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Stroke Flashcards

1
Q

What are the relative contraindications to thrombolysis? (5)

A

Already on anticoagulants

Known coagulopathy

Active diabetic haemorrhagic retinopathy

Suspected intracardiac thrombus

Major surgery / trauma in the preceding 2 weeks

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2
Q

What are the absolute contraindications to thrombolysis that relate to bleeding? (7 - quite a few)

A

Active bleeding

Suspected SAH

Previous intracranial bleed

GI bleed in the last 3 weeks

LP in past 7 days

Uncontrolled HTN I.e. above 200 systolic

Oesophageal varices

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3
Q

What are the absolute contraindications to thrombolysis that DO NOT relate to bleeding? (4)

A

Pregnancy

Intracranial neoplasm

Stroke/ traumatic brain injury in past 3 months

Seizure at onset of stroke

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4
Q

What are the time frames for thrombolysis and thrombectomy following a stroke?

A

Thrombolysis = within 4 hours

Thrombectomy = 4-6 hours

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5
Q

What is the definition of a stroke?

A

The sudden onset of focal symptoms that are mainly negative and can be explained by hypo perfusion to a specific vascular territory

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6
Q

How do ischaemic and haemorrhagic strokes lead to hypo perfusion?

A

I = blocked artery

H = Bleeding

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7
Q

What is the TOAST classification?

A

5 Types of ischaemic stroke

1) Large artery atherosclerosis (embolus or thrombus)
2) Cardioembolism (high or med risk)
3) Small vessel occlusion
4) Stroke of other aetiology
5) Stroke of undetermined origion

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8
Q

What is the NIHSS?

A

Way to quantify severity of stroke

Higher score = more severe BUT the dominant side can give a higher score for the same amount of neuronal death

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9
Q

What is the CHADSVASC?

A

Way of assessing embolic stroke risk. Score of 2 = 2.2% risk

Congestive Cardiac Failure (1)
HTN (1)
A2 = Age 65-74 or 75 (1)
Diabetes (1)
S2 = Stroke/TIA/VTE (2)
V
Ascular disease (1)
Sex
Category Female (1)
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10
Q

What is the HASBLED?

A

Way to assess risk of bleeding when anti coagulated (all score 1 each)

HTN
A3 - abnormal LFTs, renal failure, alcohol use (1 each)
Stroke
Bleeding
Labile INR
Elderly >65
Diabetes
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11
Q

Where does the anterior cerebral artery supply? How would an ACA infarct present?

A

Medial hemispheres = lower limbs and genitals

Contralateral motor deficit - initial flaccidity that becomes spastic

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12
Q

Where does the middle cerebral artery supply? How would an MCA infarct present?

A

Lateral hemispheres = face and upper limbs

Contralateral motor and sensory deficits

internal capsule affected

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13
Q

Where does the posterior cerebral artery supply? How would a PCA infarct present?

A

Occipital lobe = vision

Visual defects - contralateral homonymous hemianopia with macular sparing as macula is supplied by the MCA

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14
Q

Define a Transient Ischaemic Attack

A

An ischaemic neurological event with similar symptoms to a stroke i.e. relate to a particular vascular territory but symptoms resolve within 24 hours (in real life it is quicker so usually 1-2 hours)

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15
Q

What is the ABCD2?

A

A method of stratifying risk of a stroke following a TIA (I don’t think it is actually used any more)

Age >60 (1)
BP >140 (1)
Clinical Features (unilateral weakness (1), speech disturbance (1))
Duration >1 hour (2), 10-59 mins (1). Diabetes (1)

> 4 = high risk

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16
Q

What is now used instead of ABCD2?

A

Anyone in past week is high risk

Low risk is >1 week

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17
Q

Which bed and blood tests should be done if someone presents with a TIA?

A

Bed = BP (baseline obs)

Blood = Lipids, glucose, U&E, FBC, VBG

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18
Q

What imaging should be done in TIA clinic?

A

ECG - AF?

DWI MRI - shows acute changes or areas of ischaemia and is sensitive for up to 2 WEEKS

CT - shows older changes i.e. after 4 hours and rules out bleeding

CUSS - >50% occlusion = carotid endartectomy?

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19
Q

What is the conservative management of a TIA?

A

Urgent referral to TIA clinic as risk of recurrent stroke is 10%

No driving for 4 weeks!!!!

Lifestyle - weight loss, stop smoking

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20
Q

What is the primary medical management of a TIA?

A

Aspirin 300mg for 2 weeks (+PPI if needed)

Switch to Clopidogrel 75mg PO

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21
Q

What is the secondary medical management of a TIA?

A

Manage HTN

Statin

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22
Q

What is the surgical management of a TIA?

A

Carotid endarterectomy if >50% stenosed and are of an acceptable surgical risk

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23
Q

What are the main 6 clinical features of a stroke/TIA?

A

Focal

Sudden Onset

Mainly -ve symptoms

Relates to a vascular territory

Symptoms don’t migrate

Stereotyping is not usual

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24
Q

Give 4 general clinical features of a stroke/TIA

A

Confusion
Headache
Dizzy/vertigo/Syncope
Nausea and vomiting

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25
Give 5 neurological features of a stroke/TIA
``` Sensory loss/parasthesia Initial hypotonia that becomes hypertonic Cranial nerve deficits Homonymous hemianopia Speech - dysarthria, aphasia, dysphasia ```
26
Which blood vessel is associated with total anterior circulation syndrome (TACS)?
Proximal MCA ICA (which leads to MCA anyway)
27
What are the clinical features of a TACS?
Hemiparesis Higher cortical dysfunction e.g. dysphasia AND homonymous hemianopia
28
Which blood vessel is associated with partial anterior circulation syndrome (PACS)?
MCA +/- branches
29
What are the clinical features of a PACS?
Isolated higher cortical dysfunction OR Higher cortical dysfunction, 2x hemiparesis, hemianopia
30
Which blood vessel is associated with posterior circulation syndrome (POCS)?
Posterior circulation (surprisingly) PCA, basilar, vertebral, cerebellar arteries
31
What are the clinical features of a POCS?
Isolated hemianopia OR Brainstem/cerebellar symptoms
32
Which blood vessel is associated with Lacunar syndrome (LACS)?
Lenticulostriate arteries (branch of MCA) OR Small penetrating artery occlusion
33
What are the clinical features of a LACS?
Isolated motor OR Isolated Sensory OR Sensorimotor OR Ataxic hemiparesis OR Clumsy hand dysarthria
34
Define stereotyping
Episodic recurrence of symptoms in the same way each time e.g. capsular warning syndrome or intracranial stenosis
35
What is capsular warning syndrome?
Intermittent reduction in MCA perfusion so reduced flow to the lenticulostriate arteries Get intermittent symptoms rather than a complete resolution Usually LACS
36
What is intracranial stenosis?
Seen when there is another cause of generalised hypo perfusion so get that kind of symptoms e.g. dizziness, pallor
37
What are the 3 types of stroke mimics?
Can be identified with imaging e.g. tumour, MS Have secure features that distinguish from stroke e.g. BPPV, syncope, transient global amnesia Can be distinguished if all info is available e.g. migraine + aura, focal seizures
38
What is the mechanism of action of Warfarin?
Acts on Vit K dependent clotting factors (IX, X, VII and Prothrombin) Inhibits reductase that regenerates active vitamin K = factors don't forms SO acts on intrinsic and extrinsic pathways = prevents initiation and amplification of the cascade
39
What are 4 important things to remember when prescribing warfarin?
Requires 3 days to start working so have to cover wit LMWH during this time as become pro-thrombotic Target INR is 2-3 CYP450 metabolised Teratogenic
40
What is the mechanism of action of Heparin?
LMWH = Acts on Factor Xa, accumulates in renal failure Unfractionated = Acts on Antithrombin III. Needs protamine sulphate to reverse + risks heparin induced thombocytopenia
41
What is the mechanism of action of DOACs?
Dabigatran = acts on Thrombin Rivaroxaban, Apixaban etc = Acts on Factor Xa
42
What are the positives and negatives of DOACs?
+ves = more reliable and equally effective as Wardarin, don't require regular monitoring, lower risk of intracranial haemorrhage [than warfarin]a -ves = Higher risk of GI bleeding, CI if renal impairment or pregnant
43
What are the non-modifiable risk factors for stroke?
Age Thrombophilia Migraine + Aura + COCP (younger pt)
44
What are the modifiable risk factors for stroke?
HTN Cardiovascular disease AF Smoking T2DM
45
Define aphasia
A selective impairment of language or the cognitive processes that underlie language
46
What is Broca's aphasia? Which bit of the brain is damaged?
Non-fluent, poorly articulated, and agrammatic speech output (in both spontaneous speech and repetition) with relatively spared word comprehension. Can understand what you're saying but can't communicate coherently back left posterior inferior frontal cortex, in the distribution of the SUPERIOR division of the left middle cerebral artery (MCA).
47
What is Wernicke's aphasia? Which bit of the brain is damaged?
Fluent but meaningless speech output and repetition, with poor word and sentence comprehension. Don't understand what you've said and just say randomish words Posterior superior temporal cortex, in the distribution of the INFERIOR division of the left MCA.
48
Give 4 differential diagnoses for a stroke
Hypoglycaemia/DKA Hemiplegic migraine Post-ictal (could still be a stroke esp if haemorrhagic) Previous cerebrovascular accident + systemic illness
49
What are the targets for blood pressure control, acutely and long term?
Acute = <180 if ischaemic, <140 if haemorrhagic Long term = <130/80
50
What is the definition of malignant MCA syndrome?
Rapid neurological deterioration due to the effects of space occupying cerebral oedema or haemorrhagic transformation following a middle cerebral artery (MCA) territory stroke
51
How would a malignant MCA present? (4)
Acute onset of left sided hemiplegia. No loss of conscience, Patient is agitated and anxious. CVS risk factors
52
What are the 3 layers of meninges from out to in?
Outermost = Dura mater - tough and fibrous Middle = Arachnoid mater - Contains CSF in subarachnoid space Innermost = Pia mater - protection from chemicals/infections as adheres closely to brain and spinal cord
53
What are the 2 layers of dura?
Periosteal and meningeal They separate to contain the dural venous sinuses
54
What is the function of the arachnoid mater?
Buffer layer and allows the brain to be weightless
55
Define an aneurysm
A sac formed by the localised dilation of an arterial wall/vein due to wall weakness
56
How does a true aneurysm differ from a false?
True = at least one arterial layer is unbroken. Most associated with atherosclerosis False = usually caused by trauma + wall rupture - blood escapes to form a clot
57
What is a berry aneurysm?
An aneurysm within the cerebral blood system Usually occurs where the cerebral arteries leave the circle of willis More likely to rupture if posterior
58
Define a haemorrhage (in brain terms)
Abnormal escape of blood from an artery (subarachnoid, extradural, subdural)
59
Define a subarachnoid haemorrhage
Bleeding into the subarachnoid space (between Pia and arachnoid mater)
60
What are 5 symptoms of a subarachnoid haemorrhage?
Thunderclap headache!!!! (sudden onset, worst pain ever, occipital) N&V Reduced GCS/drowsy
61
Give 3 signs of a subarachnoid haemorrhage
Neck stiffness after 6 hours Focal neurology @ presentation Terson's Syndrome if more severe
62
What is Terson's syndrome
Increase in intraocular pressure due to intraocular haemorrhage Subhyaloid haemorrhage Vitreous haemorrhage
63
What are 5 non-modifiable risk factors for SAH?
FHx (3-5x risk) Coagulopathy Past Hx Other medical conditions: Polycystic Kidney Disease, Ehlers Danlos
64
What are 3 modifiable risk factors for SAH?
Smoking HTN Alcohol Misuse
65
What are 2 investigations for SAH?
Urgent CT Lumbar puncture (if CT is -ve but strong S&S)
66
What is important to remember about doing a lumbar puncture to investigate a SAH?
Have to wait 12hr after 1st presentation as RBCs need to break down If yellow due to bilirubin = old blood from a SAH
67
What is the very initial management of a SAH?
A to E!!!! Neurosurgery referral!!!! HDU admissioN!!!
68
What is the conservative management of a SAH?
Regular reexamining of the CNS Hydration to maintain BP and cerebral perfusion
69
What is the medical management of a SAH?
Treats actual condition - Nimodepine (Ca channel antagonist) to reduce vasospasm therefore maintaining cerebral perfusion Treats symptoms - opiate analgesia + laxative, anti-emetic, NO NSAIDS OR ANTICOAGULANTS
70
What is the surgical management of a SAH?
Coil/clip the aneurysm External ventricular drain
71
What are the causes of a SAH?
Trauma Berry aneurysm e.g. at MCA bifurcation
72
What are the early complications of a. SAH?
Rebleeding Hydrocephalus (ventricles block so CSF can't drain) Stroke Hyponatraemia
73
What are the late complications of a SAH?
Seizures epilepsy SIADH and hyponatraemia Coil prolapse
74
Define a subdural haemorrhage
A collection of blood/bleeding into the subdural space (between dura and arachnoid mater)
75
What is the aetiology of a subdural haemorrhage?
Rupture of bridging veins as they cross from the subdural space into dural sinuses e.g. due to shearing forces from trauma
76
What are the symptoms of a subdural haemorrhage?
Fluctuating levels of consciousness Pupillary changes Headache 'within the setting of head trauma'
77
What are the signs of a subdural haemorrhage?
Raised ICP Seizures
78
What are the changes of a SDH seen on CT? (4)
Colour = Acute (<3 days) = bright, white blood. Chronic (>3 weeks) = black blood Usually unilateral - fall cerebri prevents movement Crescent shaped +/- midline shift
79
What is the conservative and medical management of a subdural haemorrhage?
C - A to E M - none really
80
What is the surgical management of a subdural haemorrhage?
Acute = Relieve ICP via immediate neurosurgery (do a craniotomy) Can do burr holes for subacute or chronic
81
Define an extradural haemorrhage
Bleeding between the periosteal layer of the dura mater and the inner surface of the skull
82
What are the symptoms of an extradural haemorrhage?
LOS at time of initial injury Lucid interval - transient recover +/- ongoing headache Reduced consciousness, vomiting, seizures Coma, CN palsies, pupillary changes
83
What is the aetiology of an extradural haemorrhage?
Secondary to trauma/fracture of temporal or parietal bone e.g. at pterion Severs the middle meningeal artery Or, can be venous if tearing of dural venous sinus
84
Can an extradural haemorrhage cross the midline?
Yes! Can cross the sutures as the periosteal layer travels though the suture line Size is still limited as dura is strongly adhered to the bone at certain points
85
What are the investigations for an extradural haemorrhage?
CT - acute = blood is white Biconx/round Well demarcated +/- midline shift
86
What is the management of an extradural haemorrhage?
C - A to E M - S - urgent neurosurgery referral + craniotomy + clot removal + ligation of blleding
87
What are the acute and chronic complications of an extradural haemorrhage?
A = death + seizures C = permanent brain damage, AV fistula, pseudo aneurysm, seizures
88
Define cerebral venous thrombosis
Occlusion of venous channels in the cranial cavity including IVT, DVT
89
What is the cause of a cerebral venous thrombosis
Thrombus in dural venous sinuses = prevention of venous return in sinuses Increased deoxygenated blood in parenchyma + Increased CSG as also can't drain through arachnoid granulations
90
What is the clinical presentation of a cerebral venous thrombosis?
Depends where it is: Sagittal - headache, vomitign, seizures, papilloedema Transverse - Headache -/+ mastoid pain, papilloedema Sigmoid - cerebellar signs Inferior petrosal - CN V and CN VI palsy Cavernous - Eye signs - chemosis, proptosis, pain on movement
91
What are the modifiable risk factors for a cerebral venous thrombosis?
Hormones - COCP, pregnancy, steroids Infection - mastoiditis, folliculitis Malignancy Trauma Dehydration
92
What are the non-modifiable risk factors for a cerebral venous thrombosis?
Congenital mainly e.g. skull abnormality, connective tissue disorders, coagulopathy
93
What are the investigations for a cerebral venous thrombosis?
Digital subtraction angiography is gold standard but hard to do in practice CT to exlude SAH or meningitis
94
What is the management of a CVT?
C = A to E M = LMWH, ?thrombolyse S = Thrombectomy - not if large
95
What are the acute complications of CVT?
Venous infarction +/- haemorrhage Hydrocephalus AV fistula
96
What are the Long term complications of CVT?
Dependency | Death
97
What is lateral medullary syndrome?
Infarct of the posterior inferior cerebellar artery (PICA) Presentation ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's contralateral: limb sensory loss
98
Does a patient still need to be anti coagulated following a catheter ablation e.g. for AF
yes please continue to take medications
99
What is Weber's syndrome and what are the clinical findings?
Infarction of the arteries supplying the midbrain ipsilateral III palsy contralateral weakness

EOY4 (22 decks)

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