Year 4 > Stroke- Neuro Block > Flashcards

Stroke- Neuro Block Flashcards

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1
Q

Stroke must have symptoms lasting over ________ and no apparent cause other than a vascular event.

A

24 hours

This duration is critical for diagnosing a stroke.

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2
Q

Ischaemic stroke is divided into specific causes, name one.

A
  • Hypoxia from cardiac arrest, shock or respiratory failure
  • Embolisation causes from cardioembolic origin
  • Thrombotic cause
  • Small vessel like lenticulostriate branches
  • Large vessel like ICA, MCA

These causes highlight the various mechanisms leading to ischaemic stroke.

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3
Q

Name two non-modifiable risk factors for stroke.

A
  • Age
  • Male sex

These factors cannot be changed and contribute to stroke risk.

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4
Q

Name two modifiable risk factors for stroke.

A
  • Hypertension
  • Diabetes
  • Hyperlipidaemia
  • Smoking
  • Obesity

These factors can be managed or altered to reduce stroke risk.

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5
Q

What is a common cause of haemorrhagic stroke?

A
  • Hypertension
  • Cerebral amyloid angiopathy
  • Coagulopathy
  • Haemorrhagic transformation
  • Malignancy

These conditions can lead to bleeding in the brain.

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6
Q

Dissection of the internal carotid or vertebral arteries should be considered in which patients?

A

Younger patients with even mild neck trauma

Dissection can lead to serious complications, including Horner’s syndrome.

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7
Q

The most common sites for atherosclerosis are the:

A
  • Internal carotid
  • Middle cerebral artery

These sites are critical in the context of stroke.

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7
Q
A
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8
Q

What is a watershed infarct?

A

The tissues furthest from the brain are affected first

This type of infarct occurs in areas between major cerebral arteries.

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9
Q

What is carotid dissection associated with?

A

horner’s syndrome

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10
Q

What is vertebral dissection associated with?

A

brainstem stroke

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11
Q

What imaging modality is ideal in the first 24 hours to detect haemorrhage?

A

CT scan

It is crucial for early detection of bleeding.

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12
Q

What is the treatment for acute ischaemic stroke within 4.5 hours of symptom onset?

A

Thrombolytic enzymes such as IV alteplase

This treatment is critical for improving outcomes in ischaemic stroke.

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13
Q

What is the exclusion criteria for thrombolysis?

A
  • Previous MI, stroke or head trauma in last 3 months
  • Seizures at stroke onset
  • Pregnancy or breastfeeding
  • Major PE ration or haemorrhage in last 14-21 days

These criteria help prevent complications during treatment.

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14
Q

What does MRI show in the case of ischaemic infarct?

A
  • DWI shows ischaemic infarct as bright
  • ARC shows ischaemic infarct as dark

MRI is a valuable tool for assessing brain tissue after a stroke.

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15
Q

What should BP be prior to treatment for stroke?

A

185/110

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16
Q

What should be done once haemorrhagic stroke has been ruled out?

A

Aspirin 300mg should be administered ASAP

This is part of the management protocol for ischaemic stroke.

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17
Q

What does DWI show in MRI?

A

Diffusion weighted imaging will have Ischaemic infarct will be bright

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18
Q

What is ARC MRI?

A

ischaemic infarct will be dark

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19
Q

What lab diagnostics should be done for stroke?

A

Point of care glucose check, coagulation screen for INR and PT time
BUN and creatinine ratio to indicate if contrast CT is contraindicated
FBC for anaemia and thrombocythaemia or thrombocytopenia
ESR and CRP to screen for vasculitis, endocarditis, hyperviscosity
Carotid Doppler ultrasound to assess for stenosis
Toxicology screen
Urine test for urinary catecholeamines or porphyria
TFT levels

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20
Q

What is the threshold for carotid endarterectomy?

A

70-99% stenosis

This procedure is indicated for significant carotid artery narrowing.

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21
Q

When should airways be secured in stroke?

A

GCS of 8 or less

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22
Q

What is the anticoagulation for cardioembolic stroke?

A

heparin infusion, DOAC and warfarin.

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23
Q

What is the most common cause of death within the first week of stroke?

A

Transtentorial herniation

This complication can occur due to increased intracranial pressure.

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24
What are the systemic complications of stroke?
Systemic complications include dysphagia and aspiration, from brain stem involvement Infection, elated to pneumonia or UTI Fever from infection or DVT VTE
25
What is a **TIA**?
A sudden onset focal deficit of cerebral function or monocular blindness resolving within 24 hours ## Footnote TIAs are often precursors to full strokes.
26
What are the symptoms of **carotid TIA**?
* Hemiparesis * Dysphasia * Transient monocular blindness ## Footnote These symptoms indicate potential carotid artery involvement.
27
What are the symptoms of **posterior circulation TIA**?
* Bilateral hemiplegia * Sensory symptoms * Contralateral arm, trunk or leg deficit * Quadriplegia ## Footnote These symptoms suggest involvement of the posterior circulation of the brain.
28
What is the **Oxford Stroke Classification** also known as?
Bamford Classification ## Footnote It classifies strokes based on initial symptoms.
29
What are the three criteria assessed in the **Oxford Stroke Classification**?
* Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg * Homonymous hemianopia * Higher cognitive dysfunction e.g. dysphasia ## Footnote These criteria help in classifying the type of stroke.
30
What percentage of strokes are classified as **Total anterior circulation infarcts (TACI)**?
c. 15% ## Footnote TACI involves middle and anterior cerebral arteries and presents with all three criteria.
31
What characterises total anterior circulation infarcts?
involves middle and anterior cerebral arteries * all 3 of the unilateral hemiparesis and/or hemisensory loss of the face, arm & leg * 2. homonymous hemianopia * 3. higher cognitive dysfunction e.g. dysphasia
32
What characterizes **Partial anterior circulation infarcts (PACI)**?
* Involves smaller arteries of anterior circulation * 2 of the above criteria are present ## Footnote PACI accounts for approximately 25% of strokes.
33
What are the characteristics of **Lacunar infarcts (LACI)**?
* Involves perforating arteries around the internal capsule, thalamus and basal ganglia * Presents with 1 of the following: * Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three * Pure sensory stroke * Ataxic hemiparesis ## Footnote LACI also represents about 25% of strokes.
34
What defines **Posterior circulation infarcts (POCI)**?
* Involves vertebrobasilar arteries * Presents with 1 of the following: * Cerebellar or brainstem syndromes * Loss of consciousness * Isolated homonymous hemianopia ## Footnote POCI also accounts for approximately 25% of strokes.
35
What is **Lateral medullary syndrome** also known as?
Wallenberg's syndrome ## Footnote It presents with ipsilateral and contralateral symptoms.
36
What are the symptoms of **Weber's syndrome**?
Weber’s syndrome affects the midbrain and causes: * Ipsilateral III palsy, ataxia, nystagmus, dysphagia and facial numbness * Contralateral sensory loss weakness ## Footnote This syndrome is characterized by specific neurological deficits.
37
What is the screening tool for stroke by enteral public?
FACE/ARMS SPEECH TIME ## Footnote FAST stands for Face/Arms/Speech/Time and is widely known by the public.
38
What does the scoring system for stroke used by medical professionals?
Rosier score for: * Asymmetric facial weakness * Asymmetric arm weakness * Asymmetric leg weakness * Speech disturbance * Visual field defect Stroke is likely wit at least 1 point ## Footnote It is a validated tool recommended by the Royal College of Physicians.
39
What are the negative points for the **ROSIER score**?
* Loss of consciousness or syncope * Seizure activity ## Footnote These factors decrease the likelihood of a stroke.
40
What imaging should be done for suspected **ischaemic stroke**?
* STAT non-contrast CT of head * CT angiogram to find occlusion ## Footnote The CT will show hyperdense MCA/Basilar artery and hypodense tissue over time.
41
What does an **MRI** show in the case of a stroke?
* Hyper intensity at the affected stroke area * Hypointense at tissue risk of infarction ## Footnote MRI is done later for detailed imaging.
42
What imaging should be done for **intracerebral haemorrhage**?
* STAT CT head without contrast * MRI with SWI sequence ## Footnote SWI can detect hypo-intense vessels.
43
What does a **CT of chest, abdomen and pelvis** exclude?
Malignancy ## Footnote This imaging may be performed in stroke patients.
44
What do **acute haemorrhagic strokes** show on CT head?
* Areas of hyperdense material (blood) * Surrounded by low density (oedema) ## Footnote This helps in identifying the type of stroke.
45
What investigations are included for **subarachnoid haemorrhage**?
* STAT CT head * CT angiogram to locate vessel rupture source * Lumbar puncture to assess for xanthochromia ## Footnote These tests help confirm the diagnosis.
46
What is the **NICE recommendation** regarding fluid status assessment in patients with acute stroke?
* Regular assessment for fluid status as hypovolaema can worsen ischaemic penumbra * Assess hydration on admission * Regular review during hospital stay ## Footnote Ensures patients remain normovolaemic and prevents complications.
47
Greater than **80%** of patients who cannot swallow post stroke will recover within how many weeks?
2-4 weeks ## Footnote Important for managing fluids in the immediate post-event period.
48
What complications can arise from **hypovolaemia** in stroke patients?
* Worsening ischaemic penumbra * Increased risk of infection * Deep vein thrombosis * Constipation * Delirium ## Footnote Managing fluids is critical to avoid these complications.
49
What can **over-hydration** lead to in stroke patients?
* Cerebral oedema * Cardiac failure * Hyponatraemia ## Footnote Regular review of fluid status is essential to avoid these issues.
50
What is the **preferred method** of hydration for patients who can safely swallow?
Oral hydration ## Footnote Intravenous hydration may be necessary for others.
51
What is the **agent of choice** for intravenous hydration in most stroke patients according to UptoDate?
Isotonic saline without dextrose ## Footnote Choice may depend on electrolyte disturbances and cardiovascular status.
52
What is the target **blood sugar level** recommended by NICE for people with acute stroke?
4 to 11 mmol/L ## Footnote Important for monitoring, especially in diabetics or those nil by mouth.
53
What should be done for **diabetic patients** post acute stroke according to NICE guidelines?
* Intensive management * Optimising insulin treatment * Managing hypoglycaemia ## Footnote Hypoglycaemia can cause neuronal injury and mimic stroke deficits.
54
Under what conditions should **anti-hypertensive medications** be used post ischaemic stroke?
* Hypertensive emergency * Hypertensive encephalopathy * Hypertensive nephropathy * Hypertensive cardiac failure/myocardial infarction * Aortic dissection * Pre-eclampsia/eclampsia ## Footnote Lowering blood pressure too much can compromise collateral blood flow.
55
What is the recommended **initial blood pressure reduction** within the first 24 hours after stroke onset?
Approximately 15% ## Footnote Cautious lowering is advised to avoid complications.
56
What blood pressure should be maintained for patients eligible for **thrombolytic therapy**?
185/110 mmHg or lower ## Footnote Elevated BP can affect thrombolytic eligibility and delay treatment.
57
When should anti-hypertensives be used in post-ischaemic stroke?
patients with conditions like: Hypertensive encephalopathy * Hypertensive nephropathy * Hypertensive cardiac failure/myocardial infarction * Aortic dissection * Pre-eclampsia/eclampsia
58
What must all patients presenting with acute stroke be screened for before oral intake?
Safe swallowing function ## Footnote Dysphagia is common after stroke and can lead to aspiration.
59
What should be done if there are concerns regarding a patient's **swallowing**?
Specialist assessment of swallowing ## Footnote Should occur within 24 to 72 hours of admission.
60
What is the recommended feeding method for patients deemed **unsafe for oral intake**?
* Nasogastric tube feeding * Consider nasal bridle tube/gastrostomy if not tolerated ## Footnote Nutritional support may be required for patients at risk of malnutrition.
61
What is the score used for assessing disability in stroke?
Barthel index: Measuring disability and functional status post stroke ## Footnote Scores tasks from 0 (dependent) to 100 (independent).
62
What does Barthes index include?
Describes 10 tasks, and is scored according to amount of time or assistance required by the patient for each given task * Tasks: feeding, moving from wheelchair to bed, personal toileting, getting on/off toilet, bathing, walking on level surface, ascending/descending stairs, dressing, controlling bowels and controlling bladder * The total score is from 0 to 100, with 0 being completely dependent, and 100 being completely independent
63
What does a **clinical swallowing assessment** typically evaluate?
* Symptoms and medical history * Structures involved in swallowing * Reflexes such as gagging * Swallowing liquids and foods of varying thickness ## Footnote Aimed at identifying dysphagia or aspiration.
64
What is the most widely used **instrumental assessment** for swallowing?
Videofluoroscopic swallowing study (VFSS) ## Footnote Uses barium to visualize swallowing movements on X-ray.
65
What is the **NICE recommendation** regarding fluid status assessment in patients with acute stroke?
* Regular assessment for fluid status * Assess hydration on admission * Regular review during hospital stay ## Footnote Ensures patients remain normovolaemic and prevents complications.
66
Greater than **80%** of patients who cannot swallow post stroke will recover within how many weeks?
2-4 weeks ## Footnote Important for managing fluids in the immediate post-event period.
67
What complications can arise from **hypovolaemia** in stroke patients?
* Worsening ischaemic penumbra * Increased risk of infection * Deep vein thrombosis * Constipation * Delirium ## Footnote Managing fluids is critical to avoid these complications.
68
What can **over-hydration** lead to in stroke patients?
* Cerebral oedema * Cardiac failure * Hyponatraemia ## Footnote Regular review of fluid status is essential to avoid these issues.
69
What is the **preferred method** of hydration for patients who can safely swallow?
Oral hydration ## Footnote Intravenous hydration may be necessary for others.
70
What is the **agent of choice** for intravenous hydration in most stroke patients according to UptoDate?
Isotonic saline without dextrose ## Footnote Choice may depend on electrolyte disturbances and cardiovascular status.
71
What is the target **blood sugar level** recommended by NICE for people with acute stroke?
4 to 11 mmol/L ## Footnote Important for monitoring, especially in diabetics or those nil by mouth.
73
What should be done for **diabetic patients** post acute stroke according to NICE guidelines?
* Intensive management * Optimising insulin treatment * Managing hypoglycaemia ## Footnote Hypoglycaemia can cause neuronal injury and mimic stroke deficits.
74
Under what conditions should **anti-hypertensive medications** be used post ischaemic stroke?
* Hypertensive emergency * Hypertensive encephalopathy * Hypertensive nephropathy * Hypertensive cardiac failure/myocardial infarction * Aortic dissection * Pre-eclampsia/eclampsia ## Footnote Lowering blood pressure too much can compromise collateral blood flow.
75
What is the recommended **initial blood pressure reduction** within the first 24 hours after stroke onset?
Approximately 15% ## Footnote Cautious lowering is advised to avoid complications.
76
What blood pressure should be maintained for patients eligible for **thrombolytic therapy**?
185/110 mmHg or lower ## Footnote Elevated BP can affect thrombolytic eligibility and delay treatment.
77
What must all patients presenting with acute stroke be screened for before oral intake?
Safe swallowing function ## Footnote Dysphagia is common after stroke and can lead to aspiration.
78
What should be done if there are concerns regarding a patient's **swallowing**?
Specialist assessment of swallowing ## Footnote Should occur within 24 to 72 hours of admission.
79
What is the recommended feeding method for patients deemed **unsafe for oral intake**?
* Nasogastric tube feeding * Consider nasal bridle tube/gastrostomy if not tolerated ## Footnote Nutritional support may be required for patients at risk of malnutrition.
80
What is the **Barthel index (BI)** used for?
Measuring disability and functional status post stroke ## Footnote Scores tasks from 0 (dependent) to 100 (independent).
81
What does a **clinical swallowing assessment** typically evaluate?
* Symptoms and medical history * Structures involved in swallowing * Reflexes such as gagging * Swallowing liquids and foods of varying thickness ## Footnote Aimed at identifying dysphagia or aspiration.
82
What is the most widely used **instrumental assessment** for swallowing?
Videofluoroscopic swallowing study (VFSS) ## Footnote Uses barium to visualize swallowing movements on X-ray.
83
What must be done before medication is given in stroke?
Urgent non contrast CT head
84
What does a hyper dense lesion mean?
Blood and indicates haemorrhagic stroke
85
What does a hypodense lesion mean?
Reduced blood supply so ischaemic stroke
86
How is vision affected in occipital lobe damage?
Contralateral Homonymous hemianopia with macular sparing
87
What is macular sparing?
central vision is preserved This occurs because the macula, responsible for central vision, receives a dual blood supply from both the posterior cerebral artery and the middle cerebral artery
88
How does parietal lobe ischaemia affect vision?
Contralateral Homonymous quadrantopia: damage to the optic radiation where is passes through the parietal lobe on the contralateral side of the visual field loss
89
What is conductive aphasia?
Isolated inability to repeat speech from damage to the brain's arcuate fasciculus, a white matter tract that connects Broca's area and Wernicke's area. This is typical in the left parietal lobe
90
Which stroke type will have loss of consciousness?
Haemorrhagic
91
What is nominal dysphasia?
InCorrectly name objects
92
What causes difficulty in producing speech?
Broca’s dysphasia
93
What causes diff UCl it in understanding language?
Wernicke’s dysphasia
94
What causes Lentiform-shaped heterogenous hyper-dense extra-axial collection adjacent to the left squamous temporal bone?
Extradural ahematoma
95
What causes Crescent-shaped homogeneously hyper-dense extra-axial collection adjacent to the left frontoparietal convexity?
Subdural haematoma
96
What causes Cortical hypo-density associated with loss of grey-white matter differentiation in the vascular territory of the middle cerebral artery?
Ischaemic stroke
97
What do pinpoint pupils mean?
Opiate overdose
98
What are Lacunar infarcts?
small infarcts located around the basal ganglia, internal capsule, pons and thalamus
99
When to start statin after ischaemic stroke?
48 hours due to risk of haemorrhage
100
What to do for ischaemic stroke?
Thrombolysis within 4.5 hrs AND thrombectomy within 6 hours
101
Which level cholesterol should you consider statin?
Over 3.5 mmol/L
102
How to manage blood pressure in ischaemic stroke?
blood pressure should not be lowered in the acute phase of ischaemic stroke unless there are complications e.g. Hypertensive encephalopathy or they are being considered for thrombolysis if they present within 6 hours and have a systolic blood pressure > 150 mmHg
103
What are the routes for aspirin administration?
Rectal or oral
104
What is antalgic gait?
limping caused by pain that is worse when weight-bearing on the affected limb
105
What causes high stepping gait?
This occurs in patients that have foot drop (due to a common peroneal nerve injury). This presents with the patient lifting the affected leg up higher to prevent their foot from dragging across the floor as they walk.
106
What causes empty delta sign on imaging?
Central sinuous thrombosis
107
What causes neck pain with Horner’s syndrome?
Carotid artery dissection
108
How to manage blood pressure in ischaemic stroke?
DO NOT lower BP in acute phase stroke unless there is hypertensive encephalopathy or other features
109
When to consider lowering BP ina cute ischaemic stroke?
if they present within 6 hours and have a systolic blood pressure > 150 mmHg. Blood pressure must be ≤ 185/110 mmHg before thrombolysis
110
What is the threshold to start statin in stroke.
if the cholesterol is > 3.5 mmol
111
What to do in 4.5 hours after onset of ischaemic stroke?
Thrombolysis
112
What to do in 6 hours after onset of ischaemic stroke?
Thrombectomy
113
What is considered young in stroke?
under 55 with no obvious cause of a stroke Young' stroke blood tests include thrombophilia and autoimmune screening
114
What causes hyper-attenuation on imaging?
Haemorrhagic stroke
115
What type of stroke is associated with COCP?
Ischaemic stroke
116
Which drug is linked to hypertension?
Sympathomimetic drugs
117
Which stroke type is linked to prothrombotic state?
Venous sinus thrombosis
118
When to start antiplatelets after thrombolysis?
Wait 24 hours once CT confirms there is no haemorrhage
119
When is mechanical thrombectomy MODY benefiicsl?
those with proximal middle cerebral artery or internal carotid artery thrombus
120
What to do for unsafe swallow?
immediate implementation of nil by mouth status with IV fluids and consultation of the speech and language therapy team
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