19. Acute Neuro

Question 1

What is a stroke?

Answer 1

A sudden onset, focal neurological deficit of presumed vascular origin lasting more than 24 hours.

Question 2

Types of stroke?

Answer 2

Ischaemic - thrombotic (atherosclerotic plaque) or embolic (clot from elsewhere)
Ischaemic

Question 3

Anterior cerebral artery stroke symptoms?

Answer 3

Supplies frontal lobe and anterior parietal lobe

Contralateral hemiparesis, lower limbs more than upper.
Behavioural changes.

Question 4

Middle cerebral artery stroke symptoms?

Answer 4

Supplies lateral parts of frontal, temporal and parietal lobes

Contralateral hemiparesis, upper limb more than lower limb.
Contralateral hemisensory loss
Apraxia
Aphasia (broca’s area responsible for speech production, wernicke’s for receptive/understanding)
Quadranotopias

Question 5

Posterior cerebral artery stroke?

Answer 5

Supplies occipital lobe and inferior part of temporal

Contralateral homonymous hemianopia
Visual agnosia (faces and objects)

Question 6

What are the signs of cerebellar damage (can be in posterior circulation stroke - not to be associated with posterior cerebral artery stroke)?

Answer 6

Dysdiadochokinesia
Ataxia
Nystagmus
Intention Tremor
Slurred speech
Hypotonia 

Decreased consciousness and ipsilateral signs.

Question 7

How to investigate a stroke?

Answer 7

Urgent non-contrast CT head scan to rule out haemorrhage (blood white, necrosis dark)
Serum glucose (stroke mimicker)
U&Es for low sodium (mimicker)
Cardiac enzymes (exlcude MI)
FBC to check for anaemia or thrombocytopenia prior to possible initiation of thrombolysis or anticoagulants

ECG - vital signs of deterioration

CT angiogram and carotid doppler for causes

Question 8

What’s the immediate management of an ischaemic stroke?

Answer 8

< 4.5 hours - IV alteplase, thrombolysis. Then give aspirin (300mg oral)
> 4.5 hours OR thrombolysis contraindicated - aspirin (300mg oral)

Question 9

Contraindications for thrombolysis?

Answer 9

Symptoms > 4.5 hours
CT reveals acute trauma or haemorrhage
Symptoms suggestive of subarachnoid
High INR, APPT, PT

Question 10

Secondary prevention of a ischaemic stroke?

Answer 10

AF patients - warfarin prophylaxis

Non-AF patients - continue to 75mg aspirin for 2 weeks, switch to lifelong clopidgrel 75mg

Lifestyle changes
Carotid endarterectomy

Question 11

How do we treat a haemorrhagic?

Answer 11

Refer for neurosurgical evaluation - ICU or surgery

Review anticoagulant medications

Question 12

What is a TIA?

Answer 12

A stroke that resolves within < 24 hours