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Stroke 2 Flashcards

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1
Q

What happens in a Stroke on a cellular level?

A
  • Hypoperfusion in the endothelial lumen which eventually results in depletion of available ATP and impairment of energy dependant cell processes
  • The lack of ATP means there is a drop in the Action Potentials which leads to an absence of neuronal transmission
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2
Q

What are the features of a typical stroke syndrome event?

A
  • Evolves Suddenly ( reflecting the phase transition of AP cessation
  • Focal (only neurovascular units in the concerned vascular territory are affected)
  • Predominately negative ( reflecting the loss of function that attends AP cessation)
  • Fits into a Vascular territory
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3
Q

What features are NOT seen in a stroke syndrome event?

A
  • Isolated presentation
  • Migration (especially slow of symptoms)
  • Stereotyping ( defined as episodic recurrence of neurological disturbance in an identical fashion with complete resolution in between)
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4
Q

When there is evidence of stereotyping what stroke mimics is the event likely to be?

A
  • Migranous Aura
  • Focal Seizures
  • Functional Neurological Episodes
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5
Q

What stroke syndromes can present with something similar to stereotyping?

A
  • Capsular Warning Syndrome ( not true stereotyping but fluctuation of symptoms, with episodes usually recurrent over minutes to hours)
  • Intracranial Stenosis ( focal symptoms usually coincide with other evidence of generalised hypoperfusion - dizziness)
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6
Q

What is it called when the causes of stroke remains unclear after assessment?

A
  • Cryptogenic Stroke
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7
Q

What is the typical cause of a PACS presentation?

A
  • Embolisation
  • Cardiac Emboli determined if the patient has atrial fibrillation, cardiomegaly, valvular heart disease, heart failure, endocarditis or following an acute MI
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8
Q

What are some of the sources of a Large Embolic Source?

A
  • Carotid bruits
  • Peripheral Vascular disease
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9
Q

What would you suspect in a patient who is hypertensive or diabetic with a LACS presentation?

A
  • Fribrinolytic necrosis
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10
Q

What would you suspect in an elderly lady with a few months of headache, weight loss, lethargy, pallor, temporal arteritis and past medical history of SLE (systemic lupus erythematosus) ?

A
  • Vasculitis
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11
Q

What would you suspect in a pregnant stroke patients/ patient with previous VTE, miscarriages or active cancer?

A
  • Thrombophillia
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12
Q

What would you suspect in historical evidence of recent local neck trauma?

A
  • Dissection
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13
Q

What are some of the common post- stroke complications?

A
  • Recurrent Stoke and Extension of Stroke ( Extension of stroke - loss of ischaemic penumbra)
  • Raised ICP ( haematoma expansion, malignant oedema, haemorrhagic transformation or hydrocephalus)
  • Infections (common chest infections - aspiration, UTIs - incomplete bladder emptying, constipation - supine/ bed bound posture)
  • Complications of immobility ( VTE, constipation and bed sores)
  • Mood and Cognitive dysfunction
  • Post stroke pain and fatigue (joint dislocation, central/neuropathic pain, poor sleep - result of brain cell damage)
  • Spasticity, Contractures and Secondary Epilepsy
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14
Q

What is important in the “Stroke Bundle” for patients?

A
  1. Admission to the stroke unit
  2. Revascularisation therapy
  3. Optimising Physiology (surveillance, prevention and early intervention of complications) and nutritional support
  4. Secondary Prevention
  5. Rehabilitation and Reablement
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15
Q

What determines the recovery of the patient and how well the patient will do?

A
  • The recovery trajectory as this reflects the neuroplasticity at the site of neuronal damage
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16
Q

What are the three types of recovery trajectories?

A
  • Early, high functioning plateau ( TIA/ minor stroke)
  • Early, low functioning plateau ( TACS - no meaningful improvement in function as time passes)
  • Delayed and medium functioning plateau ( most people after a stroke, patients will benefit from a chance at sustained rehabilitation efforts until a functional plateau is achieved)
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17
Q

What is the definition of a Stroke?

A
  • A cerebrovascular accident is a serious life threatening condition that occurs when the blood supply to part of the brain is cut off
  • The symptoms and signs persist for more than 24 hours
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18
Q

What is a TIA?

A
  • A Transient ischaemic attack known as a mini stroke, it has similar clinical features of a stroke but completely resolve within 24 hours
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19
Q

What are the types of Stroke?

A
  • Ischaemic (thromboembolic)
  • Haemorrhagic (intracerebral, subarachnoid)
  • Other (dissection, venous sinus thrombosis, hypoxic brain injury)
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20
Q

What are the symptoms of ACA infarct (Anterior Cerebral Artery)?

A
  • Contralateral weakness in lower limb (Lower limb affected much worse than upper limb and face)
  • Contralateral sensory changes in same pattern as motor deficits
  • Urinary Incontinence due to paracentral lobules being affected ( paracentral lobules - essentially the most medial part of the motor/ sensory cortices and supply the perineal area)
  • Apraxia ( damage to the left frontal lobe, Inability to complete motor planning - difficulty dressing oneself even when the power is normal)
  • Dysarthria/ Aphasia ( unusual sign)
  • Split brain syndrome/ Alien hand syndrome - involvement of the corpus callosum, normally supplied by the ACA
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21
Q

What are the symptoms of a complete MCA infarct?

A
  • Contralateral full hemiparesis ( face, arm and leg affected due to the involvement of the internal capsule)
  • Contralateral sensory loss
  • Visual Field Defects ( Contralateral homonymous hemianopia without macular sparing - due to destruction of both superior and inferior optic radiations running through the temporal and parietal lobes)
  • Aphasia (usually left hemisphere)
  • Contralateral neglect ( can not acknowledge one side of the body. Features include: Tactile extinction (touch isn’t felt on one side), Visual extinction ( half clock face), Anosognosia ( does not acknowledge that they have had a stroke)
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22
Q

What are the features of Lenticulostriate Arteries Occluded?

A
  • Pure motor
  • Pure sensory
  • Sensorimotor
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23
Q

What are the features of a distal superior MCA branch?

A
  • Lateral frontal lobe
  • Primary motor cortex + Broca’s area = Contralateral face and arm weakness and expressive aphasia
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24
Q

What are the features of a distal inferior MCA branch?

A
  • Lateral parietal lobe and superior temporal lobe
  • Primary sensory cortex + Wernicke’s area + both optic radiations
  • Contralateral sensory change
  • Receptive aphasia
  • Contralateral visual field defects without macular sparing
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25
What are the features of a PCA (posterior cerebral artery) Stroke?
- Contralateral homonymous hemianopia (macular sparing due to collateral supply of MCA) - Contralateral sensory loss due to damage to the thalamus
26
What are the features of a Cerebellar Infarct?
- Symptoms: N+V, Headache & Vertigo/ Dizziness - Ipsilateral Cerebellar Signs ( Dysdiadochokinesia, Ataxia, Nystagmus, Intention Tremor, Slurred, Staccato Speech and Hypotonia) - Contralateral sensory deficit/ ipsilateral Horner's Syndrome
27
What are the features of a Distal Basilar Artery Stroke?
- Visual & Oculomotor deficits - Behavioural abnormalities - Somnolence, Hallucinations and Dreamlike behaviours
28
What are the features of Proximal Basilar Artery Stroke?
- Pontine Branches - Locked in Syndrome - Complete loss of movement
29
What are the two main causes of Stroke?
- Ischaemic (occlusion of blood vessels that supply the brain parenchyma leading to infarction) - Haemorrhagic (result of bleeding within the brain parenchyma, ventricular system or subarachnoid space)
30
What are the risk factors for Stroke?
- Smoking - DM - Hypertension - High Cholesterol - Obesity - Atrial Fibrillation - Carotid Artery Disease - Age - Thrombophilic disorders (antiphospholipid syndrome) - Sickle Cell Disease
31
What are the causes of Ischaemic Stroke?
- Thrombosis - blockage due to atherosclerosis, worsened by CVS risk factors (hypertension, smoking) or small vessel disease (vasculitis, Sickle Cell) - Emboli - propagation of a blood clot that leads to acute obstruction and ischaemia, typically due to atrial fibrillation or carotid artery disease - Dissection
32
What are the causes of Haemorrhagic Stroke?
- Hypertension - Vascular malformations ( arteriovenous malformation, ateriovenous fistula, brain tumour, vasculitis or a bleeding disorder), even trauma
33
What are the cerebral vessels?
- Anterior Cerebral Artery (frontal and parietal lobe) - Middle Cerebral Artery (lateral surface of each brain hemisphere including the internal capsule and basal ganglia - Posterior Cerebral Artery (occipital lobe and inferior portion of the temporal lobe and the thalamus)
34
What is a TACS?
- Total Anterior Circulation Stroke - Vessel: ACA or MCA - 3/3: 1. Unilateral weakness +/- sensory deficit within the face 2. Homonymous Hemianopia 3. Higher Cerebral Dysfunction
35
What is a PACS?
- Partial Anterior Circulation Stroke - Vessel: ACA or MCA - 2/3:1. Unilateral weakness +/- sensory deficit within the face 2. Homonymous Hemianopia 3. Higher Cerebral Dysfunction
36
What is a Lacunar Stroke?
- Vessel: Deep perforating arteries - 1. Pure motor hemiparesis - 2. Pure sensory - 3. Ataxic hemiparesis - 4. Dysarthria-clumsy hand syndrome - 5. Sensorimotor
37
What is a POCS?
- Vessel: Vertebrobasilar arteries - 1. Brainstem or Cerebellar Syndrome 2. Loss of consciousness 3. Isolated Homonymous Hemianopia
38
How do you make a Diagnosis of Stroke?
- The FAST test is used in the community to quickly screen patients who require urgent transfer to a hyperacute stroke unit (HASU) - New facial weakness, New arm weakness, New speech difficulty - The NIHSS score: a scoring system out of 42 which has been designed as a predictive score of clinical outcome in stroke. A score <4 is associated with a good clinical outcome. A high score >22 indicates significant proportion of the brain is affected by ischaemia. A score >26 is a contraindication to thrombolysis
39
What Investigations do you do for Stroke?
- CT HEAD (shows a cerebral haemorrhage, may be normal in the first few hours for an infarct - Bedside: Obs, BG, ECG (A fib) - Bloods: FBC, U+E, Bone Profile, LFT, ESR, Coagulation, Lipid Profile, HbA1c - Imaging: CT head +/- CT angiography +/- diffuse weighted MRI head - Special: ECHO, Carotid dopplers, 24 hour tape, young stroke screen -
40
What is the management for a Haemorrhagic Stroke?
- Decompressive Hemicraniectomy
41
What is the managment for an Ischaemic Stroke?
- Thrombolysis (alteplase) - Within 4.5 hours (thrombolysis window) - Contraindications: neurosurgery last 3 months, active internal bleeding - If thrombolysis is not appropriate then the patient should be started on 300mg aspiring for 2 weeks, this is then converted to 75mg clopidogrel unless a NOAC is appropriate because of A Fib - Thrombectomy: removal of thrombus from a vessel. Mechanical thrombectomy can be completed in specialist centres by the interventional neuroradiology team it can be combined with thrombolysis
42
What is the ongoing managment for Stroke?
- Hyperacute Stroke Unit - BP control - BG control - Anti-lipid therapy - Anti-platelet/ anti-coagulation - Carotid artery assessment - Swallow and Nutrition assessment (consider NG tube within 24 hours) - Left Atrial Appendage Closure: This is an option for stroke secondary prevention in patients for AF in whom anticoagulation is contraindicated - Rehabilitation - Palliative care
43
What is a Malignant MCA infarction?
- A term to describe rapid neurological deterioration due to cerebral oedema following an MCA
44
What is the advice regarding Driving?
- It is vital to advise all patients who have had a stroke to stop driving - Cars and Motorcycles: stop driving for one month - inform DVLA if ongoing symptoms after one month - Larger Vehicles (buses and lorries): stop driving and inform the DVLA
45
What is ASPECTS?
- The Alberta Stroke Programme early CT score - This is a 10 point quantitative CT scan score used in patients with MCA stroke - A segmental assessment of the MCA vascular territory is made and 1 point is deducted from the initial score of 10 for every region involved
46
What is OCSP Classification?
- The Oxfordshire Community Stroke Project - LACO - PACO - TACO - POCO
47
What is the Modified Rankin Scale?
- Measure of global disability used to assess baseline function and evaluate outcomes and treatment impact after interventions 0 - no symptoms 1 - no significant disability, able to carry out all usual activities, despite some symptoms 2 - Slight disability. Able to look after own affairs but unable to carry out all previous activities 3 - Moderate disability. Requires some help, but able to walk unassisted 4 - Moderately severe disability. Unable to attend to own bodily needs without assistance. Unable to walk unassisted 5 - Severe disability. Requires constant nursing care and attention, bedridden and incontinent. 6 - Dead
48
What are the scores to determine anti-coagulation after A fib?
- CHA2DS2VASc and HAS-BLED tools
49
What is the assessment tool used after a TIA?
- ABCD2 score for stroke risk assessment after a TIA - Age >60 (1 point) - BP systolic >140 OR diastolic >90 (1 point) - Clinical features: unilateral weakness with/without speech impairment (2 points) OR speech impairment without unilateral weakness (1 point) - Duration: TIA duration > 60 mins (2 points) OR TIA duration 10-59 (1 point) - Diabetes (2 points)
50
Which patients require an urgent review within 24 hours after a TIA?
- ABCD2 >4 - Multiple TIA (>2 in previous 7 days) - Patients in A fib or on anticoagulants
51
What are common stroke mimics that are readily recognised on imaging? After a contrast enhanced CT
- Brain space occupying lesions - MS - Subdural Haematoma -
52
What are common stroke mimics that have non-stroke features which allow a secure diagnosis on clinical grounds?
- BPPV - Vestibular Neuronitis - Syncope Syndrome - Transient global amnesia
53
What are common stroke mimics where features are similar and can be subtle and justify specialist assessment including clinical opinion and additional investigations?
- Complicated migraines with aura - Focal seizures - Functional syndrome - Amyloid spells
54
What is apparent neurological deficit?
- Neurological dysfunction in patients with chronic stroke and residual areas of scar tissue at the site of previous brain damage - Symptoms can return due to underperformance of the gliotic tissue in the context of suboptimal physiology as in infection, low BP, low glucose, hypoxia and fatigue
55
What are the hallmark signs of early cerebral ischaemia on CT scan?
- Hyperdense artery sign - corresponds to the responsible arterial clot - low density in the grey and white matter of the territory
56
Why would you not lower BP in the acute management of a stroke?
- As lowering blood flow too much can potentially compromise collateral blood flow to the affected region
57
What are some of the reasons why you would lower blood pressure in an acute setting of a stroke?
- Hypertensive Nephropathy - Hypertensive Encephalopathy - Hypertensive MI/ cardiac failure - Pre-eclampsia - Aortic dissection
58
Why should patients undergoing thrombolysis have their blood pressure lowered and what should the level be lowered to?
- 185/110 - After thrombolysis BP should be maintained at 180/105 for 24 hours
59
What is some more information on the managment of patients in the acute stroke setting?
- Fluid Management - Glycaemic Control - Blood Pressure Management - Feeding Assessment + Management: SALT review within 24 hours - NBM until then. NG tube if unsafe swallow and medications converted to a subcutaneous/ IV form - Disability Scales: Barthel Index, this is an outcome measure for stroke, you have to describe 10 tasks and you are scored based on the amount of time or assistance required by the patient for each given task
60
What would you see on a CT scan for an acute haemorrhagic stroke?
- hyperdense material e.g. blood
61
What are the symptoms of Lateral Medullary Syndrome?
- Posterior Inferior Cerebellar Artery is affected -ipsilateral: Ataxia, Nystagmus, Dysphagia, facial numbness and Horner's Syndrome - contralateral: limb sensory loss
62
What are the symptoms of Weber's Syndrome?
- Ipsilateral III palsy - Contralateral weakness
63
How does a Pontine Haemorrhage present with?
- Reduced GCS - Paralysis - Bilateral Pin point pupils
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