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Stroke Flashcards

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1
Q

On average how many strokes occur in one year in the UK?

A

120,000-150,000

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2
Q

Define a stroke

A

Sudden onset of focal or global neurological symptoms caused by ischaemia or haemmorhage lasting more than 24 hours

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3
Q

How is a Transient Ischaemic Attack different to stroke?

A

Symptoms resolve within 24 hours

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4
Q

2 Main causes of stroke

A

Ischaemic

Haemorrhagic

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5
Q

Causes of ischaemic stroke?

A 
Large artery atherosclerosis
Cardioembolic (infective endocarditis)
Small artery occlusion (Lacunar)
Undetermined
Rare causes - arterial dissection, venous sinus thrombosis
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6
Q

Causes of haemorrhagic stroke

A

Intracerebral haemorrhage

Secondary haemorrhage- SAH, Arteriovenous malformation

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7
Q

Define ischaemia

A

failure of cerebral blood flow; interrruption in blood supply

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8
Q

Ischaemia leads to…

A

Hypoxia

Prolonged –> anoxia –> infarction –> necrosis: STROKE

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9
Q

Further damage following prolonged hypoxia

A

Oedema

Secondary haemorrhage into stroke

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10
Q

Pathogenesis of ischaemic stroke (4)

A

Disruption or injury to plaque surface
Platelet ahdesion/aggregation and fibrin formation
Thrombus formation
Total arterial occlusion

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11
Q

Non-modifiable risk factors of stroke

A

Previous stroke
Family history
Age
Male

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12
Q

Modifiable risk factors

A 
Hypertension
Diabetes
Smoking
Lipids
Alcohol
Obesity (abdominal)
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13
Q

Other risk factors

A 
Hypercoagulable states (pregnancy, cancer, sickle cell disease)
Impaired cardiac function (Atrial fibrillation)
OC & HRT - high estrogen content
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14
Q

Arterial supply to anterior brain

A

Internal carotid artery

Divides into Anterior Cerebral artery and Middle Cerebral Artery

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15
Q

Arterial supply to posterior brain

A

Vertebral to Basilar
3 pairs of cerebellar arteries - Superior, Anterior inferior, Posterior inferior
2 Posterior cerebral arteries PCA

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16
Q

Name the anastomoses of the arterial blood supply to the brain

A

CIRCLE OF WILLIS

Anterior and posterior communicating arteries

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17
Q

Branches of the ACA

A 
Medial orbitofrontal
Frontopolar
Callosomarginal
Pericallosal
Paracenral
Precuneal artery
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18
Q

ACA occlusion symptoms

A

Contralateral paralysis of foot and leg, sensory loss over foot and leg, impaired gait and stance

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19
Q

Branches of the MCA

A 
Anterior/Middle/Posterior Temporal
Lateral orbitofrontal
Ascending frontal
Precentral
Central
Anterior/Posterior Parietal
Angular artery
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20
Q

Symptoms of MCA occlusion

A

Contralateral paralysis of face/arm/leg, sensory loss,
Homonymous hemianopia
Gaze paralysis to opposite side
Aphasia if stroke on dominant side
Unilateral neglect and agnosia for 1/2 external space if non-dominant (usually RHS)

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21
Q

Left hemisphere MCA territory contains which functional areas

A

Broca’s
Wernicke’s
Auditory complex

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22
Q

Symptoms if left hemisphere affected

A

Hemiplegia, homonymous hemianopia, dysphasia

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23
Q

Right hemisphere symptoms

A

Left hemiplegia, homonymous hemianopia, neglect syndromes (Agnosias)

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24
Q

4 Types of Agnosia

A

Visual agnosia
Sensory agnosia
Anosagnosia (denial of hemiplegia)
Prosopagnosia (failure to recognise faces)

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25
Which arteries are occluded when stroke occurs in area of basal ganglia and name the type of stroke
MCA --> Medial and Lateral Lenticulostriate arteries | Lacunar stroke
26
Name the 4 Lacunar Stroke Syndromes
Pure motor stroke Pure sensory stroke Dysarthria (clumsy hand syndrome) Ataxic hemiparesis
27
What signs are devoid in Lacunar stroke?
Cortical | No dysphasia, neglect or hemianopia experienced
28
Name the arteries within the posterior circulation to the brain
``` Basilar artery Superior cerebellar Anterior inferior cerebellar Posterior temporal Calcarine artery Parietooccipital Posterior pericallosal artery ```
29
Think of the anatomy involved in a stroke within the posterior circulation
Brainstem, thalamus, Cerebellum, Occipital and medial temporal
30
Symptoms of posterior stroke
``` Brainstem dysfunction Coma, vertigo, nausea, vomiting, cranial nerve palsie, ataxia Hemiparesis, hemisensory loss Cossed sensori-motor deficit Visual field deficits ```
31
3 Goals of Acute Ischaemic Stroke treatment
Restore blood supply Limit ischaemic damage Protect vulnerable brain tissue
32
Treatments for acute ischaemic stroke
Thrombolysis - alteplase Aspirin 300mg Thrombectomy Stroke Unit
33
Classification system for stroke
Bamford/ Oxfordshire Community Stroke Project (OCSP) classification Lacunar Stroke (LACS) Partial Anterior Circulation Stroke (PACS) Total Anterior Circulation Stroke (TACS) Posterior Circulation Stroke (POCS)
34
What system is used to differentiate from stroke mimics?
ROSIER Recognition of Stroke in the Emergency Room -Seizures, loss of consciousness - not typically stroke Assymetric facial, leg and arm weakness Speech disturbance Visual defect All score 1 point
35
Bamford classification of Lacunar Stroke (LACS)
Motor +/- sensory loss
36
Bamford classification of Partial Anterior Circulation Stroke
``` Motor +/- sensory loss 1 from Hemianopia Dysphasia Neglect ```
37
Bamford classficiation of Total Anterior Circulation Stroke
Motor +/- sensory loss 2 from Hemianopia + Neglect or Dysphasia
38
Bamford classficiation of Posterior Circulation Stroke (POCS)
Motor +/- sensory loss Hemianopia/dysphasia/neglect Brainstem and or cerebellar signs
39
Highest death rates in which type of stroke from Bamford Classification
Total Anterior Circulation Stroke (TACS) - 96%- includes dependence in 6 months
40
What is thrombolysis?
Tissue Plasminogen Activator (TPA)- Alteplase | Breaks down the clot
41
Criteria for TPA
Less than 4.5 hours since symptom onset Disabling neurological deficit Symptoms present > 60 minutes Consent
42
Exclusion criteria for TPA
``` Evidence of haemorrhage - blood on CT - Surgery - Bleeding - Coagulation problems BP > 185 systolic or 110 diastolic Glucose less than 2.8 or > 28mmol/L ```
43
What is supplied by the carotid system?
Anterior cerebral and middle cerebral hemispheres and cortical deep white matter
44
What is supplied by the vertebro-basilar system?
Brainstem, cerebellum and occipital lobe
45
What function is determined by the motor cortex?
Movement
46
What is determined by the sensory cortex?
Pain, heat and other sensations
47
What function is determined by the parietal lobe?
Comprehension of language
48
What functions are determined by the temporal lobe?
Hearing Intellect Emotion
49
What area does the occipital lobe belong to?
Primary visual area
50
What function is determined by Wernicke's area?
Speech comprehension
51
What function is determined by the cerebellum?
Coordination
52
What functions are determined by the brainstem?
Swallowing, breathing, heartbeat, wakefulness center and involuntary functions
53
What functions are related to the frontal lobe?
Smell Judgement Foresight Voluntary movement
54
What area is related to speech?
Broca's Wernicke's for comprehension
55
What key areas need to be explored in the nuerological history and examination for stroke?
``` Motor Sensory - loss of feeling Speech - dysarthria, dysphasia (weakened muscles of face and mouth) Neglect/visuospatial problems Vision Gaze palsy Ataxia/vertigo.incoordination, nystagmus ```
56
Which areas are most commonly unaffected or recover well in smaller strokes?
Frontal and speech cortex
57
Damage to which area due to stroke results in locked in syndrome/locked-in like states?
Pons
58
Why would damage to the pons cause a locked in syndrome?
Catches all of the motor and sensory fibres in cortex
59
Why are cancer patients more vulnerable to stroke?
Prothrombotic state
60
Causes of stroke
Blockage of vessel with thombus/embolus Disease of vessel wall Disturbance of normal properties of blood Rupture of vessel wall (haemorrhage)
61
Symptoms of carotid stenosis
``` Sudden severe headache Dizziness Loss of balance Unable to move limbs Sight Weakness, numbness on one side ```
62
Most common cause of cardioembolic stroke?
Atrial fibrillation
63
What arteries are branches of the middle cerebral artery?
Medial and lateral lenticulostriate arteries
64
Which stroke occurs after HT and hypertrophy of the lenticulostriate arteries?
Small lacunar stroke | Motor +/- sensory
65
What rare cause of stroke is the commonest cause of painful Horner's syndrome?
Carotid dissection | Drooping eye, can't perspire
66
What vessels are usually occluded in a Total anterior circulation stroke?
Proximal middle cerebral artery or internal carotid
67
Which vessels are more commonly occluded in a partial anterior circulation stroke?
Branches of MCA
68
Which type of stroke is often silent or misdiagnosed?
Lacunar Stroke
69
What type of presentation of lacunar stroke is most common?
Pure motor symptoms - complete/incomplete weakness of 1 side, 2 or 3 areas
70
Which investigations should be carried out when someone presents with stroke like symptoms?
``` Bloods ECG CT MRI Carotid doppler - examine vessels Echocardiogram - clots in heart ```
71
What is a priority to optimise recovery and discharge after a stroke?
Get the patient mobilising
72
What treatment alongside intravenous thrombolysis improves outcomes?
Clot retrieval/thrombectomy
73
When is hemicraniectomy indicated?
Acute MCA territory ischaemic stroke complicated by massive cerebral oedema Individuals up to 60 years of age
74
In what time frame should thrombolysis be considered for acute stroke treatment?
Within 4.5 hours onset of symptoms
75
Is CT offered for a suspected TIA?
No, unless suspicion of other condition that could be picked up by CT
76
Treatment for stroke prevention in TIA or otherwise
Clopidogrel 75mg or Aspirin Dipyridamole MR 200mg bd Statin BP drugs - even if BP normal
77
What are patients at risk of if swallow affected after stroke?
Aspiration pneumonia
78
Mechanism of aspirin
Inhibits thromboxane production Prevents platelet aggregation and vasoconstriction ANTIPLATELET
79
Mechanism of clopidogrel
Inhibits ADP receptor activated platelet aggregation
80
Newer agents to clopidogrel
Ticagrelor and prosugrel
81
Mechanism of statins (simvastatin,pravastatin, atorvastatin)
HMG CoA Reductase inhibitors | Stabilise atheromatous plaques and reduce inflammatory properties
82
Risk associated with aspirin and clopidogrel (antiplatelets)
GI bleeding
83
Treatment for carotid stenosis
Best Medical therapy - smoking cessation, BP control, antiplatelet, statin, diabetic control Confirmed TIA - carotid doppler Carotid endarterectomy
84
Complications of carotid endarterectomy
``` Wound infection Bleeding Scar Anaesthetic risk Nerve damage Perioperative stroke ```
85
Which nerves are at risk of damage during a carotid endarterectomy?
Glossopharyngeal Hypoglossal Vagus
86
Symptoms of nerve damage from carotid endarterectomy
Numbness along jaw | Issues swallowing and with speech
87
When is stenting considered in a carotid endarterectomy?
Inaccessible disease Scarring Previous surgery Area too high up for open surgery
88
Categories of ischaemic stroke
Thrombotic Embolic Hypoperfusion Lacunar
89
Causes of thrombotic stroke
Atherosclerosis | Prothrombotic state
90
Which group of patients are in a prothrombotic state?
Pregnant Cancer patients Antiphospholipid syndrome Sickle cell anaemia
91
3 examples of embolic stroke causes
Atrial fibrillation Paradoxical embolus Infective endocarditis
92
What is meant by a paradoxical embolus?
Clot occurs within venous system, embolises through right side of heart to the left via default in ventricular septum Travels to brain
93
What is the pathophysiology of lacunar strokes?
Hypertension | Occurs in basal ganglia
94
Categories of haemorrhagic stroke
Intracerebral haemorrhage | Subarachnoid haemorrage
95
Causes of intracerebral haemorrhage
Trauma Hypertension Cerebral amyloid
96
Causes of Subarachnoid haemorrhage
Trauma Berry aneurysm Arteriovenous malformation
97
What is Todd's paresis and what does this condition score on the ROSIER scale?
Hemiplegia following tonic clonic seizure | -1 - seizure; unlikely to be a stroke

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