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Stroke Flashcards

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1
Q

A 65-year-old man presents 1 hour after developing right-sided weakness and a reduced GCS. Neuroimaging shows an intracerebral haemorrhage.
What is the best treatment?

A

blood pressure reduction + consider neurosurgical referral

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2
Q

what is a stroke

A

AKA a cerebrovascular accident

sudden interruption in blood supply to the brain

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3
Q

what are the two main types of strokes

A

ischaemic (85%)
-strokes >24hrs
-TIAs <24hrs
haemorrhagic (15%)

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4
Q

what is the main problem with ischaemic stroke

A

‘blockage’ in blood vessels stops blood flow to brain

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5
Q

what is the main problem with haemorrhagic stroke

A

blood vessel ‘bursts’ leading to reduction in blood flow

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6
Q

what are the subtypes of ischaemic strokes

A 
1 thrombotic strokes
-thrombosis of large vessels (carotids)
2 embolic strokes
-blood clot, air embolus
-AF causes emboli to form in the heart which can move to the brain and cause blockage to blood supply
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7
Q

what are the subtypes of haemorrhagic strokes

A

1 intracerebral haemorrhage
-bleeding in brain
2 subarachnoid haemorrhage
-bleeding on surface of brain

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8
Q

risk factors of ischaemic stroke

A 
risk factors of CVS disease
-age
-male
-HTN
-smoking
-hyperlipidaemia
-DM
risk factors of cardioembolism
-AF
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9
Q

risk factors of haemorrhagic stroke

A
  • age
  • HTN
  • arteriovenous malformation
  • anticoagulation therapy
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10
Q

definition of stroke

A

clinical syndrome consisting of rapidly developing signs of focal disturbance of cerebral function lasting >24hrs

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11
Q

what would quariplegia indicate

A

brainstem infarction

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12
Q

what are lacunar infarcts

A

small infarcts around the basal ganglia, internal capsule, thalamus + pons

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13
Q

what do lacunar infarcts result in

A

pure motor
pure sensory
mixed motor+sensory
ataxia

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14
Q

def of ataxia

A

loss of full control of bodily movements

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15
Q

what classification system is used for strokes

A

Bamford/Oxford Stroke Classification

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16
Q

what criteria is assessed in the oxford stroke classification

A

1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg
2 homonymous hemianopia
3 high cognitive dysfunction (e.g. dysphasia)

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17
Q

using the oxford stroke classification what are the different stroke types

A

1 TACI
2 PACI
3 Lacunar infarcts
4 POCI

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18
Q

which arteries does a TACI involve

A

middle and anterior cerebral arteries

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19
Q

what features are present in a TACI

A

1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg
2 homonymous hemianopia
3 high cognitive dysfunction (e.g. dysphasia)

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20
Q

what arteries does a PACI involve

A

smaller arteries off middle and anterior cerebral arteries

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21
Q

what features are present in a PACI

A

any 2 of:
1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg
2 homonymous hemianopia
3 high cognitive dysfunction (e.g. dysphasia)

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22
Q

what arteries does a lacunar infarct involve

A

perforating arteries around internal capsule, thalamus, basal ganglia

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23
Q

what features are present in a lacunar infarct

A

any 1 of:
1 unilateral hemiparesis +/ unilateral hemisensory loss of face, arm, leg OR all three
2 pure sensory stroke
3. ataxic hemiparesis

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24
Q

what arteries does a POCI involve

A

vertebrobasilar arteries

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25
what features are present in a POCI
any 1 of: 1 cerebellar or brainstem syndromes 2 LOC 3 isolated homonymous hemianopia
26
what features are more suggestive of haemorrhagic stroke than ischaemic stroke
1 decreased consciousness 2 headache (much more common in haemorrhagic) 3 N+V 4 seizures
27
what is the first line management for stroke
CT/MRI to determine if ischaemic or haemorrhagic
28
what are the criteria for ischaemic stroke patients to be thrombolysed
1 patients present within 4.5hrs of onset of stroke symptoms | 2 patient has not had previous intracranial haemorrhage, uncontrolled HTN, pregnant
29
what is the management for ischaemic stroke patients
aspirin 300mg + antiplatelets
30
what is the treatment of TIAs based on
ABCD2 prognostic score
31
what is the ABCD2 prognostic score
determines risk of future CVA ``` Age >60yrs (1) BP >140/90 (1) Clinical features -unilateral weakness (2) -speech disturbance with no weakness (1) Duration of symptoms ->60mins (2) -10-59mins (1) Diabetes (1) ```
32
what would a ABCD2 score >4 indicate
increased risk of stroke | aspirin (300mg/daily)
33
what is the general management for haemorrhagic stroke
supportive (reduce BP) | anticoagulants (warfarin) + antiplatelets (clopidogrel) stopped
34
decrease in GCS, headache and N+V are often seen in what sort of stroke
haemorrhagic stroke
35
a patient who presents with ataxia and is found to have widespread cerebellar signs is most likely to have what sort of infarct
posterior circulation infarct
36
what is the best treatment for a 60y/o male who presents 2hrs after developing right arm weakness and loss of consciousness. neuroimaging excludes a haemorrhage
thrombolysis
37
what is the site of the lesion with: contralateral hemiparesis + sensory loss lower extremity>upper
anterior cerebral artery
38
what is the site of the lesion with: contralateral hemiparesis + sensory loss upper extremity>lower
middle cerebral artery
39
what is the site of the lesion with: contralateral homonymous hemianopia with macular sparing visual agnosia
posterior cerebral artery
40
what is visual agnosia
a person can see but not recognise or interpret visual information
41
disorder in which lobes causes visual agnosia
parietal lobes
42
nystagmus is associated with which nerve
VIII
43
what is a stroke
ischaemic infarction or bleeding (haemorrhage) into the brain
44
what are the causes of stroke
``` infarction (80%) -vessel occlusion due to thrombosis or emboli -hypotension haemorrhage -HTN -charcot-bouchard aneurysm rupture -anticoagulation ```
45
what are causes of stroke in younger patients
sudden BP drop (e.g. sepsis) | carotid artery dissection (spontaneous or trauma)
46
what is the definition of stroke
rapid onset neurological deficit by cerebrovascular insult causing focal or global impairment of the CNS function lasting >24h
47
what can cause thrombosis
in the elderly, atherosclerosis is the common cause
48
what can cause emboli
atheromatous plaques from carotids | emboli from heart in AF
49
risk factors
HTN smoking + alcohol DM AF
50
epi
common | elderly
51
history
sudden onset (seconds) weakness/paralysis, reduced/loss of sensation in the limbs visual disturbances
52
what pointers suggest haemorrhagic stroke
this is unreliable, however: - meningism - headache - coma
53
what pointers suggest ischaemic stroke
carotid bruit AF past TIA IHD
54
what are the different locations of ischaemic strokes
cerebral (most common) brainstem lacunar
55
what is characteristic of cerebral infarct
contralateral (opposite side) sensory loss and paralysis initially flacid paralysis which later becomes spastic dysphasia (cannot generate speech) homonymous hemianopia
56
what is characteristic of brainstem infarcts
quadriplegia (paralysis of all four limbs) | locked in syndrome
57
what is characteristic of lacunar infarcts
in basal ganglia, internal capsule, thalamus, pons ``` 1 ataxic hemiparesis 2 pure motor 3 pure sensory 4 sensorimotor 5 dysarthria/clumsy ```
58
in which area does a lacunar infarct cause cognitive deficit or reduced consciousness
thalamus all other areas have no effect on consciousness or cognition
59
how can cerebral infarcts be subdivided
``` by vessel 1 anterior circulation 2 posterior circulation 3 single lacunar infarct 4 multiple lacunar infacts ```
60
what areas do the anterior circulation supply and what distinguishes these areas on examination
``` anterior cerebreal -lower limb weakness (motor cortex) -confusion (frontal lobe) middle cerebral -facial weakness -dysphasia ```
61
what examination findings would you expect with a lacunar infarct to the internal capsule or pons, thalamus, basal ganglia
``` internal capsule or pons -pure sensory, pure motor or sensorimotor deficit thalamus -LOC basal ganglia -parkinsonism ```
62
what arteries can be affected in a posterior circulation infarct
posterior cerebral anterior/posterior inferior cerebellar artery basilar artery
63
feature of posterior cerebral infarct
hemianopia
64
features of anterior + posterior inferior cerebellar artery infarct
``` vertigo ipsilateral ataxia (loss of control of body movements) ```
65
what distinguishes anterior and posterior inferior cerebellar artery infarcts
anterior - ipsilateral deafness + facial weakness | posterior - ipsilateral horner's syndrome + facial sensory loss
66
features of multiple lacunar infarcts
vascular dementia urinary incontinence shuffling small-stepped gait
67
what are features of an (intracerebral) haemorrhage
headache meningism N+V seizures
68
investigations
``` 1 ABC 2 pulse, BP, ECG -AF embolus aortic dissection 3 bloods -DEFG 4 urgent CT head or MRI -CT head identifies or excludes haemorrhage -MRI used to differentiate between old and new strokes ```
69
what is the management for a hyperacute stroke
if hyperacute (<4.5h) and a haemorrhagic stroke has been excluded - thrombolyse
70
what is used to thrombolyse a patient
IV recombinant tissue plasminogen activator | alteplase
71
what is the management for an ischaemic acute stroke
>4.5hrs haemorrhage has been excluded on CT head antiplatelet therapy -aspirin + clopidogrel
72
what is the management for an intracerebral haemorrhage
control HTN + seizures | IV mannitol + hyperventilation can reduce intracranial pressure
73
what is the primary prevention for stroke (before any stroke)
control HTN, hyperlipidaemia, DM, cardiac disease exercise smoking cessation lifelong anticoagulation in AF or if rheumatic or prosthetic heart valves on left hand side
74
what is the secondary prevention for stroke (after stroke)
control risk factors aspirin/clopidogrel start warfarin 2wks post stroke (with antiplatelet therapy inbetween) if AF
75
what surgical management can be given with stroke or TIA
carotid endartectomy (unblocking of carotid artery) reduces risk of further cerebrovascular events
76
what prothrombotic conditions can increase risk of an ischaemic infarction (stroke)
thrombophilia
77
what bleeding disorder can increase risk of haemorrhagic stroke
thrombocytopenia
78
complications
cerebral oedema causing increased ICP and compression | immobility with paralysis
79
prognosis
haemorrhagic stroke has poorer prognosis than ischaemic | less than half make a full recovery

Nervous System (27 decks)

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