Clinical Neuroscience > Stroke > Flashcards

Stroke Flashcards

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1
Q

Define stroke

A

A serious life threatening condition that occurs when the blood supply to part of the brain is cut off

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2
Q

Define transient ischaemic attack

A

Similar clinical features of stroke but resolve within 24 hours

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3
Q

Different between stroke and TIA

A

Similar clinical features but TIA < 24 hours

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4
Q

Types of stroke

A
  • ischaemic: thromboembolic
  • haemorrhagic: intracerebral + subarachnoid
  • other: dissection, venous sinus thrombosis, hypoxic brain injury
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5
Q

Emergency management of stroke

A
  • are they within the window for thrombolysis (<4 hours)?
  • CT head to determine if bleed
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6
Q

Imaging of stroke

A

Non contrast CT head
MRI

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7
Q

Stroke symptoms of anterior cerebral artery infarction

A
  • contralateral weakness in lower limb (supplies medial homonculus)
  • contralateral sensory changes in same pattern as motor deficits
  • urinary incontinence
  • apraxia
  • dysarthria/aphasia
  • split brain syndrome/alien hand syndrome
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8
Q

What is apraxia?

A

Inability to complete normal day to day motor tasks
e.g. difficulty dressing oneself (buttons) even when power is normal

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9
Q

Why can anterior cerebral artery infarction cause urinary incontinence?

A

Paracentral lobule affected
Controls motor + sensory innervations to contralateral lower extremity > responsible for control of urination + defecations

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10
Q

Main points of occulsion of the middle cerebral artery

A
  • Main stem (proximal)
  • Lenticulostriate arteries
  • Cortical branches
  • Inferior division
  • Superior division
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11
Q

Stroke symptoms due to proximal middle cerebral artery infarct

A
  • contralateral hemiparesis of face, arm + leg
  • contralateral sensory loss
  • contralateral homonymous hemianopia without macular sparing
  • global aphasia (broca’s + wenicke’s) if left sided
  • right sided neglect if right sided
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12
Q

What is alien hand syndrome?

A

A phenomenon in which one hand is not under control of the mind /hand acts as if it has a mind of its own

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13
Q

Types of stroke symptoms due to lenticulostriate arteries infarct (lacunar infarct)

A
  • neglect, aphasia + visual field defects not present
  • pure motor stroke: face, arm + legs weakness
  • pure sensory stroke face, arm + legs sensory loss/change
  • sensorimotor stroke: mixture of both
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14
Q

Difference between lacunar infarct + proximal middle cerebral artery infarct symptoms

A

Neglect, aphasia + visual field defect absent in lacunar infarct

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15
Q

Stroke symptoms of inferior division of middle cerebral artery infarct

A
  • inferior division supplies lateral parietal + superior temporal lobe
  • contralateral sensory change in face + arms
  • receptive/Wernicke’s aphasia if left sided
  • homonymous hemianopia
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16
Q

What artery is most common affected in strokes?

A

Middle cerebral artery

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17
Q

What does the inferior division of middle cerebral artery supply?

A

Lateral parietal - primary sensory cortex
Superior temporal lobe - Wenicke’s area

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18
Q

What does the superior division of the middle cerebral artery supply?

A

Lateral frontal lobe - Broca’s area

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19
Q

Stroke symptoms due to superior division of middle cerebral artery infarct

A
  • contralateral face + arm weakness
  • expressive/Broca’s aphasia if left sided
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20
Q

Stroke symptoms due to posterior cerebral artery infarct

A
  • contralateral homonymous hemianopia with macular sparing
  • contralateral sensory loss/change due to involvement of thalamoperforator/thalamogeniculate branches
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21
Q

Symptoms + signs of cerebellar strokes

A
  • N + V
  • vertigo/dizziness
  • headache
  • ipsilateral cerebellar signs DANISH
  • ipsilateral cranial nerve signs
  • contralateral sensory deficit
  • ipsilateral Horner’s syndrome
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22
Q

What supplies the internal capsule?

A

Lenticulostriate arteries

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23
Q

What is neglect?

A

Failure to acknowledge the existence of the left side of space, objects + their own body

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24
Q

Signs of neglect

A

Tactile + visual extinction
Anosognosia/lack of insight

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25
Why can a basilar artery occulsion cause sudden death?
Supplies brainstem which contains many vital centres
26
Presentation of distal (superior) basilar artery infract
- visual + oculomotor deficits - behavioural abnormalities - hallucinations, somnolence + dreamlike behaviour
27
Why is motor dysfunction usually absent in basilar artery occlusion?
Cerebral peduncles ‘rescued’ by posterior communicating artery
28
Presentation of proximal (at level of pontine branches) basilar artery infract
- locked in syndrome - complete loss of movement of limbs - preserved ocular movement due to Pcomm supply - preserved consciousness
29
What is used to classify strokes?
Bamford (oxford) stroke classification
30
Presentation of brainstem strokes
Ipsilateral brainstem signs Contralateral motor + sensory deficits
31
What cranial nerve is at risk in a posterior communicating artery aneurysm?
**Oculomotor** Runs parallel
32
What is anosogonsia?
Condition in which a patients is unaware of their neurological deficit or psychiatric condition **Lack of insight**
33
Outline the Oxford Community Stroke Project Classification
**TACS** - total anterior circulation syndrome **PACS** - partial anterior circulation syndrome **POCS** - posterior circulation syndrome **LACS** - lacunar syndrome
34
Outline TACs - total anterior circulation syndrome
- middle cerebral or internal carotid artery occlusion - hemiparesis AND - higher cortical dysfunction *e.g. dysphasia* AND - homonymous hemianopia
35
Outline PACS - partial anterior circulation syndrome
- branch of middle cerebral artery occlusion - isolated higher cortical dysfunction OR - any two of: hemiparesis, higher cortical dysfunction, hemianopia
36
Outline POCS - posterior circulation syndrome
- occulsion of vertebral, basilar, cerebellar or posterior cerebral artery - isolated hemianopia, brainstem or cerebellar syndrome (DANISH)
37
Outline LACS - lacunar syndrome
- occulsion of lenticulostriate branches of MCA - pure motor stroke OR - pure sensory stroke OR - sensorimotor stroke OR - ataxic hemiparesis OR - clumsy hand dysarthria
38
What is clumsy hand dysarthria?
- **Clumsy hand**: poorly coordinated hand moments, especially during fine motor tasks *e.g. buttoning shirt* - **Dysarthria**: difficulty speaking clearly
39
What are common stroke mimics?
- seizures - sepsis - syncope - vertigo - dementia - migraine with aura - space occupying lesion
40
What is capsular warning syndrome?
- Neurological emergency - Repeated episodes of motor weakness on one side of the body - warning signs of impending large stroke
41
Treatment of capsular warning syndrome
- dual anti platelet therapy *e.g. aspirin + clopidogrel* - BP control - statins - close neurological monitoring
42
Stroke complications -
- recurrent stroke - complications from immobility *e.g. bed sores, VTE, constipation* - raised ICP - infections - mood changes - post stroke fatigue - post stroke pain - spasticity + contractures - secondary epilepsy
43
What are the four ‘ages’ of an infarct>?
- **hyperacute**: 6 hours - **acute**: up to 7 days - **subacute**: up to 4 months - **chronic**: after 4 months
44
Risk factors of ischaemic stroke
- AF - HTN - ischaemic heart disease - high cholesterol - diabetes - smoking - alcoholexcess
45
Investigations of ischaemic stroke
- **bloods**: FBC, ESR, U&Es, LFTs, lipids, glucose - **ECG** - **carotid doppler** - **transthoracic echo** - **head CT/MRI**
46
Appearance of ischaemic stroke on head imaging -
- may be normal initially - hyperdense MCA - loss of grey matter differentiation - hypodense later on
47
Management of ischaemic strokes
- **IV thrombolysis with alteplase** if within 4.5 hours of first symptom - 300mg aspirin OD for 2 weeks then clopidogrel 75mg OD - BP lowered to <185/110mmHg before thrombolysis - mechanical thrombectomy if within 6 hours of onset + large vessel occulsion
48
standard criteria for thrombolyhsis with alteplase/tenecteplase in ischaemic stroke
- administered within 4.5 hours of onset of stroke symptoms - haemorrhage has been definitively excluded (imaging has been done)
49
Contraindications to thrombolysis
**Absolute**: - previous intracranial haemorrhage - seizure at onset of stroke - intracranial neoplasms - suspected subarachnoid haemorrhage - GI haemorrhage in last 3 weeks - active bleeding - oesophageal varices - uncontrolled HTN >200/120mmHg . **Relative**: - pregnancy - major surgery in last 2 weeks - active diabetic haemorrhagic retinopathy
50
Thrombolysis complications
- anaphylaxis/ADR - extracerebral haemorrhage > drop in BP, malaena, distended abdomen - intracerebral haemorrhage > rise in BP, N+V, raised ICP, seizures, neurological decline
51
Secondary prevention of ischaemic stroke
- **clopidogrel** - aspirin if contrainidcated - carotid endarterectomy if stroke or TIA occurred in carotid territory if stenosis >50% - atorvastatin - proper diabetic control - smplomg cessation - weight loss
52
Risk factors for haemorrhagic stroke
- increasing age - HTN - arteriovenous malformation - blood thinners
53
Subtypes of intracranial haemorrhage
- intracerebral haemorrhage - subarachnoid haemorrhage
54
Although symptoms of ischaemic + haemorrhagic strokes are similar. What features make haemorrhagic stroke more likely?
- decreased level of consciousness - headache - N+V - seizures
55
Management of haemorrhagic stroke
- advice from neurosurgeons - stop anticoagulants + antithrombic meds - reversal of anticoagulants - lower BP
56
Complications of intracranial haemorrhage
- effacement of ventricles - displacement of ventricles - midline shift - hydrocephalus - cerebral herniation - raised ICP
57
What assessment tool can be used to assess stroke severity?
**NIHSS** - national institute of health stroke scale
58
what score can be used to differentitate between strokes + stroke mimics?
Rosier scale
59
what score is used for stroke risk assessment after a TIA?
ABCD2 score
60
outline the ABCD2 score
score for stroke risk assessment after TIA - **A**ge: >60years (1) - **B**lood pressure: Systolic >140 OR diastolic >90 (1) - **C**linical features of TIA: uniteral weakness +/- speech impairment (2) OR speech impairment without unilateral weakness (1) - **D**uration: >60 mins (2) or <60 mins (1) - **D**iabetes (1)
61
outline the ASPECTS score
- Alberta Stroke Programme Early CT Score - 10 point quantitative CT scan used to score pt with MCA stroke - Segmental assessment of MCA vascular territory is made - 1 point deducted from 10 for every region involved - used in revascularisation therapies + outcome predictions
62
outline the modified Rankin score
- measure of global disability used to assess baseline function + evaluate treatment impact after intervention - Fill in more if need to know
63
what are the 5 Rs of rehab
- **Realisation of Potential** - **Re-ablement**: to maximise functional independence - **Resettlement**: to provide safe transfer of care - **Role fulfilment**: to establish personal autonomy - **Readjustment**: to adapt to new lifestyle
64
Good stroke rehabilitation prognostic factors
- absence of coma - early motor recovery - continence
65
Poor stroke rehabilitation prognostic factors
- severe communication deficit - old age - incontinence - neglect - no leg movement at 2 weeks - severe upper limb weakness at 4 weeks
66
when should post stroke patients be considered for gastrostomy feeding?
- unable to tolerate NG tube feeding - unable to swallow adequate food + fluids orally by 4 weeks post stroke
67
management of incontinence
- time toileting - review caffeine intake - medication review - bladder retraining - pelvic floor exercises - laxatives
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