pipi&pi3 > * Stroke & Epilepsy > Flashcards

* Stroke & Epilepsy Flashcards

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1
Q

What are neurological disorders?

A

Disorders of the brain, spinal cord and nerves

Classified into:
1) CNS disorders
2) PNS disorders
3) Blood vessel disorders
4) Tissue and muscle disorders

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2
Q

What are the possible causes of neurological disorders?

A
  • Injury, trauma
  • Infections
  • Immunity conditions (eg myasthenia gravis)
  • Inherited genetic abnormalities
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3
Q

What are the common neurological disorders / diagnosis?

A
  • Cerebral vascular attack (CVA) ie stroke (3 types)
  • Traumatic brain injury
  • Brain infection
  • Epilepsy/seizure
  • Headache disorders
  • Degenerative disorders
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4
Q

What are the 3 types of stroke?

A
  • Transient ischemic attack (TIA)
    ~ Temporary disruption of blood flow to the brain -> temporary loss of neurological function
    ~ Blockage eventually gets removed on its own
    ~ <24 hours
    ~ No permanent damage on the brain yet but could be a sign of progressing disease
  • Ischemic stroke
    ~ Clot in the brain stops blood supply to that area, causing hypoxia
    ~ >24 hours
  • Hemorrhagic stroke
    ~ Blood leaking into brain tissue due to rupture of blood vessels
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5
Q

What are the symptoms of stroke?

A

FAST (Face, Arm weakness, Speech problems, Time to call 999)

  • Sudden weakness of one side of the body (severity/reach of sensory loss varies p2p)
  • Loss of sensation to touch
  • Sudden blurred vision or loss of sight
  • Sudden, severe headache
  • Facial drooping
  • Uneven smile
  • Inability to answer questions but ability to understand them (Difficulty in answering complete sentences)
  • Slurred speech
  • Ability to write down thoughts more easily than speaking them
  • Higher functions (eg memory, speech) affected depending on part of brain injured
  • Sudden memory loss or confusion, dizziness or sudden fall
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6
Q

What are the risk factors of stroke?

A
  • Male gender (females usually protected by certain hormones until menopause)
  • Age, race, heredity
  • Hypertension
  • Diabetes
  • HLD
  • Vices
  • Obesity
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7
Q

What are the factors affecting stroke?

A

1) Extra-cranial factors (outside brain, systemic)
- Systemic blood pressure (MAP)
- Cardiac output
~ High/low output cardiac failure
- Viscosity of blood
~ More viscous -> Flows slowly -> Increased risk of clots

2) Intracranial factors
- Intracranial pressure
- Atherosclerosis in blood vessels
- Injury to blood vessels in brain

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8
Q

What are the symptoms of TIA?

A

If carotid arteries are involved:
- Transient loss of vision on one eye
- Hemiparesis
- Inability to speak

If vertebrobasilar arteries are involved:
- Tinnitus
- Vertigo and blurred vision
- Hemiparesis

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9
Q

What is an infarction?

A

A small, localised area of dead tissue resulting from failure of blood supply/ischemia for more than a few minutes

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10
Q

What are the 2 causes of ischemic stroke?

A

1) Thrombotic
- Due to atherosclerotic plaque -> most dangerous
- Large vessel injury (eg Middle Cerebral Artery/MCA infarct)
- Small vessel injury (Lacunar infarct) –> S/s milder
- Blood disorders (eg thrombocytosis, polycythemia)

2) Embolic
- Dislodgement of blood clots from other parts of the body
- Carotid plaque (carotid artery link heart to brain)
- Atrial fibrillation
- Atherosclerotic plaques

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11
Q

How does atrial fibrillation lead to stroke?

A
  • Atria beat irregularly and often rapidly, which can cause them to quiver rather than contract effectively -> prevents the atria from fully emptying their blood into the ventricles
    ~ Because the atria aren’t contracting properly, blood can pool in the atria -> increases the risk of blood clot formation
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12
Q

What causes the difference in s/s in ischemic stroke?

A
  • Site of obstruction
    ~ Brain area supplied by the affected artery
  • State of circulation
    ~ Presence of good arteries in the adjacent area may provide collateral circulation
  • Onset
    ~ Sudden, during exertion (embolism)
    ~ Slow, during rest time (thrombosis)
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13
Q

What is the pathophysiology of ischemic stroke?

A
  • Reduced blood flow in arteries due to thrombosis or embolism -> deprives cells of O2 and glucose
    ~ Lack of energy causes membrane dysfunction and entry of ions -> cytotoxic edema then death of cells
    ~ Vascular changes aggravate edema

Progression in brain
- Ischemia in one area -> moves on to penumbra (surrounding of stroke area) which remains viable for several hours after ischemic attack due to COLLATERAL ARTERIES supplying it
~ After some time, extent of penumbra decreases
- Ischemia and inflammation damages the BBB, allowing proteins and fluid to leak from `blood vessels into brain tissue (vasogenic edema)
~ ^ ICP and compresses brain structures further

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14
Q

What are the arteries in the brain that can be affected and cause ischemic stroke?

A

1) Anterior cerebral artery (in medial aspect of frontal lobes)

2) Middle cerebral artery (in most of the lateral cerebral hemisphere)

3) Posterior cerebral artery (in occipital lobe and medial aspect of temporal lobe)

4) Vertebro-basilar territory (group of arteries supplies parts of the posterior brain, including cerebellum)

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15
Q

What are the s/s for ischemic stroke when ACA is affected?

A

Superficial branches:
- Confusion, disorientation (prefrontal lobe)
- Paralysis and sensory loss in OPPOSITE leg
- Apraxia (difficulty with motor planning to perform tasks or movement)
- Abulia (lack of will or initiative, lack of motivation)
- Urinary incontinence

Deep branches:
- Well tolerated due to collateral flow

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16
Q

What are the s/s for ischemic stroke when MCA is affected?

A

Superficial branches:
- Paralysis of face and hand
- Conjugate gaze paralysis
- Motor aphasia (left-sided stroke)

  • Conduction or sensory aphasia
  • Construction of dressing apraxia

Deep branches:
- Paralysis of opposite side

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17
Q

What are the s/s for ischemic stroke when PCA is affected?

A

Superficial:
- Vision loss
- Memory loss
- Agraphia (impaired writing ability, either due to language or motor problems)

Deep:
- Thalamic syndromes

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18
Q

What are the s/s for ischemic stroke when vertebro-basilar territory is affected?

A
  • Ataxia
  • Intention tremor (low-frequency tremor that affects fine motor movements)
  • Incoordination
  • Cerebellar dysfunction

If brain lesion present:
- Crossed paralysis and sensory loss

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19
Q

What are the characteristics of cerebellar dysfunction?

A
  • Ipsilateral lesion (affected side on the same side of cerebral lesion)
  • Cerebellar ataxia
    ~ Wide-based staggering unstead gait - tends to fall on side side as lesion
    ~ Truncal ataxia
  • Intention tremor
    ~ Incoordination of arm and leg (despite voluntary)
    ~ Worse when approaching target
    ~ Finger-nose test, heel-shin test
  • Dysmetria
    ~ Error in judging distance -> overshooting
    ~ May be accompanied by tremor
  • Rebound phenomenon
    ~ Difficulty in stopping movement when resistance is withdrawn suddenly
  • Dysdiadochokinesia
    ~ Inability to perform rapid alternating opposite movement
    ~ eg Pronation-supination, ankle flexion-extension
  • Decomposition of movements
    ~ Inability to perform actions that may involve more than one joint simultaneously
    ~ Movement appears robotic
  • Nystagmus
    ~ Rapid uncontrollable eye movements
  • Scanning speech
    ~ Words are broken into many component sounds (staccato speech)
  • Hypotonia
    ~ Decreased muscle tone
  • Asthenia
    ~ Muscles are weaker and tire more easily than normal muscles
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20
Q

What are the different s/s in right vs left brain damage?

A

Right:
- Paralysed left side
- Spatial-perceptual deficits
- Quick and impulsive
- Memory deficits in performance
- Indifference to disability

Left:
- Paralysed right side
- Speech-language deficits
- Slow and cautious
- Memory deficits in language
- Distress and depression in relation to disability

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21
Q

What is the general treatment for ischemic stroke?

A
  • Tissue Plasminogen Activator (tPA)
  • Anticoagulant and antiplatelet therapy
  • Carotid endarterectomy
    ~ Surgically remove plaque
  • Balloon angioplasty/stents
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22
Q

What are the 2 main locations of hemorrhagic stroke?

Study These Flashcards
A

1) Intracerebral
- Bleeding within the brain
- Occurs without warning
- Caused by
~ Hypertension
~ Thrombolytic drugs (tf need to stop ASAP or bleeding will continue)

2) Subarachnoid
- Bleeding in subarachnoid space
- SEVERE “thunderclap” headache
- Vomiting
- Associated with activities/exertion
- May occur after traumatic brain injury which is usually venous in nature
- From saccular aneurysm rupture of cerebral arteries (arterial bleed)

23
Q

What are the less common regions of hemorrhagic stroke?

Study These Flashcards
A

1) Ganglionic hemorrhage
- Contralateral hemiplagia
- Worsens to drowsiness and come

2) Thalamic hemorrhage
- Contralateral hemiplagia
- Involvement of 3rd nerve (eye)

3) Pontine hemorrhage
- Quadriplagia
- Pin-point pupils (unusually small)
- Death

4) Cerebellar hemorrhage
- Ataxia
- Altered sensorium
- Death

5) Saccular/Berry aneurysms
- Congenital
- Rupture occurs in adolescence
- Usually occurs in the Circle of Willis

24
Q

What is the pathophysiology of hemorrhagic stroke?

Study These Flashcards
A
  • Expanding blood clot destroys brain tissue -> space-occupying lesion that inc ICP
    ~ High ICP affects cerebral perfusion
    ~ High ICP in one compartment may displace structures and cause herniation
  • Brain stem compression causes death
25
What are the complications of a major rupture in hemorrhagic stroke?
1) Vasospasm - Presence of blood may irritate one or more arteries - Vasospasm and ischemia in 1-2 weeks 2) Hydrocephalus - Blockage of reabsorption of CSF - Inc ICP 3) Higher chances of rerupture 4) Severe headache Usually no focal deficits (problems with nerve, spinal cord, or brain function affecting a specific location)
26
What is the pre and post medical management of hemorrhagic stroke?
- Stop anti-PLT and anticoagulation meds (if any) - Reverse antithrombotic effect - Maintain BP ~ ICH: 120-160 SBP ~ SAH: 80-130 MAP - Control ICP (CCP=MAP - ICP) - CBG 6 -10 mmol/L - Monitor neurological condition - Prevent vasospasm post-op ~ NIMODIPINE vasodilator - Prevent seizures ~ PHENYTOIN or VALPROATE
27
What is the treatment for hemorrhagic stroke?
- External ventricle drainage (EVD) ~ Only if px has inc ICP following SAH ~ When hydrocephalus is present - Clipping of aneurysm ~ Secondary prevention of re-bleeding - Coiling of aneurysm ~ Helps aneurysm to shrink and not rupture
28
What are the general assessments / actions in A&E?
- ABC ~ Airway, Breathing, Circulation - Vital signs - Provide oxygen if hypoxemic - Obtain IV access - Check CBG and treat if hypoglycemic - Obtain other blood samples if needed - Obtain 12-lead ECG - Perform GCS / NIHSS - CT scan/MRI - Determine last known well time ~ Impt in diagnosing TIA ( 24 hrs) ~ Helps in therapeutic management
29
What are the main components of the Glasgow Coma Scale (GCS) and what is the danger range?
1) Eye opening response (Spontaneous, to voice, to touch/pain, no eye opening) 2) Verbal response (Oriented, confused, inappropriate words, incomprehensible sounds, none) 3) Motor response (Obeys command, localises pain, withdraws from pain, flexion, extension to pain, none) Scores (3-15) - Minor brain injury 13-15 - Moderate 9 -12 - Severe 3-8 (may need to protect airway)
30
What does it mean to protect the px airway during a stroke?
- Monitor consciousness (as px is unable to swallow/cough -> inc risk of aspiration) - Ensuring patency (may need to use OPA) - Preventing aspiration (through positioning, suctioning etc) - Swallowing assessment - Oxygenation
31
What are the components of the National Institute of Health Stroke Scale (NIHSS)
- Assesses for stroke severity - Assesses 13 areas of the brain Score (0-42) - More points -> worse function and outcome Components - Level of consciousness - LOC - Best gaze - Visual fields - Facial paresis - Motor arm / leg - Limb ataxia (involuntary movements) - Sensory - Best language - Dysarthria (physical production of speech, rather than the formation of thoughts or ideas) - Extinction and inattention
32
What are the diagnostic tests for stroke?
Imaging tests - Brain CT - MRI - Angiogram Blood flowing tests (esp in cases of embolic stroke) - Carotid ultrasound - 2D echo (to locate clots within the left atrium) Electrical activity tests - EEG (to see if px is susceptible to seizures)
33
How do you interpret a CT scan?
Recent hemorrhages (indicates hemorrhagic stroke) - White (high density) - Usually rounded and space occupying Infarcts (indicates ischemic stroke) - Dark (low density) - Occupies a vascular territory with some swelling
34
What are the benefits and drawbacks of a CT scan?
- Overview of structures - Identifying hemorrhage - Identifies boney injury - Quick to obtain BUT - Radiation - Does not immediately show early ischemia or anoxia (complete loss of oxygen in body or brain)
35
What are the benefits of an MRI scan?
- Can diagnose acute ischemic stroke within 12 hours of the first stroke symptom - Can find deep-seated bleeding in the brain (in hemorrhagic stroke)
36
What are the benefits and drawbacks of a CT angiogram?
- Identifies thrombosis in major vessels of vascular malformations (eg aneurysms) - "Spot sign" ~ Shows contrast extravasation into hematoma showing active bleed BUT - Iodinated contrast can cause allergic reaction and kidney injury
37
Flowchart of stroke management (1 hr)
First 10 mins: 1) Recognition of stroke symptoms + last known well time 2) Emergency medical services (imc ABC, CBG) Next 15 mins: 3) Immediate general assessment and stabilisation 4) Neurological assessment by stroke team Next 20 mins: 5) CT Scan shows hemorrhage/no hemorrhage 6a) Consider IV thrombolysis therapy if ischemic stroke suspected 6b) Administer aspirin if px not eligible for thrombolysis Final 15 mins: 7) Start stroke treatment
38
What are the supportive measures for stroke management?
- Airway support and ventilatory assistance (if decreased consciousness/bulbar dysfunction compromises the airway) - Supplemental oxygen to maintain >94% - Correction of hyperthermia/>38degC ~ Targeted temperature management (TTM) needed to minimise secondary neurological injury - Treatment if hypoglycemia/<60mg/dl (3mmol/L) - Treatment of hyperglycemia to stay within 140-180mg/dl (7-10)
39
What is the pathophysiology of atherosclerosis?
- Fatty streaks settle in the intima layer (innermost layer of BV) -> LDL gets oxidised and is released by macrophages, endothelial cells and smooth muscle cells ~ Endothelial injury causes platelet and fibrin deposition - Accumulation of complex lipids, proteins and carbohydrates + proliferation of cells occur in the intima layer -> forms plaque ~ May rupture or form thrombosis
40
What is epilepsy?
- Caused by abnormal electrical activity in brain - Gives rise to an "electrical storm" that produces seizures
41
What are the causes of epilepsy?
- Hereditary - Brain injury - Infections - Blood glucose alterations - Metabolic disorders ~ Hyponatremia (caused by adrenal insufficiency)
42
What is the pathophysiology of a seizure?
- Unbalanced excitatory and inhibitory receptors which favour depolarisation ~ Causes dysregulated discharge -> excessive synchronous depolarisation
43
What are the possible differential diagnosis for epilepsy, when px presents with loss of awareness?
- Transient cardiac arrhythmia - TIA - Hypoglycemia - Panic attacks
44
What are the possible differential diagnosis for epilepsy, when px presents with abnormal movement?
- Movement disorders in sleep and wake - Tremor / paroxysmal choreoathetosis / dystonia - Drop attacks / cataplexy
45
What is a seizure?
- Abnormal movements or behaviour - Due to unusual electrical activity in the brain / epilepsy
46
What are the types of seizures?
- Epileptic seizure (3 main types) - Non-epileptic seizure ~ Psychological or stressed induced - Provoked seizure ~ Trauma, hypoglycemia, hyponatremia, drug abuse
47
What are the 3 types of epileptic seizures?
1) Idiopathic generalised epilepsy 2) Idiopathic partial epilepsy 3) Status epilepticus - Px is continuously in seizure - Serious medical emergency
48
What is idiopathic generalised epilepsy?
- Whole brain affected - Appears in childhood but diagnosed in adulthood - Identified by EEG - No nervous system abnormalities and normal intelligence
49
What are the characteristics of the 6 types of generalised seizures?
1) Generalised tonic-clonic / Grand-mal - Unconsciousness - Body stiffening (tonic) - Violent jerking (clonic) - Deep sleep after (postical phase) 2) Absence / Petit-mal - Brief LOC - Stares blankly - May occur several times a day 3) Myoclonic - Sporadic jerks on both sides - "Electrical shocks" 4) Clonic - Rhythmic jerks on both sides of the body 5) Tonic - Muscle stiffness, rigidity 6) Atonic - Loss of muscle tone in all 4 limbs
50
What is idiopathic partial epilepsy?
- Part of brain affected - Begins in childhood and may be genetic - Outgrown in puberty and never diagnosed as an adult - Diagnosed by EEG - Tends to occur during sleep - May involve the face
51
What are the characteristics of the 3 types of partial seizures?
1) Simple - Motor: Jerking, muscle rigidity, spasms, head-turning - Sensory: Affected vision, hearing, smell, taste or touch - Psychological: Memory or emotional disturbances 2) Complex - Automatisms/habits (repetitive, involuntary but coordinated) 3) Partial seizure with secondary generalisation - Initially associated with a preservation of consciousness -> LOC -> convulsions
52
What is an aura in terms of seizures?
- Warning of an impending seizure - Sensation (eg specific taste or smell)
53
What are the investigations for epilepsy?
Electroencephalography (EEG) - May be normal in b/w seizures so activation techniques (eg sleep deprivation, hyperventilation) can be used to elicit the pathological mechanisms NOTE Diagnosis may not be epilepsy so try out: - CT scan/MRI - Lab diagnostic studies - Lumbar puncture
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