Stroke Flashcards

Question

Where can embolisms occur?

Answer 1

- If a clot form on the left atrium, it moves into the left ventricle and from there it has a direct route to the brain. - On the other hand, if a clot forms in the low-pressure veins or right atrium, then it goes into the tight ventricle and gets lodged in the pulmonary capillaries with no way of getting to the brain.

Answer 2

- An important exception is if a person has a heart defect like an atrial septal defect that allows blood and potentially a blood clot to go from the right side of the heart over to the left side of the heart. - In that situation, a venous or right atrial blood clot will have bypassed the pulmonary circulation and established a route to the brain.

Answer 3

A specific type of ischaemic stroke called a Lacunar stroke, they typically involve the deep branches of the middle cerebral artery that feed the basal ganglia. Lacunar refers to lake, and is called that because after a Lacunar stroke, the damaged brain tissue develops fluid filled pockets called cysts that look like little lakes under the microscope.

Answer 4

Lacunar strokes develop as a result of hyaline atherosclerosis which is when the arteriole wall gets filled with protein. This can happen as a result of hypertension or diabetes, and can make the artery wall quite thick, reducing the size of the lumen.

Answer 5

Patients typically have a focal neurological deficit which corresponds to the region of the brain that’s affected e.g. - An anterior cerebral artery stroke affects the feet and legs. - A middle cerebral artery stroke affects the hands, arms, face, and the language centers in the dominant hemisphere, including Broca’s and Wernicke's area. - A posterior cerebral artery stroke primarily affects the visual cortex, which affects a person’s ability to see clearly.

Answer 6

Both motor and sensory fibres may be affected: - Damage to motor pathways: flaccid paralysis develops almost immediately. And then over the following days to weeks, there’s spastic paralysis and hyperreflexia due to the hyperexcitable stretch reflex. - Damage to sensory pathways: numbness, reduced pain and vibration sensation.

Answer 7

Both motor and sensory symptoms usually happen on the side that’s contralateral from the stroke, except in rare cases of brain stem stroke, where both sides are affected.

Answer 8

- Atherosclerosis, migraine, vasculitis-reduce cerebral perfusion and/or result in artery-to-artery embolism - Cardiac pathologies (e.g., atrial fibrillation, myocardial ischaemia/infarction, patent foramen ovale) that lead to cerebral arterial occlusion due to embolism - Haematological pathologies (e.g., prothrombotic hypercoagulable or hyperaggregable states) that directly precipitate cerebrovascular thrombosis (particularly venous), or facilitate systemic venous or intracardiac thrombus formation and cardioembolism.

Answer 9

- There are more than 100,000 strokes in the UK each year causing 38,000 deaths, making it a leading cause of death and disability. - People are most likely to have a stroke **over the age of 55.**

Answer 10

- Stroke is the third leading cause of mortality in the US and the UK - The average age for a stroke is 68 to 75 years old - Stroke rates are higher in Asian and black African populations than in Caucasians - M>F

Answer 11

Usually sudden onset followed by gradual decline Specific symptoms depends on anatomical site of stroke

Answer 12

- Anterior cerebral artery - Contralateral hemiparesis and sensory loss with lower limbs > upper limbs - Middle cerebral artery - Contralateral hemiparesis and sensory loss with upper limbs > lower limbs - Homonymous hemianopia - Aphasia: if affecting the ‘dominant’ hemisphere (the left in 95% of right-handed people) - Hemineglect syndrome: if affecting the ‘non-dominant’ hemisphere; patients fail to be aware of items to one side of space - Posterior cerebral artery - Contralateral homonymous hemianopia with macular sparing - Visual agnosia - Contralateral loss of pain and temperature due to spinothalamic damage

Answer 13

4. Vertebrobasilar artery - Cerebellar signs - Reduced consciousness - Quadriplegia or hemiplegia 5. Weber’s syndrome (midbrain infarct; branches of osteoporosis cerebral artery) - Oculomotor palsy and contralateral hemiplegia 6. Lateral medullary syndrome (posterior inferior cerebellar artery occlusion) - Ipsilateral facial loss of pain and temperature - Ipsilateral Horner’s syndrome: miosis (constriction of the pupil), ptosis (drooping of the upper eyelid), and anhidrosis (absence of sweating of the face) - Ipsilateral cerebellar signs - Contralateral loss of pain and temperature

Answer 14

- Retinal/ophthalmic artery Amaurosis fugax - Basilar artery - ‘Locked in’ syndrome

Answer 15

- Headache - Gaze paresis Uncommon - Nausea and/or vomiting - Neck or facial pain

Answer 16

- Signs/Diagnostic factors - Unilateral weakness or paralysis in the face, arm or leg - Dysphasia: Slurred speach - Ataxia - Visual disturbance - Dysarthria - Arrhythmias, murmurs or pulmonary oedema

Answer 17

Uncommon - Vertigo - Miosis, ptosis, and facial anhidrosis (hemilateral) - Decreased level of consciousness or coma

Answer 18

The Bamford classification is commonly used and categorises stroke based on the area of circulation affected. Bamford classification - blood vessel - criteria 1. TACS (Total anterior circulation stroke) - anterior or middle cerebral artery - HHH (hemiplegia, homonymous hemianopia and higher cortical dysfunction, such as dysphasia or neglect) 2. PACS (Posterior anterior circulation stroke) - anterior or middle cerebral artery - two or three from above (HHH) 3. Lacunar stroke - perforating arteries: usually affects the posterior limb of the internal capsule - there is no higher cortical dysfunction or visual field abnormality. One of the following: - pure hemimotor or hemisensory loss - pure sensorimotor loss - ataxic hemiparesis 4. Posterior circulation stroke - posterior cerebral or vertebrobasilar artery or branches - One of the following: - cerebellar syndrome - isolated homonymous hemianopia - loss of consciousness

Answer 19

- Assessment using ROSIER scale Recognition of Stroke in the Emergency Room (ROSIER) scale is a variation of FAST (Face, Arm, Speech, Time) and is used to differentiate acute stroke from stroke-mimics FAST: - Face: has the face drooped on one side? Can the person smile? - Arms: can they lift both arms? - Speech: is the speech slurred or garbled? Can they understand what you’re saying? - Time: dial 999 immediately if there are any of the features above

Answer 20

A stroke is possible if the score is > 0 and requires an urgent non-contrast CT head. Once hypoglycaemia has been excluded, assess the following: - loss of consciousness or syncope -1 point - seizure activity -1 New, acute onset of: - asymmetrical facial weakness +1 - asymmetrical leg weakness +1 - Speech disturbance +1 - Visual field defect +1

Answer 21

- Non-contrast CT head: first-line imaging. - CT is usually normal in the first few hours of ischaemic stroke but allows exclusion of haemorrhage - ECG: assess for atrial fibrillation. - Bloods: - CT angiogram (CTA): identifies arterial occlusion and should be performed in all patients who are appropriate for thrombectomy - MRI head: MRI is an alternative to non-contrast CT head; MRI has a higher sensitivity for infarction and the same sensitivity for haemorrhage when compared to CT imaging. MRI is an alternative to con-contrast CT head.

Answer 22

- Screen for risk factors including Hba1c, lipids, clotting screen and rule out stroke mimics such as hypoglycemia and hyponatraemia - In younger patients, consider ESR, autoantibody and thrombophilia screen - FBC - serum glucose - serum electrolytes - serum urea and creatinine - Prothrombin time and PTT (with INR) - Cardiac enzymes

Answer 23

**Diffusion-weighted MRI** is the gold standard imaging technique. More sensitive but CT is safer and easier to obtain CT is an alternative.

Answer 24

- **Echocardiogram:** for the exclusion of an intracardiac aneurysm or a septal defect - **Carotid Doppler ultrasound** **:** stenosis of >70% is an indication for endarterectomy in Europe. - The stroke must be non-disabling to qualify - **Lumbar puncture:** check for small subarachnoid haemorrhage Investigations to consider - Serum toxicology screen

Answer 25

- Suspected ischaemic stroke - Stabilisation and referral to acute stroke unit Maintain stable blood glucose levels, hydration status and temperature Blood pressure should not be lowered too much during a stroke because this risks reducing the perfusion to the brain. Unless complications are present, e.g., hypertensive encephalopathy. -

Answer 26

- Confirmed ischaemic stroke Presentation within 4.5 hours AND thrombolysis not contraindicated - Supportive care + monitoring - Thrombolysis: Alteplase (intravenous) (Do not delay) - Alteplase is a tissue plasminogen activator that rapidly breaks down clots to reestablish blood flow; and can reverse the effects of a stroke if given in time. - Given if < 4.5 hours of symptom onset and haemorrhage excluded on imaging

Answer 27

- Contraindications of thrombolysis - Examples of thrombolytics include alteplase, tenecteplase and streptokinase. - The key side effect of thrombolysis is haemorrhage, whilst hypotension and allergic reactions can occur and are more common with streptokinase.

Answer 28

1. intracranial haemorrhage on CT - suspected subarachnoid haemorrhage 2. Neurosurgery, head trauma or stroke in past 3 months - uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP) 3. History of intracranial haemorrhage - known intracranial arteriovenous malformation, neoplasm or aneurysm 4. Active internal bleeding - suspected or confirmed endocarditis 5. known bleeding diathesis: coagulation or bleed disorders - aortic dissection

Answer 29

1. Major surgeries or serious non-head trauma in previous 14 days - history of GI, genitourinary or gynaecological haemorrhage within past 21 days 2. Recent lumbar puncture (usually in the past 7 days) - pregnancy

Answer 30

Thrombectomy (mechanical removal of the clot) may be offered if an occlusion is confirmed on imaging, depending on the location and the time since the symptoms started. It is not used after 24 hours since the onset of symptoms.

Answer 31

- Confirmation of stroke requires CTA or MR angiogram **prior** to thrombectomy - Must score > 5 on NIH Stroke Scale/Score (NIHSS) and pre-stroke functional status < 3 on the modified Rankin scale

Answer 32

- Proximal anterior circulation stroke: offer thrombectomy within 6 hours with IV thrombolysis (if within 4.5 hours), or within 6 to 24 hours without IV thrombolysis if there is potential to salvage brain tissue (demonstrated as limited infarct core on imaging) - Proximal posterior circulation stroke (basilar or posterior cerebral artery): consider thrombectomy within 24 hours with IV thrombolysis (if within 4.5 hours) if there is potential to salvage brain tissue (demonstrated as limited infarct core on imaging)

Answer 33

- Antiplatelet agent - aspirin - 300mg daily - Given as soon as possible once haemorrhage is excluded on CT If treated with thrombolysis, start aspirin after 24 hours once haemorrhage is excluded Continue until 2 weeks after the onset of stroke symptoms - Venous thromboembolism prophylaxis plus early mobilisation - High intensity statin (after 48 hours) - atorvastatin - Anticoagulation - If atrial fibrillation is the cause, anticoagulation should not be started until 14 days post-stroke. Patients should be on aspirin 300mg until then.

Answer 34

- Presentation after 4.5 hours OR thrombolysis contra-indicated - Supportive care + monitoring - Mechanical thrombectomy - Antiplatelet agent - aspirin - ***300mg daily*** - Venous thromboembolism prophylaxis plus early mobilisation - High intensity statin (after 48 hours) - atorvastatin

Answer 35

- **Clopidogrel** daily lifelong is first-line - Offer aspirin 75 mg daily + MR dipyridamole if clopidogrel is contraindicated - Offer MR dipyridamole alone if aspirin and clopidogrel are contraindicated - **High-dose statin** e.g. atorvastatin 20-80mg, usually after 48 hours of stroke - **Manage hypertension, diabetes, smoking and other cardiovascular risk factors** - **Carotid endarterectomy or stenting** in patients with carotid artery disease

Answer 36

- **Deep venous thrombosis:** due to immobility - **Aspiration pneumonia:** due to dysphagia - Haemorrhagic transformation of ischaemic stroke - **Depression** - Alteplase-related orolingual oedema - **Neurological sequelae**: such as weakness, impaired mobility, Middle cerebral artery syndrome and seizures - **Requirement for nutritional support**: such as nasojejunal feeding - - Intracerebral haemorrhage - Transient ischaemic attack - Hypertensive encephalopathy - Hypoglycaemia - Complicated migraine - Seizure and postictal deficits - Wernicke’s encephalopathy - Brain tumour - Sepsis - Ingestion of toxic substances - Hyponatraemia - Hypercalcaemia - Uraemia

Answer 37

- Intracerebral haemorrhage - Transient ischaemic attack - Hypertensive encephalopathy - Hypoglycaemia - Complicated migraine - Seizure and postictal deficits - Wernicke’s encephalopathy - Brain tumour - Sepsis - Ingestion of toxic substances - Hyponatraemia - Hypercalcaemia - Uraemia

Answer 38

**Strong** - Older **age**: the average age for a stroke is 68 to 75 years old - **Family history** of stroke - History of ischaemic stroke - **Hypertension:** the single greatest risk factor - **Smoking** - **Diabetes** - **Atrial fibrillation** - Comorbid cardiac conditions - Carotid artery stenosis - Sickle cell diseases - Dyslipidaemia - Lower levels of education - **Hypercholesterolaemia** - **Haematological disease**: such as polycythaemia

Answer 39

**Weak** - Poor dietary nutrition - Physical inactivity - Obesity - Alcohol abuse - **Medication**: such as hormone replacement therapy or the combined oral contraceptive pill - Oestrogen-containing therapy - Obstructive sleep apnoea - Illicit drug use - Migraine - HyPerhomocysteinaemia - Elevated lipoprotein - Hypercoagulable states - Elevated C-reactive protein - Aortic arch plaques

Answer 40

For ischaemic stroke, the prognosis depends on the severity. A total anterior circulation stroke confers the poorest prognosis. Regarding thrombolysis, if administered within 3 hours, patients are 30% more likely to have minimal or no disability. In general, mortality for haemorrhagic stroke is significantly higher than for ischaemic stroke and can be as high as 40%.

Answer 41

**Car or motorcycle** (type 1 license): - Patients must not drive for 1 month after a TIA or stroke - Driving may resume after 1 month if there has been satisfactory clinical recovery - Patients may not need to inform the DVLA if there is no residual neurological deficit beyond 1 month - Multiple TIAs over a short period requires no driving for 3 months and the DVLA must be notified

Answer 42

**Heavy goods vehicle** (type 2 license): - Patients must not drive for 1 year after a TIA or stroke and the DVLA must be notified. - Relicensing may be considered after 1 year if there is no significant residual neurological impairment and no other significant risk factors

Answer 43

- If blood leaks from a blood vessel in or around the brain, this is called a haemorrhagic stroke. - Bleeding from a single vessel within the brain. - High blood pressure is the main cause of intracerebral haemorrhagic stroke

Answer 44

- Intracerebral: bleeding within the brain parenchyma - Subarachnoid: bleeding into the subarachnoid space - Intraventricular: bleeding within the ventricles; prematurity is a very strong risk factor.

Answer 45

The Circle of Willis comprises an anterior circulation, which consists of the branches of the internal carotid, and a posterior circulation which consists of the branches of the vertebrobasilar arteries.

Answer 46

- Anterior circulation - Anterior choroidal artery - Anterior cerebral artery (ACA) - Middle cerebral artery (MCA)

Answer 47

- Posterior circulation - Posterior cerebral artery (PCA) - Basilar artery - Superior cerebellar artery - Anterior inferior cerebellar artery - Posterior inferior cerebellar artery

Answer 48

- Rupture of a saccular ‘berry’ aneurysm is the most common cause of a spontaneous subarachnoid haemorrhage - These occur at points of arterial bifurcation within the Circle of Willis; the junction between the anterior communicating artery and ACA is the most common location -

Answer 49

Watershed zones: account for 5-10% of infarcts - These areas are furthest from arterial supply and are most vulnerable to reduced perfusion - Cortical border zone infarction: border of ACA/MCA and MCA/PCA - Internal border zone infarction: borders of penetrating MCA branches, or borders of the deep branches of the MCA and ACA (resulting in deep white matter infarction)

Answer 50

- in the frontal lobe function: - motor production of speech Arterial supply: middle cerebral artery Effects of a lesion: patients can understand speech but can’t produce it themselves (Broca’s aphasia - non-fluent)

Answer 51

- parietal and temporal lobe Superior temporal gyrus in the dominant hemisphere (brodmann area 22) Function: understanding speech and using correct words to express thoughts Arterial supply: middle cerebral artery Effects of a lesion: patients can produce speech but do not grasp the meaning of spoken words (wernickes aphasia ‘fluent’)

Answer 52

- Cerebral dominance - Majority of people are 'left dominant' (95%): this means that the Wernicke's and Broca's areas are located in the left cerebral hemisphere - A stroke affecting the left MCA causes expressive aphasia (Broca's area) or receptive aphasia (Wernicke's area) - In contrast, left-handed people are more likely to be 'right dominant', meaning that these areas are more likely to be on the right - Therefore, in left-handed people, a right MCA stroke usually causes aphasia - MCA stroke affecting a patient’s 'non-dominant' hemisphere often results in hemisensory neglect, not aphasia

Answer 53

- The occipital pole is responsible for supplying the macula and has a rich anastomosis; this region is also supplied by the MCA - The macular is often spared in a posterior circulation stroke (e.g. PCA infarct), resulting in contralateral homonymous hemianopia with macular sparing - This is because of the dual blood supply of the occipital lobe (MCA and PCA)

Answer 54

- A condition whereby the patient is fully aware but cannot move or communicate verbally due to almost complete paralysis - All voluntary muscles are generally affected, except for vertical eye movements and blinking - It may be caused by a stroke affecting the basilar artery, thus denying blood to the pons - There are also numerous other causes, such as central pontine myelinosis and traumatic brain injury - In contrast, persistent vegetative state affects the upper portions of the brain but spares the lower portions

Answer 55

- A condition whereby the patient is fully aware but cannot move or communicate verbally due to almost complete paralysis - All voluntary muscles are generally affected, except for vertical eye movements and blinking - It may be caused by a stroke affecting the basilar artery, thus denying blood to the pons - There are also numerous other causes, such as central pontine myelinosis and traumatic brain injury - In contrast, persistent vegetative state affects the upper portions of the brain but spares the lower portions

Answer 56

Ruptured blood vessel leading to reduced blood flow. - Aetiology - **Haemorrhagic** (15%) of strokes - Ruptured blood vessel leading to reduced blood flow

Answer 57

- **Intracerebral:** bleeding within the brain parenchyma - Trauma - Arteriovenous malformation - Cerebral amyloid - Hypertension

Answer 58

- Subarachnoid: bleeding between the pia mater and arachnoid mater - Trauma - Berry aneurysm - Arteriovenous malformation - Intraventricular: bleeding within the ventricles

Answer 59

- Brain bleeds - Aneurysm rupture → SAH - Anticoagulation - Thrombolysis - Carotid artery dissection - Atherothromboembolism - Vasculitis

Answer 60

In the UK, around 15% of strokes are haemorrhagic (due to a bleed), and about 85% are ischaemic (due to a blockage to the blood supply in the brain). Haemorrhagic stroke tends to affect younger people than ischaemic stroke, and is most common in people aged between 45 and 70. Most strokes in the UK happen over the age of 70.

Answer 61

There are two main types of haemorrhagic stroke: - Bleeding within the brain: called an intracerebral haemorrhage, or intracranial haemorrhage (ICH). - Bleeding on the surface of the brain: called a subarachnoid haemorrhage (SAH)

Answer 62

Primarily intracerebral haemorrhage. Risk factors -> small vessel disease and aneurysms -> rupture and haemorrhage - Compression of the internal capsule with no death of cells - Large territory of loss of motor and sensory function - Possibility of complete recovery

Answer 63

Patients typically have a focal neurological deficit which corresponds to the region of the brain that’s affected e.g. - An anterior cerebral artery stroke affects the feet and legs. - A middle cerebral artery stroke affects the hands, arms, face, and the language centers in the dominant hemisphere, including Broca’s and Wernicke's area. - A posterior cerebral artery stroke primarily affects the visual cortex, which affects a person’s ability to see clearly.

Answer 64

Both motor and sensory fibres may be affected: - Damage to motor pathways: flaccid paralysis develops almost immediately. And then over the following days to weeks, there’s spastic paralysis and hyperreflexia due to the hyperexcitable stretch reflex. - Damage to sensory pathways: numbness, reduced pain and vibration sensation. Both motor and sensory symptoms usually happen on the side that’s contralateral from the stroke, except in rare cases of brain stem stroke, where both sides are affected.

Answer 65

Usually sudden onset followed by gradual decline Specific symptoms depends on anatomical site of stroke 1. Anterior cerebral artery - Contralateral hemiparesis and sensory loss with lower limbs > upper limbs 2. Middle cerebral artery - Contralateral hemiparesis and sensory loss with upper limbs > lower limbs - Homonymous hemianopia - Aphasia: if affecting the ‘dominant’ hemisphere (the left in 95% of right-handed people) - Hemineglect syndrome: if affecting the ‘non-dominant’ hemisphere; patients fail to be aware of items to one side of space 3. Posterior cerebral artery - Contralateral homonymous hemianopia with macular sparing - Contralateral loss of pain and temperature due to spinothalamic damage -

Answer 66

- Vertebrobasilar artery - **Cerebellar** signs - **Reduced consciousness** - **Quadriplegia** or **hemiplegia** - Weber’s syndrome (midbrain infarct) - **Oculomotor palsy** and **contralateral hemiplegia** - Lateral medullary syndrome (posterior inferior cerebellar artery occlusion) - **Ipsilateral** facial loss of pain and temperature - **Ipsilateral** Horner’s syndrome: miosis (constriction of the pupil), ptosis (drooping of the upper eyelid), and anhidrosis (absence of sweating of the face) - **Ipsilateral** cerebellar signs - **Contralateral** loss of pain and temperature

Answer 67

Patients tend to have headaches, Altered mental status, Seizures, Nausea and Vomiting

Answer 68

- Slurred speech - Arm/leg weakness - Facial drooping

Answer 69

- Pulse, BP and ECG - Look for AF

Answer 70

Haemorrhagic stroke management The exact management of haemorrhagic stroke depends on the subtype (refer to haemorrhage topics) - Admit to neurocritical care: patients will need intensive monitoring due to the risk of raised intracranial pressure and airway compromise - If features of raised intracranial pressure: consider intubation with hyperventilation, head elevation (30°) and IV mannitol (IV hypertonic saline) - Surgical intervention: decompression may be needed

Answer 71

- Control BP – Beta blocker/ARB - Stop anticoagulants. - Beriplex or vitamin K if warfarin related - Surgery – clot evasion

Answer 72

- Deep venous thrombosis / pulmonary embolism - Aspiration pneumonia**:** due to dysphagia - Infection - Seizures - Delirium - **Neurological sequelae:** such as weakness, impaired mobility, MCA syndrome and seizures - **Requirement for nutritional support:** such as nasojejunal feeding - **Depression**

Answer 73

- Ischaemic stroke - Stroke mimics e.g. - **Hypoglycaemia** - **Hyponatraemia** - **Hypercalcaemia** - **Uraemia** - **Hepatic encephalopathy** - **Brain tumours** - **Seizure** disorder - **Complicated migraine** - Conversion and somatisation disorders

Answer 74

- **Hypertension** - Older **Age**: the average age for a stroke is 68 to 75 years old - Male sex - Ethnicity – Asian, black and/or Hispanic - Heavy Alcohol use - Illicit sympathomimetic drugs - **Family history** of intracerebral haemorrhage - Haemophilia - Cerebral amyloid angiopathy - Autosomal dominant mutations in the COL4A1 gene - Hereditary Haemorrhagic telangiectasia - Autosomal dominant mutations in the KRIT1 gene, CCM2 gene, or PDCD10 gene - Anticoagulation - Vascular malformations - Moyamoya disease ---

Answer 75

- **Smoking** - Non-steroidal anti-inflammatories - **Diabetes mellitus** - Sympathomimetic medications - Cerebral vasculitis - Thrombocytopenia - Leukaemia --- - Past TIA - Heart disease **Atrial fibrillation** – stasis of blood in poorly contracting atria → thrombus formation - **Hypercholesterolaemia** - **Vasculitis** - **Haematological disease**: such as polycythaemia - **Medication**: such as hormone replacement therapy or the combined oral contraceptive pill

Answer 76

In general, mortality for haemorrhagic stroke is significantly higher than for ischaemic stroke and can be as high as 40%.

Answer 77

A transient ischaemic attack (TIA) is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction. It usually resolves spontaneously within 24 hours. defined as transient neurological dysfunction secondary to ischaemia without infarction.

Answer 78

Transient ischaemic attacks often precede a full stroke. A crescendo TIA is where there are two or more TIAs within a week. This carries a high risk of developing in to a stroke. It is a medical emergency, within the first week following a TIA, the risk of stroke is up to 10%.

Answer 79

The definition is now 'tissue-based' rather than 'time-based' with the incoporation of the phrase ‘without evidence of acute infarction’. Thus, the end-point is biological tissue damage, not an arbitrary time cut-off.

Answer 80

1. In situ thrombosis of an intracranial artery or artery-to-artery embolism of thrombus as a result of stenosis or unstable atherosclerotic plaque (16%). 2. Cardioembolic events (29%). 3. Small-vessel occlusion (16%). 4. Uncertain mechanism (36%).

Answer 81

- Intracardiac thrombus may form in response to some secondary risk factor such as stasis from impaired ejection fraction or atrial fibrillation. - The precipitating factor may be a thrombogenic nidus within the heart such as an infectious vegetation or artificial valve. - Rarely, thrombus can pass from the venous system across a cardiac shunt to create paradoxical emboli.

Answer 82

- Microatheromas, fibrinoid necrosis, and lipohyalinosis of small penetrating vessels are seen. - Hypertension and diabetes predispose to small ischaemic lesions. - Because these may occur in the brainstem and internal capsule, a small lesion can result in significant symptoms. - Occlusion due to hypercoagulability, dissection, vasculitis, vasospasm, or sickle cell occlusive disease (3%). These are less common aetiologies.

Answer 83

Ischaemia refers to the absence of blood flow to an organ, which deprives it of oxygen. Cerebral ischaemia may be due to in situ thrombosis, emboli, or rarely, dissection. Thrombosis: local blockage of a vessel due to atherosclerosis. Precipitated by cardiovascular risk factors (e.g. hypertension, smoking) or small vessel disease (e.g. vasculitis, sickle cell). Emboli: propagation of a blood clot that leads to acute obstruction and ischaemia. Typically due to atrial fibrillation or carotid artery disease. Dissection: a rare cause of cerebral ischaemia from tearing of the intimal layer of an artery (typically carotid). This leads to an intramural haematoma that compromises cerebral blood flow. May be spontaneous or secondary to trauma.

Answer 84

TIA is caused by temporary blockage to blood flow, which leads to ischaemia. During a TIA, there is a transient reduction in blood flow to an area of cerebral tissue that causes neurological symptoms. TIA commonly occurs secondary to embolisation from atrial fibrillation or carotid artery disease.

Answer 85

The severity of clinical neurological impairment after arterial occlusion depends on the complex interplay between the degree of obstruction, area and function of tissue supplied by the vessel, the length of time thrombus obstructs the vessel, and the ability of collateral circulation to provide supplemental perfusion to the area at risk.

Answer 86

The severity of clinical neurological impairment after arterial occlusion depends on the complex interplay between the degree of obstruction, area and function of tissue supplied by the vessel, the length of time thrombus obstructs the vessel, and the ability of collateral circulation to provide supplemental perfusion to the area at risk.

Answer 87

- The age-adjusted annual incidence rate for transient ischemic attack in the UK has been estimated at 190 cases per 100,000 population - Often called a ministroke, a transient ischemic attack may be a warning. - About 1 in 3 people who has a transient ischemic attack will eventually have a stroke, with about half occurring within a year after the transient ischemic attack. - It is estimated that approximately 15% of patients have at least one TIA prior to a stroke. - The estimated incidence of TIA within the UK is 50 per 100,000 people per year. - **M**>F

Answer 88

- Unilateral weakness or paralysis - **Facial weakness** - **Limb weakness** - **Dysphasia: slurred speech** - Ataxia, vertigo, loss of balance or incoordination - Homonymous hemianopia**:** visual field loss on the same side of both eyes - Sudden transient loss of vision in one eye (**amaurosis fugax**) ****a painless temporary loss of vision, usually in one eye - This is a classical syndrome of short-lived monocular blindness, which is often described as a black curtain coming across the vision. - It is a term usually reserved for transient visual loss of ischaemic origin. - The principle cause of amaurosis fugax is transient obstruction of the ophthalmic artery, which is a branch of the internal carotid artery. - However, other ischaemic causes to consider include giant cell arteritis (i.e. temporal arteritis) and central retinal artery occlusion. - An important differential of transient visual loss, particularly in young patients, is migraine. - Contralateral sensory/ motor deficits

Answer 89

- Unilateral weakness or paralysis - **Facial weakness** - **Limb weakness** - **Dysphasia: slurred speech** - Ataxia, vertigo, loss of balance or incoordination - Homonymous hemianopia**:** visual field loss on the same side of both eyes - Sudden transient loss of vision in one eye (**amaurosis fugax**) ****a painless temporary loss of vision, usually in one eye - This is a classical syndrome of short-lived monocular blindness, which is often described as a black curtain coming across the vision. - It is a term usually reserved for transient visual loss of ischaemic origin. - The principle cause of amaurosis fugax is transient obstruction of the ophthalmic artery, which is a branch of the internal carotid artery. - However, other ischaemic causes to consider include giant cell arteritis (i.e. temporal arteritis) and central retinal artery occlusion. - An important differential of transient visual loss, particularly in young patients, is migraine. - Contralateral sensory/ motor deficits

Answer 90

- Sudden onset and brief duration of symptoms - Patient / witness report of focal neurological deficit - **Focal neurology:** on examination - Homonymous hemianopia**:** visual field loss on the same side of both eyes - Diplopia - **Irregular pulse:** suggests atrial fibrillation as an underlying cause - **Carotid bruit:** suggests carotid artery stenosis - **Hypertension**

Answer 91

- The Face Arm Speech Time Test (FAST test): check for/ ask about facial weakness, arm weakness, speech difficulty - ECG: rule out Atrial fibrillation as an underlying cause - Auscultation: listen for carotid bruit - Bloods: - Screen for risk factors with bloods including Hba1c, lipids, clotting screen and rule out TIA mimics such as hypoglycemia and hyponatraemia - Blood glucose - Full blood count and platelet count - Prothrombin time, INR, Partial thromboplastin time - Fasting and lipid profile - Serum electrolytes - TIA clinic: - If the suspected TIA occurred less than a week ago: urgent assessment within 24 hours - If the suspected TIA occurred more than a week ago: urgent assessment within 7 days - At TIA clinic, a specialist assessment is conducted and further imaging is arranged, such as an MRI head and carotid doppler

Answer 92

- CT head: imaging is not advocated until the patient is seen in the TIA clinic. However, imaging is indicated if other pathology is suspected, or to rule out an intracranial haemorrhage - Echocardiogram: for the exclusion of an intracardiac aneurysm or a septal defect - ABCD2: a risk stratifying tool to determine the risk of future stroke.

Answer 93

- CT head: imaging is not advocated until the patient is seen in the TIA clinic. However, imaging is indicated if other pathology is suspected, or to rule out an intracranial haemorrhage - Echocardiogram: for the exclusion of an intracardiac aneurysm or a septal defect - ABCD2: a risk stratifying tool to determine the risk of future stroke.

Answer 94

- **Antiplatelet:** initially **aspirin 300mg** daily - the **first-line**, immediate management Do not offer aspirin in these circumstances: - Bleeding disorder or taking an anticoagulant: needs immediate admission and assessment - Taking low-dose aspirin regularly: continue the current dose and arrange a specialist review - Aspirin is contraindicated: needs specialist advice - **Discuss urgently with a stroke specialist** for admission/observation in the case of: They should be referred and seen within 24 hours by a stroke specialist. - More than one TIA (crescendo TIA) - Suspected cardioembolic source - Severe carotid stenosis - **Carotid endarterectomy:** surgical procedure to remove the blockage, ****stenosis of > 70% on Doppler is an indication for urgent endarterectomy

Answer 95

- **Clopidogrel** (antiplatelet) **75 mg** daily is first-line - Offer **aspirin** 75 mg daily with **MR dipyridamole** if clopidogrel is contraindicated - Offer **MR dipyridamole alone** if both aspirin and clopidogrel are contraindicated - Offer **aspirin 75mg** daily if both clopidogrel **and** MR dipyridamole are contraindicated - **High-dose statin**: for lipid modification e.g. **atorvastatin** 20-80mg - **Manage hypertension, diabetes, smoking and other cardiovascular risk factors**

Answer 96

- **Clopidogrel** (antiplatelet) **75 mg** daily is first-line - Offer **aspirin** 75 mg daily with **MR dipyridamole** if clopidogrel is contraindicated - Offer **MR dipyridamole alone** if both aspirin and clopidogrel are contraindicated - Offer **aspirin 75mg** daily if both clopidogrel **and** MR dipyridamole are contraindicated - **High-dose statin**: for lipid modification e.g. **atorvastatin** 20-80mg - **Manage hypertension, diabetes, smoking and other cardiovascular risk factors**

Answer 97

Driving: - **Cars and motorcycles**: stop driving one month, do not need to inform DVLA - **Larger vehicles (e.g. buses, lorries)**: stop driving, inform the DVLA - **Lifestyle advice:** increase physical activity, smoking cessation, diet optimisation and advice on alcohol intake - Start secondary prevention measures for cardiovascular disease.

Answer 98

- Suspected transient Ischaemic attack - Antiplatelet therapy - Referral for specialist assessment - Confirmed transient Ischaemic attack - Anti platelet therapy - High-intensity statin - Anticoagulant (for atrial fibrillation)

Answer 99

- **Toxic/metabolic** - Hypoglycaemia - drug and alcohol consumption - **Neurological**: - Seizures with post-seizure (Todd’s) paralysis - Complex migraine - Bell’s palsy - Stroke - **Space occupying lesion**: tumour, haematoma - Intercranial Haemorrhage - Abscess - Mass - Global hypoperfusion / syncope - Conversion disorder - Labyrinthine disorders - Multiple sclerosis - Peripheral neuropathy - **Infection**: meningitis/encephalitis, systemic infection with ‘decompensation’ of old stroke

Answer 100

- Stroke - TIA is a medical emergency as the risk of recurrent stroke is up to 10% in the next week - Myocardial infarction - TIA represents underlying atherosclerotic disease, thus increasing the risk of acute coronary syndrome

Answer 101

- **Atrial fibrillation** - Valvular disease - **Carotid stenosis** - Congestive heart failure - **Hypertension** - **Diabetes mellitus** - **Cigarette smoking** - Alcohol use disorders - **Increasing age** --- - Hyperlipidaemia - Patent foramen ovale (PFO) - Inactivity - Obesity - Hypercoagulability Risk factors for TIA are due to conditions that affect the integrity of vessels or increase the risk of embolisation - **Hypercholesterolaemia** - Thrombophilic disorders e.g. antiphospholipid syndrome - Sickle cell disease

Answer 102

- Over 10% of TIA patients seen in the emergency department will have a stroke within 3 months. - Additionally, a TIA is a marker of underlying atherosclerotic disease, therefore these patients are at risk for ischaemic heart disease.

Answer 103

Migraine with an **aura** → Opthamic artery involvement → Contraindicated oestrogen birth control → as it increases the risk of stroke. They should only have pogesterone based birth control.

Answer 104

Extradural - bleeding into the potential space between dura mater and skull - typically due to trauma to the temporal area and pterion resulting in middle meningeal artery rupture - patients present with loss of consciousness followed by a lucid interval, followed by deterioration Subdural - bleeding into the space between the dura and arachnoid mater - due to rupture of bridging veins - acute < 3 days - chronic > 21 days ans seen in elderly or alcoholics Subarachnoid - bleeding into the space between the arachnoid and pia mater - usually small volume and occurs at the site of impact (coup) or opposite side (countercoup) - trauma is teh most common cause of a subarachnoid haemorrhage - atraumatic causes include berry aneurysms and AVMs

Answer 105

Intraparenchymal/intracerebral - bleeding with the brain parenchyma itself - a traumatic causes include hypertension Contusions - represent bruises of the brain parenchyma - they are typically found in the anterior fossa floor or the temporal pole - contusion can be coup (site of impact) or countercoup (opposite side of impact) Intraventricular - bleeding into the ventricular system - usually originates from extension form an intraparenchymal or subarachnoid bleed

Answer 106

Intracerebral haemorrhage describes bleeding within the cerebrum. Haemorrhagic strokes can be split into two types: an intracerebral haemorrhage which is when bleeding occurs within the cerebrum, and a subarachnoid haemorrhage which is when bleeding occurs between the pia mater and arachnoid mater of the meninges. An intracerebral haemorrhage that involves just the brain tissue is called an intraparenchymal haemorrhage, whereas if the blood extends into the ventricles of the brain which store cerebrospinal fluid, it’s called an intraventricular haemorrhage.

Answer 107

- An intracerebral haemorrhage occurs when the blood vessel bursts inside the brain. The blood then spills into the nearby brain tissue. This can cause the affected brain cells to lose their oxygen supply. They become damaged or die. **Intraparenchymal/intracerebral →** Bleeding **within the brain parenchyma** itself → Atraumatic causes include hypertension

Answer 108

Rupture due to: 1. Cerebral amyloid angiopathy (CAA) accounts for a significant number of primary Intracerebral haemorrhages, specifically in the older population. - A degenerative disease where abnormal protein deposits in the walls of arterioles making them less compliant. 2. Hypertension can cause haemorrhage in any intracranial location. - Hypertension, causing: - Arteriosclerosis: stiffening of vessels - Microaneurysms: called Charcot-Bouchard aneurysms, most likely to be found on small arteries 3. Vasculitis

Answer 109

Arises from an identifiable vascular malformation or as a complication of other medical or neurological diseases that either impair coagulation or promote vascular rupture. - **Arteriovenous malformations:** blood vessels that directly connect an artery to a vein. Over time these abnormal vessels dilate and can rupture - **Secondary to ischaemic stroke:** ischaemia causes brain tissue death. If there is reperfusion, there’s an increased chance that the damaged blood vessel might rupture. Bleeding into dead tissue is called haemorrhagic conversion. - Cerebral infarction or cerebral tumour with haemorrhage into the diseased tissue. - Vascular tumours - Drug misuse-cocaine

Answer 110

- Intracerebral haemorrhage (ICH) is caused by vascular rupture with bleeding into the brain parenchyma, resulting in a primary mechanical injury to the brain tissue. Once there’s an intracerebral haemorrhage, blood starts to spew out from a damaged blood vessel creating a pool of blood which increases pressure in the skull and puts direct pressure on nearby tissue cells and blood vessels. Haemorrhage also means that less blood is flowing downstream to the cells that need it, which leaves the downstream tissue deprived of oxygen-rich blood. Healthy tissue can die from both the direct pressure and the lack of oxygen within a few hours. Increased pressure within the skull can also lead to brain herniation, which is when the brain moves across structures in the skull.

Answer 111

This can occur anywhere, e.g. - Lobar intracerebral haemorrhage - Deep intracerebral haemorrhage - Intraventricular haemorrhage - Basal ganglia haemorrhage - Cerebellar haemorrhage

Answer 112

- Epidemiology - There are more than 100,000 strokes in the UK each year causing 38,000 deaths, making it a leading cause of death and disability. - People are most likely to have a stroke over the age of 55. - Stroke is the second largest cause of death globally (5.5 million deaths) after ischaemic heart disease.

Answer 113

- Headache - Nausea - Vomiting - Weakness - Seizures - Reduced consciousness

Answer 114

- Unilateral weakness or paralysis in the face, arm, or leg - Sensory loss (numbness) - Dysphasia - Dysarthria - Visual disturbance - Photophobia - Ataxia Specific stroke symptoms depend on part of brain affected e.g. - Anterior or middle cerebral artery stroke: **numbness and sudden muscle weakness.** - Broca’s area or Wernicke’s area stroke: **slurred speech or difficulty understanding speech, respectively.** - Posterior cerebral artery stroke: **vision disturbances.**

Answer 115

- **non-contrast CT head** - **CT/ MRI:** to confirm size and location of haemorrhage - **Angiography:** visualise the exact location of haemorrhage - FBC - Clotting screen - Serum glucose - Serum electrolytes - Serum urea and creatinine - Liver function tests - ECG

Answer 116

- Suspected intracerebral haemorrhage - Stabilisation - Urgent referral to hyperacute or acute stroke unit - Confirmed intracerebral haemorrhage - Supportive care - Monitoring - Immediate referral for neurosurgery assessment - Consider - Rapid blood pressure control - Urgent reversal of anticoagulation

Answer 117

- **Consider intubation, ventilation and ICU care if they have reduced consciousness** - **Correct any clotting abnormality** - **Correct severe hypertension but avoid hypotension** - Drugs to relieve intracranial pressure e.g. **Mannitol** - **Craniotomy:** part of the skull bone is removed to drain any accumulated blood and relieve pressure. Good for if the bleed is close to the surface of the skull - **Stereotactic aspiration:** aspirate off blood and relieve intracranial pressure, guided by CT scanner. Good for bleeding that is located deeper in brain tissue

Answer 118

- Delirium - Infection - DVT - Pulmonary embolism - Seizures - Aspiration pneumonia

Answer 119

- Hypertension - Older age - Male sex - Asian, black and/or Hispanic - Heavy alcohol use - Family history - Head injury - Aneurysms - Ischaemic stroke can progress to haemorrhage - Brain tumours - Anticoagulants such as warfarin

Answer 120

- Ischaemic stroke - Hypertensive encephalopathy - Hypoglycaemia - Complicated migraine - Seizure disorder

Answer 121

The outer layer of the meninges is the dura mater, the middle layer is the arachnoid mater, and the inner layer is the pia mater. These last two, the arachnoid and pia maters, are the leptomeninges. Between the leptomeninges there’s the subarachnoid space, which houses cerebrospinal fluid, or CSF. CSF is a clear, watery liquid which is pumped around the spinal cord and brain, cushioning them from impact and bathing them in nutrients.

Answer 122

Subarachnoid haemorrhages can lead to a pool of blood under the arachnoid mater that increases the intracranial pressure and prevents more blood from flowing into the brain.

Answer 123

Subarachnoid haemorrhage (SAH) is a type of intracranial haemorrhage characterised by blood within the subarachnoid space.

Answer 124

Spontaneous arterial bleeding into the subarachnoid space Subarachnoid haemorrhage involves bleeding in to the **subarachnoid space**, where the **cerebrospinal fluid** is located, between the **pia mater** and the **arachnoid membrane.** This is usually the result of a ruptured **cerebral aneurysm.**

Answer 125

- Rupture of saccular aneurysms (70%) - Idiopathic (<15%) - Trauma → It is most commonly caused by **trauma** (traumatic SAH). - **Atraumatic** cases are referred to as **spontaneous** SAH and are caused by the following: - **Berry aneurysm**: saccular aneurysm is the most common cause of spontaneous SAH (80% of spontaneous SAH) - Arise at points of arterial bifurcation within the Circle of Willis; the junction between the anterior communicating and anterior cerebral arteries is the most common location - Associated with adult polycystic kidney disease, coarctation of the aorta and Ehlers-Danlos/ Marfan's syndrome - Arterio-venous malformations (10%) - **Arteriovenous malformation** (AVM) - abnormal connections between artery and vein can dilate and cause rupture - **Perimesencephalic**: venous bleeding with normal CT and excellent prognosis - **Mycotic aneurysm**: due to bacterial infection e.g. secondary to emboli from infective endocarditis - **Vertebral artery dissection** - **Pituitary apoplexy**: bleeding into the pituitary gland, often associated with a tumour

Answer 126

- Rupture of the arteries forming the circle of Willis - Rupture of the junction of the anterior communicating artery and the anterior cerebral artery or the posterior communicating artery and the internal carotid artery - Leads to tissue ischaemia (since less blood can reach the tissue) as well as rapid raised ICP as the blood acts like a space-occupying lesion and puts pressure on the brain → neurological deficits - Arteriovenous malformations (AVM) - Vascular development malformation often with a fistula between arterial and venous systems causing high flow through the AVM and high-pressure arterialisation of draining veins → rupture --- - Subarachnoid haemorrhages can lead to a pool of blood under the arachnoid mater that increases the intracranial pressure. This puts direct pressure on nearby tissue cells and blood vessels as well as preventing more blood from flowing into the brain. - Healthy tissue can die from both the direct pressure and the lack of oxygen within a few hours. - Blood vessels that are “bathing” in a pool of blood can start to intermittently vasoconstrict - **vasospasm.** If the vasospasm affects arteries in the circle of Willis, it will reduce the supply of blood flow to the brain, causing further ischaemic injury. - Over time, blood in the subarachnoid space can irritate the meninges and cause inflammation which leads to scarring of the surrounding tissue. The scar tissue can obstruct the normal outflow of cerebrospinal fluid, causing fluid build up which dilates the ventricles at the centre of the brain. This is referred to as **hydrocephalus.**

Answer 127

- Typical age 35-65 – mean age 50 - Account for ~5% of strokes - The incidence of Subarachnoid haemorrhage in most populations is between 6-8 cases out of 100,000 per year Subarachnoid haemorrhage is more common in: - Black patients - Female patients - Most commonly presents in people age 45-70

Answer 128

- Sudden onset severe occipital “thunderclap” **headache** – like being kicked in the head - Severe, sudden onset - Occipital - ‘Thunderclap’ headache - Neck stiffness - **Meningism**: photophobia and neck stiffness - **Seizures** - Vision changes - **Nausea and vomiting** - Speech changes - Loss of consciousness - Weakness - **Confusion** - **Coma** - Drowsiness

Answer 129

- 3rd nerve palsy An aneurysm arising from the posterior communicating artery will press on the 3rd nerve, causing a palsy with a fixed dilated pupil - 6th nerve palsy A non-specific sign which indicates raised intracranial pressure - Reduced Glasgow Coma Scale - Meningeal irritation Kernig’s sign – unable to extend patient’s leg at the knee when the thigh is flexed Neck stiffness - Brudzinski’s sign – when patient’s neck is flexed, patient will flex their hips and knees - Subhyaloid haemorrhages (bleeding between retina and vitreous membrane) ± papilloedema

Answer 130

- FBC - Serum glucose - Clotting screen - Urgent non-contrast CT head: - Diagnostic (but can be negative in a minority of patients) - CT imaging typically shows blood in the basal cisterns - Shows subarachnoid or intraventricular blood in 95% of cases undergoing scanning within 24 hours, sensitivity decreases after that time, spider or 5 star sign. - ECG: should be requested for all patients and may demonstrate arrhythmias, ischaemia and ST-elevation

Answer 131

- Other investigations to consider - Lumbar puncture (LP):perform if CT head is negative and clinical suspicion remains If CT normal but SAH still suspected → Perform from 12 hours of symptom onset (not earlier) Findings - RBCs or xanthochromia (yellow pigmentation due to degradation of haemoglobin to bilirubin and is present at 12 hours post-bleed) with normal or raised opening pressure Xanthochromia helps to differentiate SAH from a ‘traumatic tap’, which is simply blood in the CSF due to the procedure itself CSF in Subarachnoid haemorrhage is uniformly blood early on and becomes xanthrochromic (yellow) after several hours due to the breakdown products of haemoglobin (bilirubin) - CT angiogram or digital subtraction angiography (DSA): after spontaneous SAH has been confirmed, further imaging may be conducted to find the source, such as an aneurysm or AVM; this is usually done in a specialist neurosurgical unit - ABG – to rule out hypoxia

Answer 132

- **Refer to neurosurgeon** - On confirmation of SAH, all patients must be **immediately** referred to **neurosurgery.** Intervention should generally be performed within 24 hours due to the risk of rebleeding. - **Nimodipine** (calcium channel blocker) – reduces cerebral artery spasm, used to prevent vasospasm - 60mg 4-hourly should be offered to all patients immediately upon diagnosis; this is thought to prevent vasospasm and a 21-day course ****is usually offered - Early intervention to prevent re-bleeding - Radiologically - Surgically – surgical clipping or endovascular coiling - **Intervention**: first-line is **endovascular coiling** of the aneurysm; second-line is **surgical clipping** via craniotomy - **If features of raised intracranial pressure**: consider intubation with hyperventilation, head elevation (30°) and IV mannitol - **Conservative:** - **Bed rest** - **Antitussive (anti-cough) agent and stool softeners**: prevents straining and therefore reduce the risk of rebleeding

Answer 133

- Differential diagnosis - Migraine - Meningitis - Corticol vein thrombosis

Answer 134

- **Rebleeding**: 22% risk at 1 month - **Vasospasm**: accounts for 23% of deaths; at highest risk for the first 2-3 weeks after SAH; treated with (induced) **h**ypertension, **h**ypervolaemia and **h**aemodilution (triple-H therapy). - **Hydrocephalus**: acutely managed with external ventricular drain (CSF drainage into an external bag) or a long-term ventriculoperitoneal shunt, if required - **Seizures**: seizure-prophylaxis is often administered (e.g. Keppra) - **Hyponatraemia**: commonly due to syndrome of inappropriate antidiuretic hormone secretion (SIADH) - Death

Answer 135

**Hypertension** and smoking are the two most important modifiable risk factors. - **Smoking** - **Hypertension** - **Increasing age**: most commonly presents in people > 50 years old - Alcohol misuse - **Alcohol excess**: there is a significantly increased risk with **current** alcohol abuse - Bleeding disorders - Mycotic aneurysm - Cocaine use - **Family history** - **Polycystic kidney disease** (PKD): 5 times more common in autosomal dominant PKD - Connective tissue disorders: such as Marfan syndrome or Ehlers-Danlos - Neurofibromatosis: tumours form on your nerve tissues

Answer 136

- At 6 months, 25% of patients are dead and 50% are moderately to severely disabled. - Important predictors of 30-day mortality include age, level of consciousness on admission and the amount of blood visible on CT. - Causes of mortality include medical complications (23%), vasospasm (23%), rebleeding (22%) and initial haemorrhage (19%)

Answer 137

- The outer membrane, the dura mater consists of two layers. The internal layer of the dura mater lies above the arachnoid mater - the two are separated by the subdural space. - The external layer of the dura mater adheres to the inner surface of the skull. These two layers of the dura mater travel together, but at certain spots, the internal layer of the dura mater separates from the external one to form the meningeal folds.

Answer 138

- The subdural space plays a major role in venous blood drainage in the brain. - The surface of the brain is supplied by numerous arteries in the subarachnoid space that provides oxygen rich blood to the brain. After the brain tissue has taken up the oxygen and nutrients, the blood drains into superficial cerebral veins, or bridging veins, that also sit in the subarachnoid space. - These veins travel through the arachnoid mater, pass through the subdural space and penetrate the inner layer of the dura mater to drain into the dural venous sinuses located between the two layers of the dura mater. - Eventually the blood in the venous sinuses drain into the internal jugular vein and returns to the heart.

Answer 139

- The subdural space plays a major role in venous blood drainage in the brain. - The surface of the brain is supplied by numerous arteries in the subarachnoid space that provides oxygen rich blood to the brain. After the brain tissue has taken up the oxygen and nutrients, the blood drains into superficial cerebral veins, or bridging veins, that also sit in the subarachnoid space. - These veins travel through the arachnoid mater, pass through the subdural space and penetrate the inner layer of the dura mater to drain into the dural venous sinuses located between the two layers of the dura mater. - Eventually the blood in the venous sinuses drain into the internal jugular vein and returns to the heart.

Answer 140

Bleeding above the dura mater. An **extradural haemorrhage** (also known as an ‘**epidural’** haemorrhage) is bleeding into the potential space between the skull and the dura mater. The blood then collects in this space and is referred to as an **extradural haematoma** (EDH).

Answer 141

- Traumatic head injury – typically after trauma to temple - Usually at the pterion - Ruptures middle meningeal artery EDH is usually caused by **trauma,** e.g. blunt trauma to the head - **Arterial bleeding:** the majority of EDHs occur as a result of rupture of the middle meningeal artery. This is commonly affected through trauma to the temporal region or pterion (thinnest part of the skull) - **Venous bleeding:** this is rarer and usually due to venous bleeding from dural venous sinus laceration and is usually seen at the vertex, middle cranial fossa or posterior cranial fossa Rarely, EDH can be due to **non-traumatic** events such as: - Haemorrhagic tumour - Coagulopathy - Infection - Vascular malformation

Answer 142

- Head injury leading to fracture in temporal/parietal bone resulting in laceration of middle meningeal artery - Blood accumulates rapidly over minutes-hours between the bone and the dura

Answer 143

The classic presentation is an **initial loss of consciousness followed by a lucid interval** - Initial loss of consciousness on trauma to the temporal region - **Lucid interval:** patient regains consciousness as there is **venous shunting** directing blood out of the epidural space - **Continued expansion of haematoma:** leads to local compression of the temporal lobe and eventual cerebral herniation, e.g. **uncal herniation** - Uncal herniation results in compression of third nerve resulting in a **fixed, dilated ipsilateral pupil** - Uncal herniation results in compression of the ipsilateral cerebral peduncle resulting in **contralateral hemiparesis** - Further compression will lead to brainstem compression, Cushing’s reflex, tonsillar herniation, and eventual death

Answer 144

They are about half as common as a subdural hematomas and usually occur in young adults. - Usually occurs in young adults (rare < 2 and > 60) EDHs occur in approximately 2% of all head injuries and up to 15% of all fatal head injuries

Answer 145

- Characteristic history - Head injury - Loss of consciousness following trauma or initial drowsiness - Lucid interval – period of time between traumatic brain injury and decrease in consciousness - Occurs in ~ 20% of patients - Patients regain full consciousness - Signs of raised ICP – **headache**, **vomiting**, **nausea**, **seizure** - ± hemiparesis with brisk reflexes - Ipsilateral pupil dilation - **Pupil dilation** if bleeding continues - **Confusion**

Answer 146

**Worsening neurological status** - **Cushing’s reflex:** hypertension and bradycardia - Bradycardia and raised BP - Decreased Glasgow coma scale - **Reduced GCS:** loss of consciousness after the trauma due to concussion - There might be a **lucid interval** after initial trauma if there is a slower bleed. This is followed by rapid decline. - **Uncal herniation:** ipsilateral, fixed dilated pupil and contralateral hemiparesis - Local compression results in mass effect and brain herniation - Coning of brain through foramen magnum - May be focal neurological symptoms e.g. **muscle weakness, hemiparesis, abnormal plantar reflex (upgoing plantar) or sensory problems** - Signs of raised ICP – headache, vomiting, nausea, seizure - ± hemiparesis with brisk reflexes **Evidence of head injury:** - Bruising or scalp haematoma - Battle’s sign (bruising behind mastoid process) - Bleeding from one/both ears - Haemotympanum - Periorbital haematoma (Racoon eyes) - Rhinorrhea or otorrhea

Answer 147

- Non-contrast **CT head scan** – shows biconvex hypodense haematoma that is adjacent to the skull - Blood forms a more rounded/biconvex shape compared with the sickle-shaped subdural haematomas as the tough dural attachments to the skull keep it more localised - Don’t cross suture lines Findings: - Hyperdense mass = looks “more white” than the surrounding healthy brain tissue - EDH appears as a hyperdense well-demarcated biconvex collection, most frequently beneath the temporal bone, and the bleed should be limited by the cranial sutures - Can also assess for skull fracture - Features of mass effect, such as uncal herniation, may be present - Venous bleeds may be located at the vertex, middle cranial fossa, or posterior cranial fossa - Epidural haemorrhages cause blood to build up between the outer layer of the dura mater and the skull so epidural haematomas don’t cross suture lines and they push on the brain forming a biconvex shape. This is not the case with subdural haematomas. - **Skull X-ray** – may be normal or show **fracture** lines crossing the course of the middle meningeal artery - Skull fracture increases the extradural haemorrhage risk so do an urgent CT on anyone with suspected skull fracture - **Check FBC and clotting**

Answer 148

Definitive management - Refer to neurosurgeon - **Clot evacuation** - Burr hole craniotomy and Irrigation/removal of haematoma via burr twist drill - **Craniotomy and haematoma evacuation:** part of the skull bone is removed in order to remove accumulated blood below. - Indicated if the EDH is greater than 30cm3 should be regardless of the GCS score - An EDH less than 30cm3 and with less than 15-mm thickness with less than a 5-mm midline shift in patients with a GCS score greater than 8 without focal deficit **can be managed non-operatively** with **serial CT scanning** and **close neurological observation** in a neurosurgical centre - Ligation of bleeding vessel - Followed by **ligation of the vessel.** - Stabilise patient – ABCDE management - IV mannitol – to reduce ICP - Consider intubation, ventilation and ICU care if they have reduced consciousness - Correct any clotting abnormality - Correct severe hypertension but avoid hypotension **General principles:** aim to reduce/control intracranial pressure - **Bed position:** have the head of the bed tilted up at ~30 degrees - **Intubation:** if the patient has reduced GCS - **Oxygen:** ensure adequate oxygenation - **Maintain adequate cerebral perfusion (Perfusion = MAP - ICP)** - **Hyperventilation:** may be considered in a deteriorating patient; hyperventilation can reduce pCO2 which causes cerebral vasoconstriction and reduces ICP - **Inotropes and vasopressors** - **Fluids** - **Osmotherapy:** hypertonic saline or mannitol help shift extracellular fluid and CSF into the vascular compartment, reducing ICP - **Decrease cerebral metabolic rate:** hypothermia and sedation/paralysis - **Burr hole:** temporising measure to reduce ICP prior to definitive management

Answer 149

- Death due to respiratory arrest - Brain displacement - Raised ICP - Herniation – supratentorial (cerebrum pushed against skull or tentorium) or infratentorial (cerebellum pushed against brainstem) - Increased intracranial pressure can also cause the brain to herniate, these can be lethal: - **Supratentorial herniation:** cerebrum is pushed against the skull or the tentorium, can compress the arteries that nourish the brain leading to an ischaemic stroke - **Infratentorial herniation:** cerebellum is pushed against the brainstem, can compress the vital area in the brainstem that control consciousness, respiration, and heart rate. - Patients present with deep irregular breathing, high BP, low HR - **Coma** Secondary injury refers to the **evolving consequences** of primary injury and includes the following: - **Cerebral oedema** - **Raised intracranial pressure** and **herniation** - **Ischameia:** can occur due to mass effect, herniation, hypoperfusion, vasospasm - **Seizures** - **Infection**

Answer 150

- **Age:** mean age of affected patients is 20-30 years of age. As patients get older the dura becomes more adherent to the skull, making EDH less likely. - **Male sex:** men are more often affected than females - **Anticoagulant usage:** patients on anticoagulants who sustain a head injury are at an increased risk of developing a haemorrhage. Usually occurs in young adults General risk Factors - **Head injury** - **Hypertension** - **Aneurysms** - **Ischaemic stroke can progress to haemorrhage** - **Brain tumours** - **Anticoagulants such as warfarin**

Answer 151

- The **mortality rate** for acute EDH is **approximately 25%**. - Prognosis is good if diagnosed and operated on early. - Most patients with an EDH have a **good prognosis if they receive early evacuation of the haematoma.** - Poor prognosis factors include reduced GCS on arrival, older age, large haematomas, rapid clinical progression, pupillary abnormalities and raised intracranial pressure. - Poor prognosis if coma, pupil abnormalities or decerebrate rigidity are present pre-op.

Answer 152

Bleeding below the dura mater A **subdural haemorrhage** occurs when blood accumulates between the dura and arachnoid mater (**subdural space**), forming a collection known as a **subdural haematoma (SDH).**

Answer 153

- A subdural haematoma is a collection of clotting blood that forms in the subdural space. This is the space between two of the meninges, which form the protective lining that covers the brain.

Answer 154

- - **Acute** - where the blood collects quickly after a head injury; symptoms can occur immediately or within hours. - **Subacute** - where symptoms develop between 3-7 days after the injury. - **Chronic** - the blood collects slowly after a head injury; symptoms can occur 2-3 weeks after the initial injury. SDH can be classified in terms of acuity

Answer 155

Acute - <3 days old - traumatic rupture of bridging cortical veins Chronic - >21 days old - traumatic rupture of bridging cortical veins - associate with cortical atrophy e.g. elderly or alcoholics - bridging veins are more prone to rupture with cortical atrophy - requires lower impact trauma compared to acute - because there is cortical atrophy, the subdural space is larger; these haematoma can enlarge significantly over time whilst patients remain asymptomatic Subacute SDH - 3-21 days

Answer 156

- Occurs more frequently in the elderly or alcoholics. - Acute subdural haematoma is found in about 11% to 20% of patients admitted to hospital with mild to severe traumatic brain injury.

Answer 157

Subdural haemorrhage commonly occurs after **trauma**. The subdural space contains **bridging veins** which take blood from the brain to the dural venous sinuses. If these veins rupture, they can bleed into the subdural space. **Rupture of bridging veins, usually caused by:** - **Brain atrophy:** in the elderly the brain shrinks in size which means that the bridging veins are stretched across a wider space where they are largely unsupported - **Alcohol abuse:** caused the wall of the veins to thin out, and make them more likely to break. - **Trauma/ injury** e.g. - Falls - Shaken baby syndrome - Acceleration-deceleration injury: speeding on the road and then suddenly slamming the brakes. Causes damage to the front of the brain as the body jerks forward, and then the back of the brain as the body moves backwards.

Answer 158

- The meninges are the protective lining that surrounds the brain within the skull, and the spinal cord within the backbone. - There are three layers of meninges - There are also three thin spaces between the layers of meninges - The main cause of a subdural haemorrhage is a rupture of the bridging veins located in the subdural space. This can be due to trauma or without trauma e.g. reduced intracranial pressure or dural metastases - When there is active bleeding, it’s called a haemorrhage, and the collection of blood that results is called a haematoma. - As the damaged bridging veins are under low pressure, the bleeding can be slow causing delayed onset of symptoms which might develop over the course of days to weeks as the haematoma gradually expands. - An acute subdural haematoma causes symptoms within 2 days, a subacute subdural haematoma causes symptoms between 3 and 14 days, and a chronic subdural haematoma causes symptoms after 15 days. - The haematoma can compress the brain and cause increased intracranial pressure. A large subdural haematoma on one side of the skull can cause a midline shift which is a displacement of the whole brain towards the opposite side of the skull. The increased intracranial pressure can also cause the brain to herniate.

Answer 159

- The meninges are the protective lining that surrounds the brain within the skull, and the spinal cord within the backbone. - There are three layers of meninges - There are also three thin spaces between the layers of meninges - The main cause of a subdural haemorrhage is a rupture of the bridging veins located in the subdural space. This can be due to trauma or without trauma e.g. reduced intracranial pressure or dural metastases - When there is active bleeding, it’s called a haemorrhage, and the collection of blood that results is called a haematoma. - As the damaged bridging veins are under low pressure, the bleeding can be slow causing delayed onset of symptoms which might develop over the course of days to weeks as the haematoma gradually expands. - An acute subdural haematoma causes symptoms within 2 days, a subacute subdural haematoma causes symptoms between 3 and 14 days, and a chronic subdural haematoma causes symptoms after 15 days. - The haematoma can compress the brain and cause increased intracranial pressure. A large subdural haematoma on one side of the skull can cause a midline shift which is a displacement of the whole brain towards the opposite side of the skull. The increased intracranial pressure can also cause the brain to herniate.

Answer 160

The epidural space is the space between the vertebral column and the dura mater. (There is only a potential epidural space in the skull.) - The subdural space is the space between the dura mater and the arachnoid mater. - The subarachnoid space is the space between the arachnoid mater and the pia mater.

Answer 161

Acute - symptom onset within 3 days of inciting event - may have lucid interval - reduced consciousness - headaches and vomiting - slurred speech - focal neurological deficit, e.g. weakness or fixed dilated pupil - cushing’s reflex - seizures Chronic - insidious onset usually in the elderly or alcoholics - progressive confusion and cognitive deficit - headaches and vomiting - focal neurological deficit e.g. weakness or fixed dilated pupils

Answer 162

Acute - symptom onset within 3 days of inciting event - may have lucid interval - reduced consciousness - headaches and vomiting - slurred speech - focal neurological deficit, e.g. weakness or fixed dilated pupil - cushing’s reflex - seizures Chronic - insidious onset usually in the elderly or alcoholics - progressive confusion and cognitive deficit - headaches and vomiting - focal neurological deficit e.g. weakness or fixed dilated pupils

Answer 163

- headache - nausea/vomiting - Confusion - Seizure - Loss of consciousness

Answer 164

- **Reduced GCS**: loss of consciousness right after the injury or in the ensuing days to weeks as the haematoma increases in size. - Sometimes there can be focal neurological symptoms e.g. **muscle weakness, unequal pupils, hemiparesis or sensory problems** - evidence of trauma - Diminished eye response - Diminished verbal response - Diminished motor response

Answer 165

- **Non-contrast CT head** scan - **Immediate CT head** to establish the diagnosis. Shows clot and midline shift. Findings: A hyperdense crescent shaped haematoma suggestive of an acute subdural haematoma as indicated by red arrows on this CT head. - SDH appears as a **crescentic collection** around the surface of the brain which is **not limited by the suture lines** of the skull unlike in an extradural haemorrhage. There may be evidence of mass effect such as midline shift or herniation - **Acute:** hyperdense (bright) - **Subacute:** as the clot matures, the density starts to drop until it is isodense to the brain cortex - **Chronic:** becomes hypodense (dark) - Acute subdural haematoma: hyperdense mass = looks “more white” than the surrounding healthy brain tissue - Chronic subdural haematoma: hypodense masses = “less white” than the surrounding brain tissue. - Acute on chronic bleeding: combination of hyperdense and hypodense, seen in individuals who have a rebleed in the bridging veins after a chronic haematoma has already formed. Bleeding is between the dura and arachnoid so subdural haematomas follow the contour of the brain and form a crescent-shape and cross suture lines. This is different to an epidural haemorrhage!

Answer 166

- **Non-contrast CT head** scan - **Immediate CT head** to establish the diagnosis. Shows clot and midline shift. Findings: A hyperdense crescent shaped haematoma suggestive of an acute subdural haematoma as indicated by red arrows on this CT head. - SDH appears as a **crescentic collection** around the surface of the brain which is **not limited by the suture lines** of the skull unlike in an extradural haemorrhage. There may be evidence of mass effect such as midline shift or herniation - **Acute:** hyperdense (bright) - **Subacute:** as the clot matures, the density starts to drop until it is isodense to the brain cortex - **Chronic:** becomes hypodense (dark) - Acute subdural haematoma: hyperdense mass = looks “more white” than the surrounding healthy brain tissue - Chronic subdural haematoma: hypodense masses = “less white” than the surrounding brain tissue. - Acute on chronic bleeding: combination of hyperdense and hypodense, seen in individuals who have a rebleed in the bridging veins after a chronic haematoma has already formed. Bleeding is between the dura and arachnoid so subdural haematomas follow the contour of the brain and form a crescent-shape and cross suture lines. This is different to an epidural haemorrhage! Check FBC and clotting

Answer 167

An **urgent neurosurgical opinion** is required. - General principles **General principles:** aim to reduce/control intracranial pressure - **Bed position:** have the head of the bed tilted up at ~30 degrees - **Intubation:** if the patient has reduced GCS - **Oxygen:** ensure adequate oxygenation - **Maintain adequate cerebral perfusion (Perfusion = MAP - ICP)** - **Hyperventilation:** may be considered in a deteriorating patient; hyperventilation can reduce pCO2 which causes cerebral vasoconstriction and reduces ICP - **Inotropes and vasopressors** - **Fluids** - **Osmotherapy:** hypertonic saline or mannitol help shift extracellular fluid and CSF into the vascular compartment, reducing ICP - **Decrease cerebral metabolic rate:** hypothermia and sedation/paralysis - **Burr hole:** temporising measure to reduce ICP prior to definitive management

Answer 168

An **urgent neurosurgical opinion** is required. - General principles **General principles:** aim to reduce/control intracranial pressure - **Bed position:** have the head of the bed tilted up at ~30 degrees - **Intubation:** if the patient has reduced GCS - **Oxygen:** ensure adequate oxygenation - **Maintain adequate cerebral perfusion (Perfusion = MAP - ICP)** - **Hyperventilation:** may be considered in a deteriorating patient; hyperventilation can reduce pCO2 which causes cerebral vasoconstriction and reduces ICP - **Inotropes and vasopressors** - **Fluids** - **Osmotherapy:** hypertonic saline or mannitol help shift extracellular fluid and CSF into the vascular compartment, reducing ICP - **Decrease cerebral metabolic rate:** hypothermia and sedation/paralysis - **Burr hole:** temporising measure to reduce ICP prior to definitive management

Answer 169

- **Conservative:** small acute and chronic SDHs which are not causing neurological deficit can be observed - **Surgery:** involves craniotomy and evacuation. Indications for acute SDH are as follows - Acute SDH with a **thickness > 10mm** or a **midline shift > 5mm** - GCS < 9 and GCS score decreased between the time of injury and hospital admission by 2 or more points - Patient presents with asymmetric or fixed and dilated pupils - ICP > 20 mmHg - A patient with a chronic SDH should be considered for evacuation, particularly if the hematoma is producing mass effect or the patient is symptomatic

Answer 170

- **Conservative:** small acute and chronic SDHs which are not causing neurological deficit can be observed - **Surgery:** involves craniotomy and evacuation. Indications for acute SDH are as follows - Acute SDH with a **thickness > 10mm** or a **midline shift > 5mm** - GCS < 9 and GCS score decreased between the time of injury and hospital admission by 2 or more points - Patient presents with asymmetric or fixed and dilated pupils - ICP > 20 mmHg - A patient with a chronic SDH should be considered for evacuation, particularly if the hematoma is producing mass effect or the patient is symptomatic

Answer 171

- Observation, monitoring and follow-up imaging-CT - **Correct any clotting abnormality** - **Correct severe hypertension but avoid hypotension** - **Address cause of trauma/ injury** - Prophylactic antiepileptics - **Mannitol:** used to reduce ICP - Surgery - **Drainage:** - Small subdural haematomas are drained via **burr hole washout** - by placing a small tube called a catheter, through a drilled hole in the skull. - Large subdural haematomas require a **craniotomy,** which is when part of the skull bone is removed in order to remove accumulated blood below - **Consider intubation, ventilation and ICU care if they have reduced consciousness**

Answer 172

- Observation, monitoring and follow-up imaging-CT - **Correct any clotting abnormality** - **Correct severe hypertension but avoid hypotension** - **Address cause of trauma/ injury** - Prophylactic antiepileptics - **Mannitol:** used to reduce ICP - Surgery - **Drainage:** - Small subdural haematomas are drained via **burr hole washout** - by placing a small tube called a catheter, through a drilled hole in the skull. - Large subdural haematomas require a **craniotomy,** which is when part of the skull bone is removed in order to remove accumulated blood below - **Consider intubation, ventilation and ICU care if they have reduced consciousness**

Answer 173

- Complications - Epilepsy **related to trauma** - Neurological deficits - Coma - Increased intracranial pressure can also cause the brain to herniate, these can be lethal: - **Supratentorial herniation:** cerebrum is pushed against the skull or the tentorium, can compress the arteries that nourish the brain leading to an ischaemic stroke - **Infratentorial herniation:** cerebellum is pushed against the brainstem, can compress the vital area in the brainstem that control consciousness, respiration, and heart rate - **Stroke** Secondary injury refers to the **evolving consequences** of primary injury and includes the following: - **Cerebral oedema** - **Raised intracranial pressure** and **herniation** - **Ischameia:** can occur due to mass effect, herniation, hypoperfusion, vasospasm - **Seizures** - **Infection**

Answer 174

- Complications - Epilepsy **related to trauma** - Neurological deficits - Coma - Increased intracranial pressure can also cause the brain to herniate, these can be lethal: - **Supratentorial herniation:** cerebrum is pushed against the skull or the tentorium, can compress the arteries that nourish the brain leading to an ischaemic stroke - **Infratentorial herniation:** cerebellum is pushed against the brainstem, can compress the vital area in the brainstem that control consciousness, respiration, and heart rate - **Stroke** Secondary injury refers to the **evolving consequences** of primary injury and includes the following: - **Cerebral oedema** - **Raised intracranial pressure** and **herniation** - **Ischameia:** can occur due to mass effect, herniation, hypoperfusion, vasospasm - **Seizures** - **Infection**

Answer 175

- Epidural haematoma - Intracerebral haematoma - Diffuse axonal injury (DAI) - Stroke - Seizure - Substance abuse - **Dementia** - **CNS masses e.g. tumours or abscesses** - **Subarachnoid haemorrhage**

Answer 176

- Epidural haematoma - Intracerebral haematoma - Diffuse axonal injury (DAI) - Stroke - Seizure - Substance abuse - **Dementia** - **CNS masses e.g. tumours or abscesses** - **Subarachnoid haemorrhage**

Answer 177

- Mortality following acute and chronic SDH **increases with age; those above 80 have a mortality of almost 90% if they have an acute SDH**. - Poor prognostic factors for acute and SDH include **reduced GCS on arrival**, **size of the SDH**, and **increasing age**. - For chronic SDH, the prognosis is more favourable.

Answer 178

- Mortality following acute and chronic SDH **increases with age; those above 80 have a mortality of almost 90% if they have an acute SDH**. - Poor prognostic factors for acute and SDH include **reduced GCS on arrival**, **size of the SDH**, and **increasing age**. - For chronic SDH, the prognosis is more favourable.

Stroke Flashcards

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