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Stroke Infarction Flashcards

1
Q

What is the pathology of ischaemic stroke?

A

Acute occlusion of an intracranial vessel leading to hypoxia and infarction; if blood flow restored w/o significant infarction = TIA.

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2
Q

What is the aetiology of ischaemic stroke?

A
  • DM, HTN, smoking, hypercholesterolemia
  • FHx
  • AF, valvular lesions, cardiac congenital defects, hypercoaguable states, vasculitis
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3
Q

What are the symptoms of ACA occlusion?

A
  • Contralateral hemiplegia
  • Gait apraxia
  • Abulia (severe apathy)
  • Urinary incontinence
  • Lower limb sensory loss
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4
Q

What are the symptoms of MCA occlusion?

A

-Contralateral hemiplegia
-Homonymous hemianopia
-Contralateral sensory loss
-Dysarthria, dysphasia
Non-dominant symptoms: aphasia, neglect, contructional apraxia.

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5
Q

What are the symptoms of posterior cerebral artery occlusion?

A 
Homonymous hemianopia +/- macular sparing
Contralateral hemiplegia
Ataxia/hemiballismus
Visual agnosia
Cortical blindness
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6
Q

What are the symptoms of posterior inferior cerebellar artery occlusion?

A 
Syncope
Vertigo
Hemiplegia
Dysarthria
Ipsilateral face numbness
Contralateral limb numbness
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7
Q

What are the symptoms of basilar artery occlusion?

A

Dizziness, vertigo, diplopia, dysarthria, facial numbness, ipsilateral hemiparesis

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8
Q

What Ix in ischaemic stroke?

A

CT, MRI, MR angiography, carotid dopplers, ECG, echo.

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9
Q

Rx ischaemic stroke?

A

-Medical: aspirin, clopidogrel, dipyramidole, anticoagulation.
Thrombolysis as indicated.
-Collateral blood flow BP dependent - don’t lower BP unless signs of malignant HTN.
-Surgical: carotid endarterectomy

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10
Q

What is a stroke?

A

Sudden on set of neurological deficits of a vascular basis with infarction of CNS tissue

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11
Q

What is a TIA?

A

Sudden onset of neurological deficits of a vascular basis without infarction (i.e. resolution)

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12
Q

Pathophysiology of small vessel / lacunar ischaemic strokes?

A

Chronic HTN and DM cause vessel wall thickening and decreased luminal diameter

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13
Q

Where do small vessel / lacunar strokes generally occur?

A

Small penetrating arteries: primarily basal ganglia, internal capsule, thalamus

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14
Q

What are the different mechanisms of ischaemic stroke?

A
  • Arterial thrombosis
  • Cardioembolic
  • Systemic hypoperfusion
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15
Q

What is the most common mechanisms of hemorrhagic stroke?

A

Hypertensive: rupture of small micro aneurysms causing intraparenchymal haemorrhage

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16
Q

What are the most common sites of hemorrhagic stroke?

A

Putamen, thalamus, cerebellum, pons

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17
Q

ACA stroke syndrome?

A

Contralateral leg paresis and sensory loss

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18
Q

MCA stroke syndrome?

A

Proximal occlusion involves:

  1. Contralateral weakness and sensory loss of face and arm
  2. Cortical sensory loss
  3. +/- contralateral homonymous hemianopia or quadrantanopia
  4. L hemisphere: aphasia
  5. R hemisphere: neglect
  6. eye deviation towards the side of the lesion and away from the weak side
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19
Q

PCA stroke syndrome?

A
  1. Contralateral hemianopia or quadrantanopia
  2. Midbrain findings (CNIII/IV palsy/pupillary changes, hemiparesis)
  3. Thalamic findings: sensory loss, amnesia, dec LOC
  4. If bilateral: cortical blindness or prospagnosia
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20
Q

Basical artery stroke syndrome?

A

Locked in syndrome:

  1. Quadriparesis
  2. Dysarthria
  3. Impaired eye movements
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21
Q

PICA stroke syndrome?

A

Lateral medullary / Wallenburg syndrome:

  1. Ipsilateral ataxia
  2. ispilateral Horner’s
  3. ipsilateral facial sensory loss
  4. contralateral limb impairment of pain & temp
  5. nystagmus vertigo
  6. N/V
  7. Dysphagia
  8. Dysarthria
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22
Q

Anterior spinal artery stroke syndrome?

A

Medial medullary infarct:

  1. contralateral hemiparesis
  2. contralateral impaired proprioception and vibration
  3. ipsilateral tongue weakness
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23
Q

Lacunar infarct stroke syndrome to posterior limb of internal capsule?

A

-Pure motor: posterior limb of internal capsule => contralateral leg, arm, face

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24
Q

Thalamic lacunar infarct stroke syndrome?

A

Pure sensory loss: hemisensory loss

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25
Assessment of stroke?
- ABCs - Full vitals monitoring - BSLs - Urgent code stroke
26
Hx features to ascertain in stroke?
-Onset: time when last known to be awake and Sx free
27
Mimics to r/o in stroke Hx?
- Seizure / post-ictal - Hypoglycemia - Migraine - Conversion disorder
28
Ix in stroke work up?
- Non contrast CT: r/o haemorrhage - ECG: r/o AF (Cardioembolic cuase) - FBE - UEC - Coags - Blood glucose
29
What are the signs of stroke on imaging?
- Loss of white-grey differentiation - Sulcal effacement (i.e. mass effect decreases visualisation of sulci) - Hypodensity of parenchyma - Insular ribbon sign - Hyperdense MCA sign
30
Mx of acute stroke?
1. Thrombolysis 2. Anti-platelet therapy 3. Anti-coagulant therapy 4. Other - NBM if dysphagia - DVT prophylaxis - initiate early rehab
31
Principles of thrombolysis?
- rtPA (recombinant tissue plasminogen activator) | - given within 4.5h onset and no CIx
32
Contraindications to thrombolysis?
``` Hx: - improving / minor Sx -Seizure at stroke onset -recent major surgery/trauma -recent GI or urinary haemorrhage -recent LP or arterial puncture at non-compressible site -Pregnancy PMHx: -ICH -Sx of: SAH/pericarditis/MI PEx: -sBP: >185 -dBP: >110 -Uncontrolled serum glucose -Thombocytopenia CT: haemorrhage or mass ```
33
When is anti-platelet therapy indicated in acute stroke management?
At presentation of TIA / stroke if rtPA not received
34
Anti-platelet agents in acute stroke management?
- Aspirin | - Clopidogrel (if aspirin CIx)
35
Anti-coagulant therapy in acute stroke management?
Patients with TIA / stroke and atrial fibrillation if rtPA not received
36
Anti-coagulant therapy in acute stroke management if pt already on warfarin?
IV heparin (or ensure INR 2-3)
37
Maintenance of BSL in acute stroke management?
Avoid hyperglycemia (can increase infarct size)
38
Principles of BP management in peri-stroke period?
- Acutely elevated BP required to maintain brain perfusion to ischaemic penumbra - Do not lower BP unless sBP >220 / dBP >120
39
Further investigations to consider in ascertaining stroke aetiology?
- Additional neuroimaging (MRI) - Vascular imaging: CTA / MRA / carotid dopplers - Cardiac: echo, holter monitors
40
Stroke primary prevention with anti platelets?
No current evidence for low risk pts w/o previous TIA/stroke
41
Stroke secondary prevention with anti-platelets?
- Aspirin first line | - Clopidogrel (if aspirin unsuitable / ongoing neuro Sx)
42
What was demonstrated by the MATCH and CHARISMA trials?
No benefit and risk of major bleeding if combining aspirin and clopidogrel
43
Primary prevention of stroke if carotid stenosis?
Carotid endarterectomy controversial: - if stenosis >60% RR stroke 2%/y - reduces risk by 1% per year - BUT 5% chance of complications
44
Secondary prevention of stroke with carotid stenosis?
(Previous stroke / TIA) -carotid endarterectomy of CLEAR benefit if symptomatic severe stenosis (less benefit if moderate symptomatic stenosis 50-69%). Benefits time linked to last symptomatic event
45
Role of CHADS2 score stroke primary / secondary prevention?
Risk stratification: - 0 = v low risk, anti platelet - 1 = low risk, anti platelet or anti coagulant (pt specific) - 2 = mod/high risk, anticoagulant
46
Anticoagulation therapy in stroke secondary prevention?
-Warfarin (titrate to INR 2-3) -Dabigatran (110 or 150mg bd) Factor Xa also as effective as warfarin.
47
BP target in stroke primary prevention?
BP
48
What is the role of ACEi in stroke primary prevention?
Reduce risk of stroke beyond their anti-hypertensive effects
49
What was the outcome of the PROGRESS trial?
ACEi and thiazide diuretic recommended in pts with previous stroke / TIA
50
What are the components of CHADS2?
- CHF - HTN - Age (>75) - Diabetes - Previous stroke/TIA (2 pts)
51
How does smoking affect stroke risk?
Smoking increases stroke risk in a dose dependent manner
52
Features favouring stroke (v mimic)?
Stroke predicted by: - exact time of onset - pt could recall what they were doing at symptom onset - well in the last week - definite focal Sx or signs, worse NIHSS
53
Features favouring mimic (v stroke)?
- Known cog impairment - lost consciousness or seizure at onset - pt could still walk - no lateralising Sx - confusion, non-vascular or no neurological signs
54
Classification of ICH?
Deep and lobar
55
What are the areas affected by deep ICH?
- Putamen - Thalamus - Brainstem - Cerebellum
56
Aetiology of deep ICH?
Usually due to HTN and rupture of deep penetrating arteries
57
Aetiology of superficial ICH?
Often secondary to: - amyloid angiopathy - tumour - arteriovenous malforamtion - aneurysm
58
What is the aim of acute ischaemic stroke treatment?
Rescuing the penumbra; time is brain
59
Non modifiable risk factors for ischaemic stroke?
- Age - Gender - FHx - Ethnicity - OCP use
60
Main modifiable ischaemic stroke RFx?
- HTN - DM - Smoking - Obesity
61
What does CHADS2 score of one or more recommend?
Oral anti-coagulant
62
What is the ABCD2 score?
To predict / identify individuals at high risk of stroke after TIA: -Age (>60) -BP (>140/90 at presentation) -Clinical features (2 for focal weakness, 1 for speech disturbance w/o weakness) -Diabetes -Duration (2 if 60min+) 0-3 = LOW; 4-5 = MODERATE; 6-7 = HIGH

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