Stroke and Vascular Disease
Info History/RF Examination Investigation Management
Migraine Ax – unclear; genetic predisposition potential triggers – 1 Prodrome (hrs-days) – food cravings, mood changes, photophobia, To exclude other Dx Lifestyle – avoid known triggers;
Primary alcohol, nicotine, poor sleeping habits, emotional stress, phonophobia, osmophobia headache diary to identify triggers;
headache weather changes, hormonal changes in women 2 Aura - positive phenomena i.e visual sparkles, flashing lights; negative Bedside – regular sleep cycle, regular meals,
characterised by (menstruation, hormone intake – OCP) phenomena i.e vision loss; sensory changes – paresthesia; speech stress Mx
recurrent Pathophys – language Sx; hemiplegic migraine i.e aura involving motor weakness Mild-moderate
episodes of Neurogenic inflammation – inflammation (vasodilation, 3 Main event Bloods – Nonopioid analgesia (aspirin or
unilateral, fluid and protein extravasation, etc) caused by the Throbbing, drilling, ice pick to the head, burning FBE, UEC, CRP, ESR (↑ in temporal ibuprofen or other NSAID +
localised pain action of neuro-peptides on blood vessels Unilateral usually, but can shift sides during attack arteritis) paracetamol)
that can be Cortical spreading depression – slow wave of electrical Fronto-temporal pain distribution If nauseated – metoclopramide
accompanied by activity → ? auras + activating the nerves that sense Vomiting Triptan (serotonin agonists) – can
N/V and pain in the meninges + change the function of blood 4-72hrs duration, worse in PM w/ gradual onset be given subcut if more severe
Imaging –
sensitivity to vessels 4 Postdrome/hangover – decreased mood, concentration difficulty, Refractory pts
MRI brain w/ contrast – concerning
light and sound Trigeminovascular system – group of nerve cells that fatigue and so on Ergots/ergotamine
headaches – identifies space-
sense pain in the face and covering of the brain – causes (vasoconstrictor) via serotonin
occupying lesions or ischaemia
Chronic, neurogenic inflammation via the release of a substance; RF – Female; OCP use; FHx; Overuse of analgesia; altitude; stress; lack of receptor agonist, but also action on
CT head – looking for intracranial
genetically normal pulsations of the vessels are sensed by CNV as sleep dopamine and NA
haemorrhage, raised ICP
driven, episodic, painful stimuli Paraenteral Mg (for migraine +
neurological Common migraine – no aura, paroxysmal headache +/- aura)
vomiting; classic migraine – aura, paroxysmal Clinical Dx Other anti-emetic (chlorpromazine
disorder
headache, N+V Other – – an anti-psychotic)
N/V, photophobia, fever, neck pain/stiffness, loss of weight or appetite, LP if thinking meningitis Stronger NSAID (Ketorolac)
Epi – early-mid-life; more common in females trauma, aura – flashing lights/loss of vision, speech, movement or CSF culture Prophylaxis – antiepileptics, TCA,
sensation, seizure propranolol, CCB (verapamil)
NO objective sensory or motor neurological signs
Stroke Pathophys – PC – face change, heavy arm etc, Bedside – BSL (elevated in AIS); ECG + ACUTE
Sudden onset of Ischaemic (~85%) – sudden onset neurological Sx Vitals, BSL, GCS (important to Telemetry – AF, STEMI/NSTEMI, prev Ischaemic – DRSABCD
neurological Arterial thrombosis (formation in artery i.e local); large <30min – TIA; >30min – stroke track progression of stroke) ischaemic events Ensure haemodynamic stability
deficits of a vessel – stenosis or occlusion of ICA, vertebral or Pain Rapid neurological assessment (HTN is expected; treat if >200)
vascular basis w/ intracranial a leading to insufficient blood flow beyond Headache (NIHSS score /42 – favours MCA Bloods – FBE, UEC (?electrolytes, Stroke admission
infarction of CNS lesion; small vessel/lacunar – chronic HTN and DM Neck pain strokes) contrast for CT) Thrombolysis – IV alteplase tPA if
tissue cause vessel wall thickening and decreased luminal Weakness in arms or legs Troponin (intramural thrombus → <4.5hr from Sx onset
diameter Sensory changes on limbs or face stroke) Endovascular clot retrieval if <6hr
TIA – same thing Cardioembolic (blockage of cerebral arterial flow from a Visual changes – all vision or part Coag studies – pro-thrombotic from Sx onset
but w/o cardiac source) – AF usually, left ventricular aneurysm, of vision BAC/drug screen – cerebellar Neurosurg referral
infarction rheumatic valve disease, prosthetic heart valves, recent Speech – expressive or receptive presentation Haemorrhagic – DRSABCD
, MI, IE, paradoxical embolus (patent foramen ovale) aphasia, dysarthria HbA1c Surg Mx – IV cannula, NBM
AIS – w/ Systemic Hypoperfusion (global cerebral ischaemia) – Ax – AF, hyperlipidaemia, previous Lipid profile Tranexamic acid (considered if
infarction inadequate blood flow to the brain secondary to cardiac TIAs Coags – thrombocytopaenia NOAC or bleeding)
arrest, arrythmia, MI, severe respiratory failure; affects RF – age, male, post-menopausal BP control via BB
watershed areas b/w major cerebral arterial territories women, atherosclerotic RF (HTN, Imaging – Reverse anti-coag
Haemorrhagic (~15%) – DM, smoking, hyperlipidaemia, Non-contrast CT head – rule out ICH, Neurosurg referral for Mx; surgical
Intracerebral haemorrhage – hypertensive – rupture of obesity), embolic RF (AF, SAH evacuation
small microaneurysms causing intraparenchymal COCP/HRT, IVDU), FHx or PMHx CT angiography – will tell us how Ongoing – statin, aspirin, BB,
haemorrhage usually at the putamen, thalamus, much tissue is dead (umbra) + how clopidogrel, SNAPW, treat
cerebellum and pons; trauma, amyloid angiopathy, SAH – sudden onset, thunderclap much can be saved (penumbra) underlying Ax (AF, carotid
vascular malformations, vasculitis, drug use headache; worst headache ever CT perfusion endarterectomy/revascularisation),
SAH – cerebral aneurysms (saccular/berry), AVM, MRI – DWI, FLAIR DM control, HTN control
trauma (blunt, penetrating) TTE Long term antithrombotic therapy
Non-AF – antiplatelets – aspirin,
DDx – peripheral vertigo, migraine, delirium, seizures, clopidogrel
Complete – carotid a doppler studies AF – anti-coagulation – warfarin,
electrolyte disturbances for stenosis, lupus anti-coag + anti DOACs
cardiolipin, ESR/CRP, blood cultures, Dedicated stroke unit
fasting serum lipids, echocardiogram
(IE or thrombus)
ACA MCA ICA (gives off ACA/MCA) PCA (supplies occipital lobe) ICH
Contralateral weakness - LL>>face, UL Contralateral weakness - Face, Very similar to ACA/MCA Contralateral homonymous Headahce
Contralateral sensory loss - LL>>face, UL UL>>LL syndrome heminaopia Increased ICP signs - N/V, Cushing's
Personality change Contralateral sensory loss - Face, Also gives off opthalmic a - Alexia w/o agraphia triad - bradycardia, irregular
Abulia, disinhibition, executive dysfunction UL>LL temporary monoocular vision loss Contralateral hemibody pain respirations, widened pulse
Akinetic mutism - no movement or speech Ipsilateral gaze deviation (towards Midbrain syndromes pressure
Speech unclear or dysarthric side of lesion) Watershed areas - hypoxic Ax Diplopia and ataxia
Contralateral homonymous MCA/ACA zone - Proximal UL/LL Lacunar Infarcts SAH
heminaopia (lesion at visual weakness, sensory loss Pure motor stroke Worst headache ever - thunderclap
radiations) MCA/PCA zone - visual Pure sensory stroke Meningeal signs
If L dominant: dysfunction Mixed sensorimotor Increase ICP signs - N/V, Cushing's
Broca's Aphasia - expressive Ataxic hemiparesis - weakness + loss triad
Wernicke's Aphasia - receptive of coordination
If R non-dominant: Dysarthria
Apraxia - inability to perform
learned movements on command
Sensory/visual neglect
Intracranial Epidural haemorrhage: bleeding between the dura EDH – Bedside – BSL EDH
Haemorrhage mater and the calvarium; middle meningeal a (red High impact history Conservative if small
Bleeding within lemon) Initial LOC → lucid interval → coma Bloods – Evacuation of the clot
the skull Epi – 20-30yr males, good prognosis CN III palsy – down + out FBE, UEC, LFT, CRP, coags, VBG, SDH
Ax – head trauma – MVA, falls + assaults, 70-95% have High ICP – headaches, vomiting, confusion, seizures, aphasia blood cultures – if febrile Conservative Mx - generally benign
Encompasses pterion fracture SDH – if conservative is appropriate
epidural, PPx – high impact → skull fracture + tears of middle Older pt falls ~days ago Evacuation of the clot
meningeal a Anticoagulants Imaging – -Burrhole or craniotomy
subdural, CTB –
subarachnoid Subdural haemorrhage: bleeding between the dura and Progressive neurological decline -If surg – 50-90% mortality
the arachnoid layer (subdural space); damage to High ICP Sx as above EDH – Red lemon, midline shift, SAH
and intracerebral ventricular compression
haemorrhage. bridging veins (blue banana) SAH – DRS ABCD
Epi – common in infant/toddlers Sudden, onset, severe ‘thunderclap’ headache, +/- sentinel headache SDH – Blue banana Address ICP – bed elevation,
Ax – non-accidental injury in infants/toddlers (physical may occur 1-2 weeks before, high ICP + mass effects – LOC, N/V, SAH – starfish of death hypoventilation, BP control
Cx – tonsillar abuse); falls in elderly (atrophy of vessels -> friable) confusion + seizures ICH – hyperdense lesion where the Analgesia – Panadol
herniation, PPx – trauma + friable blood vessels in elderly → Meningism – photophobia, neck stiffness, headache; Kernig’s haemorrhage occurred Nimodipine PO for 21d – CCB to
Info History/RF Examination Investigation Management
Migraine Ax – unclear; genetic predisposition potential triggers – 1 Prodrome (hrs-days) – food cravings, mood changes, photophobia, To exclude other Dx Lifestyle – avoid known triggers;
Primary alcohol, nicotine, poor sleeping habits, emotional stress, phonophobia, osmophobia headache diary to identify triggers;
headache weather changes, hormonal changes in women 2 Aura - positive phenomena i.e visual sparkles, flashing lights; negative Bedside – regular sleep cycle, regular meals,
characterised by (menstruation, hormone intake – OCP) phenomena i.e vision loss; sensory changes – paresthesia; speech stress Mx
recurrent Pathophys – language Sx; hemiplegic migraine i.e aura involving motor weakness Mild-moderate
episodes of Neurogenic inflammation – inflammation (vasodilation, 3 Main event Bloods – Nonopioid analgesia (aspirin or
unilateral, fluid and protein extravasation, etc) caused by the Throbbing, drilling, ice pick to the head, burning FBE, UEC, CRP, ESR (↑ in temporal ibuprofen or other NSAID +
localised pain action of neuro-peptides on blood vessels Unilateral usually, but can shift sides during attack arteritis) paracetamol)
that can be Cortical spreading depression – slow wave of electrical Fronto-temporal pain distribution If nauseated – metoclopramide
accompanied by activity → ? auras + activating the nerves that sense Vomiting Triptan (serotonin agonists) – can
N/V and pain in the meninges + change the function of blood 4-72hrs duration, worse in PM w/ gradual onset be given subcut if more severe
Imaging –
sensitivity to vessels 4 Postdrome/hangover – decreased mood, concentration difficulty, Refractory pts
MRI brain w/ contrast – concerning
light and sound Trigeminovascular system – group of nerve cells that fatigue and so on Ergots/ergotamine
headaches – identifies space-
sense pain in the face and covering of the brain – causes (vasoconstrictor) via serotonin
occupying lesions or ischaemia
Chronic, neurogenic inflammation via the release of a substance; RF – Female; OCP use; FHx; Overuse of analgesia; altitude; stress; lack of receptor agonist, but also action on
CT head – looking for intracranial
genetically normal pulsations of the vessels are sensed by CNV as sleep dopamine and NA
haemorrhage, raised ICP
driven, episodic, painful stimuli Paraenteral Mg (for migraine +
neurological Common migraine – no aura, paroxysmal headache +/- aura)
vomiting; classic migraine – aura, paroxysmal Clinical Dx Other anti-emetic (chlorpromazine
disorder
headache, N+V Other – – an anti-psychotic)
N/V, photophobia, fever, neck pain/stiffness, loss of weight or appetite, LP if thinking meningitis Stronger NSAID (Ketorolac)
Epi – early-mid-life; more common in females trauma, aura – flashing lights/loss of vision, speech, movement or CSF culture Prophylaxis – antiepileptics, TCA,
sensation, seizure propranolol, CCB (verapamil)
NO objective sensory or motor neurological signs
Stroke Pathophys – PC – face change, heavy arm etc, Bedside – BSL (elevated in AIS); ECG + ACUTE
Sudden onset of Ischaemic (~85%) – sudden onset neurological Sx Vitals, BSL, GCS (important to Telemetry – AF, STEMI/NSTEMI, prev Ischaemic – DRSABCD
neurological Arterial thrombosis (formation in artery i.e local); large <30min – TIA; >30min – stroke track progression of stroke) ischaemic events Ensure haemodynamic stability
deficits of a vessel – stenosis or occlusion of ICA, vertebral or Pain Rapid neurological assessment (HTN is expected; treat if >200)
vascular basis w/ intracranial a leading to insufficient blood flow beyond Headache (NIHSS score /42 – favours MCA Bloods – FBE, UEC (?electrolytes, Stroke admission
infarction of CNS lesion; small vessel/lacunar – chronic HTN and DM Neck pain strokes) contrast for CT) Thrombolysis – IV alteplase tPA if
tissue cause vessel wall thickening and decreased luminal Weakness in arms or legs Troponin (intramural thrombus → <4.5hr from Sx onset
diameter Sensory changes on limbs or face stroke) Endovascular clot retrieval if <6hr
TIA – same thing Cardioembolic (blockage of cerebral arterial flow from a Visual changes – all vision or part Coag studies – pro-thrombotic from Sx onset
but w/o cardiac source) – AF usually, left ventricular aneurysm, of vision BAC/drug screen – cerebellar Neurosurg referral
infarction rheumatic valve disease, prosthetic heart valves, recent Speech – expressive or receptive presentation Haemorrhagic – DRSABCD
, MI, IE, paradoxical embolus (patent foramen ovale) aphasia, dysarthria HbA1c Surg Mx – IV cannula, NBM
AIS – w/ Systemic Hypoperfusion (global cerebral ischaemia) – Ax – AF, hyperlipidaemia, previous Lipid profile Tranexamic acid (considered if
infarction inadequate blood flow to the brain secondary to cardiac TIAs Coags – thrombocytopaenia NOAC or bleeding)
arrest, arrythmia, MI, severe respiratory failure; affects RF – age, male, post-menopausal BP control via BB
watershed areas b/w major cerebral arterial territories women, atherosclerotic RF (HTN, Imaging – Reverse anti-coag
Haemorrhagic (~15%) – DM, smoking, hyperlipidaemia, Non-contrast CT head – rule out ICH, Neurosurg referral for Mx; surgical
Intracerebral haemorrhage – hypertensive – rupture of obesity), embolic RF (AF, SAH evacuation
small microaneurysms causing intraparenchymal COCP/HRT, IVDU), FHx or PMHx CT angiography – will tell us how Ongoing – statin, aspirin, BB,
haemorrhage usually at the putamen, thalamus, much tissue is dead (umbra) + how clopidogrel, SNAPW, treat
cerebellum and pons; trauma, amyloid angiopathy, SAH – sudden onset, thunderclap much can be saved (penumbra) underlying Ax (AF, carotid
vascular malformations, vasculitis, drug use headache; worst headache ever CT perfusion endarterectomy/revascularisation),
SAH – cerebral aneurysms (saccular/berry), AVM, MRI – DWI, FLAIR DM control, HTN control
trauma (blunt, penetrating) TTE Long term antithrombotic therapy
Non-AF – antiplatelets – aspirin,
DDx – peripheral vertigo, migraine, delirium, seizures, clopidogrel
Complete – carotid a doppler studies AF – anti-coagulation – warfarin,
electrolyte disturbances for stenosis, lupus anti-coag + anti DOACs
cardiolipin, ESR/CRP, blood cultures, Dedicated stroke unit
fasting serum lipids, echocardiogram
(IE or thrombus)
ACA MCA ICA (gives off ACA/MCA) PCA (supplies occipital lobe) ICH
Contralateral weakness - LL>>face, UL Contralateral weakness - Face, Very similar to ACA/MCA Contralateral homonymous Headahce
Contralateral sensory loss - LL>>face, UL UL>>LL syndrome heminaopia Increased ICP signs - N/V, Cushing's
Personality change Contralateral sensory loss - Face, Also gives off opthalmic a - Alexia w/o agraphia triad - bradycardia, irregular
Abulia, disinhibition, executive dysfunction UL>LL temporary monoocular vision loss Contralateral hemibody pain respirations, widened pulse
Akinetic mutism - no movement or speech Ipsilateral gaze deviation (towards Midbrain syndromes pressure
Speech unclear or dysarthric side of lesion) Watershed areas - hypoxic Ax Diplopia and ataxia
Contralateral homonymous MCA/ACA zone - Proximal UL/LL Lacunar Infarcts SAH
heminaopia (lesion at visual weakness, sensory loss Pure motor stroke Worst headache ever - thunderclap
radiations) MCA/PCA zone - visual Pure sensory stroke Meningeal signs
If L dominant: dysfunction Mixed sensorimotor Increase ICP signs - N/V, Cushing's
Broca's Aphasia - expressive Ataxic hemiparesis - weakness + loss triad
Wernicke's Aphasia - receptive of coordination
If R non-dominant: Dysarthria
Apraxia - inability to perform
learned movements on command
Sensory/visual neglect
Intracranial Epidural haemorrhage: bleeding between the dura EDH – Bedside – BSL EDH
Haemorrhage mater and the calvarium; middle meningeal a (red High impact history Conservative if small
Bleeding within lemon) Initial LOC → lucid interval → coma Bloods – Evacuation of the clot
the skull Epi – 20-30yr males, good prognosis CN III palsy – down + out FBE, UEC, LFT, CRP, coags, VBG, SDH
Ax – head trauma – MVA, falls + assaults, 70-95% have High ICP – headaches, vomiting, confusion, seizures, aphasia blood cultures – if febrile Conservative Mx - generally benign
Encompasses pterion fracture SDH – if conservative is appropriate
epidural, PPx – high impact → skull fracture + tears of middle Older pt falls ~days ago Evacuation of the clot
meningeal a Anticoagulants Imaging – -Burrhole or craniotomy
subdural, CTB –
subarachnoid Subdural haemorrhage: bleeding between the dura and Progressive neurological decline -If surg – 50-90% mortality
the arachnoid layer (subdural space); damage to High ICP Sx as above EDH – Red lemon, midline shift, SAH
and intracerebral ventricular compression
haemorrhage. bridging veins (blue banana) SAH – DRS ABCD
Epi – common in infant/toddlers Sudden, onset, severe ‘thunderclap’ headache, +/- sentinel headache SDH – Blue banana Address ICP – bed elevation,
Ax – non-accidental injury in infants/toddlers (physical may occur 1-2 weeks before, high ICP + mass effects – LOC, N/V, SAH – starfish of death hypoventilation, BP control
Cx – tonsillar abuse); falls in elderly (atrophy of vessels -> friable) confusion + seizures ICH – hyperdense lesion where the Analgesia – Panadol
herniation, PPx – trauma + friable blood vessels in elderly → Meningism – photophobia, neck stiffness, headache; Kernig’s haemorrhage occurred Nimodipine PO for 21d – CCB to
