Stroke - Aetiology, Features and Long-term management Flashcards Preview

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Flashcards in Stroke - Aetiology, Features and Long-term management Deck (73):
1

 

 

What is the frontal lobe involved in?

 

  • High level cognitive functions - abstraction, concentration, reasoning
  • Memory
  • Control of voluntary eye movement
  • Motor control of speech (dominant hemisphere)
  • Motor cortex
  • Urinary continence
  • Emotion and personality

2

 

 

What are the functions of the parietal lobe?

 

  • Sensory cortex
  • Sensation - touch, pressure, position
  • Awareness of parts of the body
  • Spatial orientation and visuospatial information - non dominant hemisphere
  • Ability to perform learned motor tasks (dominant)

3

 

 

What are the functions of the temporal lobe?

 

  • Primary auditory receptive area
  • Comprehension of speech (dominant) – Wernicke’s
  • Visual, auditory and olfactory perception
  • Important role in learning, memory and emotional affect

4

 

 

What is the function of the occipital lobe?

 

  • Primary visual cortex
  • Visual perception
  • Involuntary smooth eye movement

5

 

 

What are the main functions of the cerebellum?

 

 

Balance and coordination

6

 

 

What are the main components of the brainstem?

 

  • Midbrain
  • Pons
  • Medulla

7

 

 

How many of the cranial nerves arise from the brainstem?

 

 

10 out of 12

8

 

 

What is the definition of a stroke?

 

Rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting >/= 24 hrs, or leading to death with no apparent cause other than vascular

9

 

 

What is the definition of a TIA?

 

A brief episode of neurological dysfunction caused by focal brain or retinal ischemia with clinical symptoms typically lasting less than one hour and without evidence of acute brain infarction

10

 

 

How many neurons can you lose per minute in an ischaemic stroke?

 

 

5 million per minute

11

 

 

What proportion of strokes are ischaemic?

 

 

85%

12

 

 

What proportion of strokes are haemorrhagic?

 

 

15%

13

 

 

What are causes of ischaemic stroke?

  • Cartoid plaques
  • Aortic arch plaque
  • Cardiogenic emboli
  • Penetrating artery disease
  • Flow reducing carotid stenosis
  • Carotid dissection
  • AF
  • Valve disease
  • LV thrombi

14

 

 

What are risk factors for having a stroke?

  • Hypertension
  • Smoking
  • Lifestyle/Obesity
  • Diabetes
  • AF
  • Hyperlipidaemia
  • Sleep apnoea
  • Carotid artery stenosis
  • Age
  • Ethnicity - Black, Asian
  • FH
  • Male

15

 

 

What are the most common sites for stenosis of the extracerebral arteries?

 

  1. Common carotid
  2. Internal carotid
  3. Vertebral
  4. Subclavian

16

 

 

What is the most common cause of ischaemic stroke?

 

 

Carotid plaque with arteriogenic emboli - 35%

17

 

 

What are cardioembolic causes of stroke?

 

  • AF
  • Cardioversion
  • Acute MI + akintic LV - Mural thrombosis
  • Infective endocarditis
  • Cardiac surgery
  • Valvular disease
  • Patent foramen ovale/septal defect - DVT can pass through

 

18

 

 

If someone below the age of 40 presented with a stroke, what might you consider investigating for as a cause?

 

  • Sudden drop in BP >/= 40mmHg
  • Carotid artery dissection
  • Vasculitis
  • SAH
  • Venous sinus thrombosis
  • Antiphospholipid syndrome
  • Thrombophilia

19

 

 

What are 5 impotant points to detrmine when trying to make the diagnosis of stroke?

 

  1. What is the neuro deficit?
  2. Where is the lesion?
  3. What is the lesion?
  4. Why has it happened?
  5. What are the potential complications?

20

 

 

If you had a stroke in the brainstem, where would you see neruological signs?

 

  • Ipsilateral cranial nerve signs
  • Contralateral motor signs/Quadraplegia
  • Disturbances of gaze and vision
  • Locked in syndrome

21

 

 

Are abnormal movements after a stroke normal?

 

 

No

22

 

 

Are headaches after a stroke normal?

 

 

No

23

 

 

What are the main stroke syndromes?

CLINICALLY CLASSIFIED - OCSP Bamford classification

  • TACS
  • PACS
  • LACS
  • POCS

24

 

 

What are general features which are seen in a stroke?

 

  • Motor - clumsy or weak limb
  • Sensory loss
  • Speech - Dysarthria/Dysphasia
  • Neglect / visuospatial problems
  • Vision - loss in one eye (amaurosis fugax) or hemianopia
  • Gaze palsy
  • Ataxia/ vertigo / incoordination / nystagmus

25

 

 

What is a TACS?

 

Total anterior circulation stroke

Constellation of symptoms of a patient who clinically appears to have suffered from a total anterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to confirm the diagnosis.

26

 

 

What are features of a TACS?

3 out of 3 of:

  • Complete hemiparesis/numbness - Face, arm and leg (2/3)
  • Homonymous hemianopia
  • Higher function loss - inattention, dyshasia dominant

 

 

27

 

 

What is a PACS?

 

Partial anterior circulation syndrome

Constellation of symptoms of a patient who clinically appears to have suffered from a partial anterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to confirm the diagnosis.

28

 

 

What arteries are most commonly affected in a TACS?

 

 

Large cortical stroke in middle/anterior cerebral artery area

29

 

 

What arteries are most commonly affected in a PACS?

 

 

Cortical stroke in middle/anterior cerebral artery areas

30

 

 

What are features of a PACS?

 

  • 2 of 3 TACS criteria

or 

  • One higher cortical deficit:
    • Inattention
    • Or dysphasia

or

  • Monoparesis

31

 

 

What are features of a POCS?

 

One of the following:

  1. Cerebellar/brainstem syndromes - Loss of balance/coordination (cerebellar dysfunction), Ipsilateral CNIII-XII nerve motor/sensory loss, Vertigo, Dysarthria
  2. Isolated Homonymous hemianopia/Cortical blindness
  3. Loss of consciousness

32

 

 

What is a LACS?

 

Lacunar syndrome

Constellation of symptoms that result from the occlusion of small penetrating arteries that provide blood to the brain's deep structures. Small infarcts called are called ‘lacunes’

33

 

 

What are the subtypes of LACS strokes?

 

  • Pure motor stroke
  • Pure sensory Stroke
  • Sensory motor stroke
  • Ataxic hemiparesis
  • Dysarthria/clumsy hand

34

 

 

What are features of a LACS?

 

  • Weakness/numbness of:
    • Face + arm + leg
    • Or Face + arm
    • Or Arm + leg
  • May have dysarthria
  • Ataxic hemiparesis

35

 

 

What structures can be affected in a lacunar stroke?

 

  • Basal ganglia
  • Internal capsule
  • Thalamus
  • Pons

36

 

 

What functions of the brain does a lacunar infarct affect?

 

 

Motor and sensory pathways - THINK HOMUNCULUS

37

 

 

What medications would you start if someone had a stroke secondary to AF?

 

 

Warfarin/DOAC - 10-14 days after stroke onset

38

 

 

What is a POCS?

 

Posterior Circulation Syndrome

Symptoms of a patient who clinically appears to have had a posterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to confirm the diagnosis.

39

 

 

What are features of a basal artery occlusion?

 

  • Predominantly motor/oculomotor signs/symptoms
  • Bilateral but asymmetrical
  • Alteration in level of consciousness common
  • May present as reduced responsiveness

40

 

 

If someone presenting with a brainstem stroke had sensory loss, what spinal tracts might be affected?

 

  • Medial lemniscus/Dorsal columns
  • Spinathalamic tracts

41

 

 

What does occlusion of the anterior cerebral artery cause in terms of clinical signs?

 

  • Contralateral leg +/- similar/milder arm features
  • Spared face

42

 

 

What spinal tracts would be affected if someone with a brainstem infarct had hemi/tetraparesis?

 

 

Corticospinal tracts

43

 

 

What artery is implicated in lateral medullary syndrome?

 

 

Thrombosis of posterior inferior cerebellar artery (PICA)

44

 

 

If someone having a stroke presented with right-sided weakness involving face and arms more than the leg, and dysphasia, what artery might be the culprit?

 

 

Left middle cerebral artery

45

 

 

If someone having a stroke presented with left-sided weakness involving face and arms more than the leg, and visual and/or sensory neglect, what artery might be the culprit?

 

 

Right middle cerebral artery

46

 

 

If someone having a stroke presented with ipsilateral horner's syndrome, CNX palsy, Facial sensory loss, limb ataxia with contralateral spinothalamic sensory loss, and vertigo, what might be the diagnosis?

 

 

Lateral medullary syndrome

47

 

 

What structure would be affected if someone with a brainstem infarct had diplopia?

 

 

Occulomotor nuclei

48

 

 

What structure would be affected if someone with a brainstem infarct had nystagmus/vertigo?

 

 

Vestibular connections

49

 

 

What structure would be affected if someone with a brainstem infarct had facial weakness?

 

 

 

 

Facial nerve nuclei

50

 

 

What structure would be affected if someone with a brainstem infarct had facial numbness?

 

 

Trigeminal nerve nuclei

51

 

 

What structure would be affected if someone with a brainstem infarct had dyphagia or dysarthria?

 

 

CNIX and CNX nuclei

52

 

 

What structure would be affected if someone with a brainstem infarct had altered consciousness?

 

Reticular formation

53

 

 

What can occlusion of the middle cerebral artery cause in terms of clinical signs?

 

  • Contralateral hemiparesis
  • Hemisensory loss - esp face and arm (look at homunculus)
  • Contralateral homonymous hemianopia - optic radiation involvement
  • Dysphasia - dominant hemisphere
  • Visuospatial disturbance - non-dominant hemisphere

54

 

 

What can occlusion of the posterior cerebral artery cause in terms of clinical signs?

 

  • Contralateral homonymous hemianopia

55

 

 

If someone was presenting with features of a stroke, what would be part of your differential diagnosis?

  • Head injury
  • Hypo/hyperglycaemia
  • Subdural haemorrhage
  • Intracranial tumours
  • Hemiplegic migraine
  • Post-ictal features - e.g. Todd's paralysis
  • CNS lymphoma
  • Wernicke's/hepatic encephalopthy
  • Encephalitis
  • Toxoplasmosis
  • Cerebral abscesses
  • Mycotic aneurysm
  • Drug overdose

56

 

 

What features of a stroke may point to an intracranial haemorrhage as the cause?

These may give an indication, but are very unreliable

  • Features of meningism
  • Severe headache
  • Coma

57

 

 

What features in history and examination may point towards an ischaemic cause for a stroke?

 

  • Carotid bruit
  • AF
  • Past TIA
  • IHD

58

 

 

What investigations would you always perform in someone with a stroke?

 

  • Bloods - FBC, ESR, U+E, Glucose, TSH, Cholesterol
  • ECG
  • CXR
  • Non-contrast CT Scan

 

59

 

 

What investigations would you consider doing in someone with a stroke on top of the standard investigations?

 

  • Coag studies
  • Auto-antibodies
  • Thrombophilia screening
  • Lupus anticoagulant
  • Anticardiolipin antibodies
  • ECHO
  • 24 hr holter
  • Carotid US

60

How might the following stroke present clinically (i.e. clinical stroke syndrome)?

 

 

PACS

61

How might the following stroke present clinically (i.e. clinical stroke syndrome)?

 

 

TACS

62

How might the following present clinically (i.e. clinical stroke syndrome)?

 

 

LACS

63

How might the following present clinically (i.e. clinical stroke syndrome)?

 

 

POCS

64

 

 

What are CTs good at looking for?

 

 

Haemorrhagic stroke - can help distinguish from ischaemic stroke

 

65

 

 

What medications would you give to reduce the risk of strokes recurring in someone who has had an ischaemic stroke?

 

  • Aspirin 300mg - acutely up to 2 weeks
  • Clopidogrel monotherapy - long term
  • Warfarin/DOAC - if underlying AF
  • Statin - artovastatin
  • ACEi - BP management

66

 

 

What are important aspects of long-term stroke management to consider?

  • Swallowing and fluids
  • Temperature
  • Primary/Secondary prevention
  • Urinary incontinaence
  • DVT prophylaxis
  • Skin Care
  • Positioning
  • Feeding
  • Depression
  • Pain
  • Rehabilitation

67

 

 

What are primary prevention measures that can be taken to prevent high risk individuals from having a stroke?

 

  • Control Risk factors - hypertension, obesity, lipids, cholesterol, diabetes smoking
  • Anticoagulation – lifelong therapy for those with rheumatic heart disease or prosthetic valves, or AF

 

 

68

 

 

What are secondary prevention measures for prevention of further strokes?

 

  • Control risk factors – controlling BP and cholesterol greatly reduces the risk
  • Anticoagulation  – if embolic stroke, then aspirin (2 weeks), followed by clopidogrel

69

 

 

What investigations might you do to identify risk factors that may need intervention as part of your long term management following a stroke?

 

  • Hypertension - Eyes, kidneys, CXR
  • Cardiac source - ECG, CXR, ECHO
  • Cortid artery stenosis - doppler, CT/MRI
  • Vasculitis - ESR, ANCA
  • Hypervisciocity - FBC
  • Thrombocytopenia - FBC
  • Diabetes - fasting glucose

70

 

 

What is the role of the occupational therapists in stroke rehabilitation?

 

Looks at levels of function, and teaches patient how to cope. Also arranges home alterations (stair lifts, hand rails etc) to help the patient stay living at home.

71

 

 

What is the role the the speech therapist in stroke rehabilitation?

Help with:

  • Dysphasia
  • Dysphagia

72

 

 

What is the role of the physiotherapist in stroke rehabilitation?

 

Helps to prevent spasticity and contractures. Also teaches patients how to cope with their current level of function

73

 

 

What antiplatelet therapy would you use as secondary prevention following a stroke?

 

 

Aspirin - 300mg, followed by Clopidogrel long-term