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Stroke Flashcards

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1
Q

What does the Basal Ganglia control?

A

Voluntary Motor Function
higher cortical functions - processes sensory info etc

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2
Q

Types of Stroke

A

Ischemic - due to disrupted blood supply such as thrombus
Haemorrhage - bleeding in or around the brain

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3
Q

How do you assess facial weakness? What causes facial weakness?

A

Ask them to smile
Testing lower facial muscles
Upper facial muscles has contralateral control
facial nerve; number 7
upper motor neuron in upper cortex
lower motor neuron in the pons

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4
Q

What is rTPA?

A

aka Alteplase
is a thrombolysis treatment that dissloves blood clots

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5
Q

What are contraindications to thrombolysis

A

Clinical diagnosis of stroke in doubt
Taking anticoagulants or **INR over 1.7 **
Hx of bleeding
Possible subarachnoid haemorrhage
**Stroke symptoms longer then 4.5hrs **

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6
Q

What is a carotid endartectomy?

A

Removal of atheroscleosis from the vessel wall to prevent (further) stroke

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7
Q

Which type of matter is myelinated?

A

White matter

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8
Q

What do hypoxic/ischemic neurons look like under the microscope?

A

Red nerve cells
weeks - Microglia (macrophages)
months/year - liquifactive necrosis - depression filled with CS fluid

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9
Q

What does Warfrin act on?

A

Vit K antagonist
Protein S, Protein C
Factor II, VII, IX, X

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10
Q

What is the Glasgow Comma Scale?

A

Three aspects of behaviour that are independently measured as part of an assessment of a patient’s GCS – motor responsiveness, verbal performance and eye-opening.

The highest possible score is 15 (fully conscious) and the lowest possible score is 3 (coma or dead).

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11
Q

What are risk factors for TIA?

A
  • African descent
  • Male
  • Increased age
  • FHX of TIA & Stroke
  • HTN & atherosclerosis
  • Diabetes
  • Obesity & OSA
  • high LDL, low HDL
  • Cocaine abuse
  • Smoking
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12
Q

Explain the pathophysiology behind TIA?

A

Blood vessel occlusion/stenosis/hypo-perfusion leads to decreased blood flow in the affected region. Leads to short lasting neurological dysfunction and stroke-like symptoms.
Blockage self-resolves within 24hrs

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13
Q

What is the presentation for TIA?

A

Symptoms usually last a few mins to 1 hour (within 24 hours at the most)
* Numbness/paresis
* Face, arms, legs etc
* Aphasia - If dominant hemisphere affected
* Hemispatial neglect - If non-dominant hemisphere affected
* Dizziness
* Double vision
* Amaurosis fugax - If affecting ophthalmic artery
* Focal hearing loss

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14
Q

Investigations for TIA?

A

Bloods; To rule out conditions that mimic TIA
* Hypoglycaemia, hyponatraemia, thrombocytosis
CT/MR/conventional catheter angiography
Diffusion-weighted MRI scan - Changes seen within first few hours of symptoms
Perfusion-weighted MRI - Checks for decreased tissue blood flow
Everyone presenting with stroke or TIA should be
given a neck doppler ultrasound and ECG; To rule out carotid stenosis and AF respectively
If there is >50% stenosis of vessel -> carotid
endarterectomy
ABCD2 score
* To evaluate risk for possible ischaemic stroke
* Age, Bp, Clincial feature, Duration, Diabetes

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15
Q

Management of TIA

A

Early presentation - < 24hrs
Aspirin 300mg stat, 75mg OD for 21 days
Clopidogrel 300mg stat, 75mg OD lifelong
Late presentation - > 7days
Aspiring 300mg stat, 75mg OD till seen by specialist
Clopidogrel 300mg stat, 75mg OD lifelong

Lifestyle modifications, BP control, Lipid control, Anticoag in AFib

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16
Q

What is the advice around driving for all Strokes & TIAs?

A

Advise not to drive;
1 month if only 1 event
3 months if HX of multiple events

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17
Q

What is the prognosis of TIA?

A

Recurrent TIA or ischemic stroke
ABCD2 - to work out risk of stroke in week following TIA

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18
Q

What are the 3 branches of the Internal Carotid? And where do they supply?

A

The anterior carotid generally supples the anterior portion of the brain
1. Opthalmic artery - supplies the retina
2. Anterior cerebral artery - supplies the frontal lobe & superior parietal lobe
3. Middle cerebral artery - supplies the rest of the parietal lobe and portions of the frontal & temporal lobe

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19
Q

What does the vertebrobasilar artery supply?

A

posterior portion of the cerebrum & cerebellum

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20
Q

What does the posterior cerebral artery supply? What is the origin of the PCA?

A

Occipital and posteromedial parts of the temporal lobe
The PCA lies just above the circle of Willis so comes of the basilar artery

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21
Q

What comes off the Basilar artery?

A

Posterior cerebral artery
Anterior cerebellar artery - supply the cerebellar
Superior cerebellar artery - supply the cerebellar

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22
Q

What artery causes locked in syndrome?

A

Basilar artery

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23
Q

What artery is blocked with thalamic pain syndrome and burning pain on the contralateral side of the body?

A

Posterior cerebral artery

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24
Q

What artery is blocked when there is behavioural changes and weakness/paralysis of the leg over the arm
difficulty forming words, often shows struggle in speaking

A

Anterior Cerebral Artery

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25
What are specific symptoms associated with a blockage of the middle cerebral artery?
Difficulty understanding words and instructions, Gaze preference towards the side of the lesion and Paralysis/weakness of the arm over the leg or total contralateral hemiparesis
26
What is a Lacunar stroke?
A Lacunar stroke is a stroke that **affects the subcortical structures of the braindue to damage to the branches of the main circulation such as the MCA**. This leads to specific symptom disorders depending on the location of the stroke. It also leads to no higher cerebral dysfunctions such as Dysphasia.
27
What typically causes a total anterior circulation stroke?
An occlusion of the Internal Carotid artery The circle of Willis is meant to reperfuse the anterior circulation, if there is sudden complete occlusion of the ICA the circle of Willis can become overwhelmed and insufficiently perfuse the Anterior circulation. A complete occlusion of the Middle cerebral artery can also cause a TACS as the MCA supplies a significant portion of the frontal lobe as well as the parietal and temporal lobes. Therefore it can cause ischaemia to a significant portion of the anterior circulation causing the clinical symptoms required to label the stroke as a TACS. This occlusion would occur above the circulation of Willis in an End artery so there would be no perfusion in this case
28
What are the symptoms of a Total Anterior Circulation stroke?
Affecting areas of brain supplied by both middle and anterior cerebral arteries All three of the following: * Unilateral weakness (and/or sensory deficit) of the face, arm and leg * Homonymous hemianopia * Higher cerebral dysfunction (dysphasia, visuospatial disorder)
29
What is a Partial anterior circulation stroke?
Affecting part of the anterior circulation Two of the following: * Unilateral weakness (and/or sensory deficit) of the face, arm and leg * Homonymous hemianopia * Higher cerebral dysfunction (dysphasia, visuospatial disorder) * Higher cerebral dysfunction alone is also classified as PACS.
30
What is the function of the frontal lobe?
Personality and emotions, Sense of smell and contains Broca’s area which allows for the ability to speak thoughts. The Motor cortex sits at the back of the frontal lobe towards the central sulcus.
31
What is the function of the parietal lobe?
The sensory cortex is located in the parietal lobe, so damage to this will cause issues in sensory processing such as pain and temperature control. The parietal lobe is also involved in spatial coordination
32
What is the function of the Temporal lobe?
Deals largely with long-term memory, auditory and language processing, Wernicke's area is also located here which is responsible for understanding the spoken word
33
What is the function of the Occipital lobe?
Responsible for visual awareness, such as spatial processing, distance and depth perception, colour determination and facial recognition
34
What are the risk factors for Stroke?
* Older age * Family history of stroke * History of ischaemic stroke or TIA * Hypertension * Smoking * Diabetes Mellitus * Atrial Fibrillation * Comorbid Cardiac Conditions * Carotid Artery Stenosis * Sickle Cell Disease * Dyslipidaemia * Lower Levels of Education
35
What is the pathophysiology of Ischemic Stroke?
Ischaemic stroke occurs when blood supply in a cerebral vascular territory is critically reduced due to occlusion or critical stenosis of a cerebral artery. Ischaemic strokes can be broadly classified as: * Primary vascular pathologies - Directly reduce cerebral perfusion and/or result in embolism * Cardiac pathologies - Lead to cerebral arterial occlusion due to embolism * Haematological pathologies including vasculitis * Global hypoperfusion - diabetes or cardiac arrest * Emobolus - septic, fatty
36
What are 3 aetiologies of stroke?
1. Large artery atherosclerosis 2. Hypoperfusion 3. Cardioembolism Others & undeterminate
37
What is a lacunar stroke?
Subcortical stroke that occurs secondary to small vessel disease One of the following * Pure sensory stroke * Pure motor stroke * Sensori-motor stroke * Ataxic hemiparesis
38
What are the 4 parts of the Bamford Classification?
1. Total anterior circulation stroke 2. Partial anterior circulation stroke 3. Posterior circulation syndrome 4. Lacunar stroke
39
What is a Posterior Circulation Syndrome?
Damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem) One of the following: * Cranial nerve palsy and a contralateral motor/sensory deficit * Bilateral motor/sensory deficit * Conjugate eye movement disorder (e.g. horizontal gaze palsy) * Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia) * Isolated homonymous hemianopia
40
What are the investigations of Stroke?
* Non-contrast CT - to differentiate between ischemic & haemorrhagic before thrombolysis * Serum glucose & serum electrolytes - to rule out ddx * FBC, PTT, INR before thrombolysis * ECG - AFib, cardiac enzymes * Serum urea & creatinine - to exclude renal failure
41
What is the management for ischemic stroke?
* Supportive care * Aspirin 300mg OD for 2 weeks * Thrombolysis once haemorrhage excluded & within 4.5hrs * Thrombectomy - blockage in proximal anterior or posterior circulation
42
What is the secondary prevention post-stroke?
* Clopidogrel 75mg OD * Atorvastatin 20-80mg OD after 48hrs * BP & diabetes control * Lifestyle changes
43
What is the Epidemiology & Risk Factors for Haemorrhagic Stroke?
10% of strokes with higher mortality rate than ischemic strokes * HTN * Old age & Male * heavy alcohol use, drugs * Asian, black, hispanic * FHX * Haemophillia, Sickle cell * Cerebral amyloid angiopathy * Vascular malformations * Pregnancy
44
What is the pathophysiology of haemorrhagic stroke?
Vascular rupture leading to bleeding into the brain paarenchyma resulting in mechanical injuy to the brain tissue. The expanding haemotoma may 'shear' neighbouring arteries leadinf to further bleeding & expansion resulting in secondary injurgy due to; * mass effect * increased intracranial pressure * reduced cerebral perfusion * secondary ischaemic injury * cerebral herniation
45
What are the 2 types of causes of haemorrhagic stroke?
1. Primary spontaneous Idiopathic or Anticoagulation 2. Secondary Vascular malformation or mechanical/neuro diseases that affect coagulation
46
What is the presentation of haemorrhagic stroke?
Similar to ischemic but some features are more suggestive og haemorrhagic * decrease in level of consciosness * headache, nausea, vomiting * Seizures in up tp 25% of patients
47
What IX in haemorrhagic stroke?
**Non-contrast CT HEAD** all as in ischemic stroke & LFTs as a cause Clotting screens
48
What is the management of haemorrhagic stroke?
Rapid BP control to ~100 systolic Reversal of anticoagulation Refer for neurosurgical assessment
49
What is secondary prevention of haemorrhagic stroke?
Clopidogrel 75mg OD for life Atorvastatin 20-80mg OD for life (start 48hrs after) BP & Diabetes control Lifestyle changes for modifiable risk factors
50
What are the different imaging modalities in stroke?
1. Non-contrast CT 2. CT angiography 3. Catheter angiography 4. CT perfusion scan 5. MRI brain 6. Magnetic resonance angiography 7. Carotid doppler
51
What are some key differentials for stroke & how to differentiate?
* **Bells palsy** - weakness due to lower motor neuron of 7th facial nerve so facial weakness extends above the eyebrows * Epilepsy & Todd's palsy * Tumour & abscess causing compression * Wernicke's encephalopathy - different cause of wernicke's aphasia * Migraine * Old strokes who are unwell & Dementia These mimics often have a **long onset** * **Hypoglycemia** - check glucose levels
52
What does cellular neurovascular repair look like in the chronic phase?
Primary recovery involves angiogensis & neurogenesis. Neuroblasts migrate along perivascular routes, promotion of neurogensis enhances vascular regrowth & conversly angiogenic stimulation enhances neurogenesis
53
What 2 structural adaptations does the brain have to ensure blood supply?
1. The circle of Willis 2. Microcirculation
54
What is the circle of Willis?
A ring of 4 blood vessels in the posterior region of the brain, protecting against ischemia in a single vessel
55
What is Microcirculation?
High capillary density optimies oxygen transport in the brain - Every neurone in the brain has its own capilary
56
What is the blood brain barrier?
The non-fenestrated endothelial cells of brain capillarie form a continous lining allowing them to be highly selective & prevent harmful substances getting into the brain
57
What is the neurovascular unit?
This is a component of the blood brain barrier where the neurons, glia & cerebral blood vessels function together
58
What is Cerebral perfusion pressure?
The amount of pressure needed to maintain blood flow to the brain. It is regulated by 2 opposing forces; * Mean arterial pressure - the force that pushes blood to the brain * Intracranial pressure - the pressure the brain is uner which can force blood out of the brain
59
How do you calculate Cerebral perfusion pressure?
CPP= MAP - ICP | MAP - Mean arterial pressure, ICP - Intracranial pressure
60
What can increase Intracranial pressure & what does that affect?
Increase ICP = increase in volume; * intracranial bleeding * cerebral oedema * tumour An increase in ICP leads to a decrease which can collapse veins & reduceblood flow
61
What is autoregulation?
Autoregulation maintians a relatively constant cerebral blood flow despite changes in arterial/venous pressure * An increase in MAP causes vasodilation & decreased HR * A decrease in MAP causes vasoconstriction & increased HR | MAP - Mean arterial pressure
62
What 3 pathways can the brain change cerebral blood flow using? | (Autoregulation)
1. Metabolic 2. Myogenic 3. Neural
63
What is metabolic control of cerebral blood flow?
Vasodilation/constriction in the brain in response to metabolic by-products
64
Name 3 vasodilators in the brain
1. CO2 2. Adenosine 3. Potassium
65
How does increased neural activity lead to vasodilation?
* Increased neural activity leads to ATP breakdown & high pCO2 & the production of adenosine * Adenosine is a vasodilator so increases blood flow to the area to replace O2 & ATP * The increase in CO2 causes a fall in pH which trigggers vasodilation
66
What is myogenic autoregulation?
Cerebral arteries change their diameter due to changes in blood pressure Increased pressure = vascoconstriction Decreased pressure = vasodilation
67
What is neural autoregulation?
* The sympathetic nerve terminals release norepinephrine which causes vasoconstriction (NO pathway) * The parasympathetic nerves cause vasodilitation * Cerebral vessels have sensory nerves which can release calcitonin gene-related peptide which is a vasodilatory neurotransmitter | Neural control is compartively weak to metablic/myogenic autoregulation

Stoke & Vascular (5 decks)

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