS?
either large or small vessel posterior +/- weakness (>2/3 face arm leg) +/- numbness (>2/3 face arm leg) +/-hemianopia/dysphagia/neglect (must have hemianopia) + cerebellar signs
50
what would a patient present with following a stroke affecting right hemisphere?
Left hemiplegia, homonymous hemianopia Neglect syndromes (agnosias) Visual agnosia Sensory agnosia Anosagnosia (denial of hemiplegia) Prosopagnosia (failure to recognise faces)
51
describe the criteria for a TACS?
Main artery to one hemisphere “Full house” of effects 3 of 3: Complete hemiparesis/numbness Loss of vision on one side (hemianopia) Loss of awareness on one side (inattention) non-dominant or Dysphasia dominant TACS is often due to blocked Carotid or Middle cerebral artery
52
describe criteria for a PACS?
Branch of main artery In-between LACS and TACS 2 of 3 TACS criteria or One higher cortical deficit: Inattention Or dysphasia or Monoparesis
53
describe the criteria for a LACS?
Small “perforating” artery Movement and sensation pathways Weakness/numbness of: Face + arm + leg Or Face + arm Or Arm + leg May have dysarthria Ataxic hemiparesis No affect on higher function Will not have dysphasia, inattention or hemianopia
54
describe the criteria for a POCS?
Any posterior artery Combination of symptoms including: Loss of balance/coordination Vertigo Double vision Dysarthria Visual loss (hemianopia)
55
describe the criteria for a basilar artery occlusion?
Ischaemia in pons Predominantly motor/oculomotor signs/symptoms Bilateral but asymmetrical Alteration in level of consciousness common – may progress over 12-24hours May present as reduced responsiveness ?cause requiring critical care
56
what is the mortality and reccurance rate of TACS at 12 months?
mortality - 60% recurrance rate - 6%
57
what is the mortality and reccurance rate of PACS at 12 months?
16% 17%
58
what is the mortality and reccurance rate of LACS at 12 months?
11% 9%
59
what is the mortality and reccurance rate of POCS at 12 months?
19% 20%
60
what conditions can mimic symptoms of a stroke?
Seizures Syncope (hypotension) Sugar (hypo or hyper) Sepsis (+previous stroke) Severe migraine Space occupying lesions Si-chological (Functional) And Vestibular disorders Demyelination Transient global amnesia Mononeuropathy
61
what are positive symptoms for a stroke?
excess CNS neurone electrical discharges visual (eg, flashing lights, zigzags, shapes, lines, objects) somatosensory (eg, pain, paraesthesia) motor (eg, jerking limb movements)
62
what are negative symptoms of a stroke?
Loss or reduction of CNS neurone function Loss of vision Loss of sensation Loss of limb power
63
what do >20% of patients with suspected TIA have?
migraine aura - most common mimic
64
what is a migraine aura?
Migraine aura symptoms include temporary visual or other disturbances that usually strike before other migraine symptoms — such as intense head pain, nausea, and sensitivity to light and sound. Migraine aura usually occurs within an hour before head pain begins and generally lasts less than 60 minutes.
65
what symptoms occur alongside a migraine aura?
Visual disturbances scintillating scotomata geometric (especially zigzag) patterns positive symptoms (like a kaleidoscope, running water etc) Can include sensory, motor or speech disturbance Headache onset can be >1hour after the end of the aura or no headache
66
who does functional/anxiety disorder most commonly affect?
Younger More common in women No conventional risk factors
67
what is hoovers sign?
Hoover's sign1 is a manoeuvre aimed to separate organic from non-organic paresis of the leg. The sign relies on the principle of synergistic contraction. Involuntary extension of the “paralysed” leg occurs when flexing the contralateral leg against resistance
68
what are the signs and symptoms of acute vestibular syndrome?
Common, onset can be acute Can be very disabling ‘True vertigo’ vs unsteadiness vs dizziness Nystagmus – unidirectional, increases in intensity when patient looks in direction of fast phase Vomiting Even an expert taking a careful history may remain uncertain MRI can be helpful
69
what investigations are done for a stroke in all patients?
Routine blood tests (FBC, glucose, lipids, ESR...) CT or MRI head scan (infarct vs. hemorrhage) ECG + Holter (?AF, LVH) Carotid doppler ultrasound (?stenosis)
70
what investigations are done for stroke in some patients?
Echocardiogram (valves, ASD, VSD, PFO) Cerebral angiogram/venogram (vasculitis?) Hyper-coaguable blood screen
71
what should acute ischaemic stroke therapies do?
Restore blood supply. Prevent extension of ischemic damage. Protect vulnerable brain tissue.
72
what are different stroke treatments offered?
aspirin thrombolysis thrombectomy
73
what are compoenents of a stroke unit
Clinical staff Stroke nurses Physiotherapists Speech and Language therapists Occupational therapists Dietician Psychologist Orthoptist
74
what is the strict criteria dor use of TPA?
< 4.5 hours from symptom onset. Disabling neurological deficit. Symptoms present > 60 minutes. Consent obtained.
75
what is exclusion criteria for IV TPA?
Anything that increases the possibility of hemorrhage: blood on CT scan recent surgery recent episodes of bleeding coagulation problems BP >185 systolic or >110 diastolic Glucose <2.8 or > 22mmol/L
76
what is effective treatment in symptomatic internal carotid artery stenosis?
Carotid endarterectomy
77
what is secondary preventatives for stroke?
Anti-hypertensives >25% Anti-platelets 25% Lipid lowering agents 25% Warfarin for AF 66% Carotid endarterectomy NNT of 3 (Absolute reduction of 30%)

Nervous System (40 decks)

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