Central Nervous system Stroke

Question 1

What are the 2 types of strokes and their proportionality

Answer 1

1) Ischaemic stroke - 85% of total stroke

2) Hemorrhagic stroke - 15% of total stoke

Question 2

Which vessels are commonly involved

Answer 2

80% carodit artery is the source

20% from the posterior circulation

Question 3

What are the 3 types of Ischaemic stroke

Answer 3

1) Thrombotic stroke
2) Cardioembolic stroke
3) Hypoperfusion state

Question 4

What are the aetiologies of thrombotic stroke

Answer 4

1) arthrosclerosis + clot formation on ulceration
2) Hypercoagulable state - polycythemia, sickle cell,thrombophilia
3) Vessel narrowing - vasculitis, disection, vasospasm

Question 5

What are the source of intravascular material in Cardioembolic stroke

Answer 5

1) Cardiac - clot from AF, MI, Vegetative material on valves
2) Proximal aorta - clot, disection
3) peripheral - Fat from fracture of long bone or air from diving, Particulate matter from IV drug user

Question 6

What are the difference in the presentation of these 3 types of ischaemic stoke

Answer 6

• Thrombotic stroke tend to be gradual onset and warning signs like TIA may preceed the full stroke
• Embolic stroke is sudden and acute
  Hypoperfusion Wax and wane depending on the vascular state

Question 7

What are the risk factors for stroke

Answer 7

hypertension
Diabetes
Hyperlipidaemia
Male gender
increasing AGE

Question 8

What is the TIA Risk assesment score

Answer 8

1) Age >60yr old score 1
2) BP >140/90mmhg Score 1
3) Clinical features
- unilateral weakness Score 2
- Speech impairement without weakness score 1
4) Duration
- >60mmhg 2 points
10 min - 59min 1 point
5) Diabetes 1 point
total 9 points

Question 9

Scoring system mean for ABCD2 score

Answer 9

1) Score >6 or 6 - High risk
- 2 days risk 8%
- 7 day risk 25 - 30%
2) Score 4 to 5 - moderate risk
- 2 days risk 4%
- 7 days risk 20 to 25%
3) score < 3 or 3 - low risk
- 2 days risk 1%
- 7 day risk 0 to 17%

Question 10

NICS/NSF - recomendation for ABCD2 score

Answer 10

> 4 - high risk
- admit to facilitate  rapid assessment
- CT ?MR head with 24hrs
< 4 - low risk
- CT brain and carotid US within 48 - 72 hrs
- Outpatient follow up advice

Question 11

What is your admission criteria for TIA

Answer 11

• 4 TIA within 2 weeks or 2 within 24 hrs
• Crescendo TIA - 3 in last 72hrs
• High grade carodit stenosis
• Presume cardiac stenosis
• Embolic TIA
• anticoagulation
  High risk as per ABCD2 score

Question 12

What are the 4 main areas of preventing stroke

Answer 12

1) Antiplatelet
- Asprin proven CAST/IST trials - reduce risk of stroke by 20 to 30%
- 50% occurs early in the 1st 2 weeks of therapy
- 15/1000 prevent stroke
2) Anticoagulation with AF
- effective in preventing recurrent stroke in AF patient ( exception of rheumatic AF - reduce by 2/3 risk stroke
- 30/1000 prevent stroke but 2/1000 major hemorrhage
3) Blood pressure control
- active reduction of BP - reduces the risk of recurrent stroke by 4%
4) Smoking
- 66% relative risk reductionfrom cessation
NB Carotid endarterectomy - Benefit in symptomatic patient with high degree of stenosis
- reduce by 50% - >80% stenosis
- reduce by 25% - 70 - 80% stenosis
- lesser stenosis - no benefit

Question 13

What is the indication for the carotid endarterectomy

Answer 13

• recent ( 6 month) carotid territory TIA
• > 70 % stenosis of the carotid artery
• Otherwise fit for surgery
• done in specalised centers
  Alternative is angioplasty with stending

Question 14

What are the causes of ICH

Answer 14

• 80 to 90% - primary hemorrhage - sponateneous rupture of small vessels damaged by the chronic hypertension or amyloid angiopathy
• 10 to 20% - secondary hemorrhage - association with vascular abnormality like AVM or aneurysm

Question 15

Can you name different types of hemorrhage

Answer 15

1) hypertensive haemorrhage (Charcout - Bouchard) - microaneurysm of penetrating arteries of MCA, Basilar and Circle of Willis - evolves a few minutes
2) Lobar hemorrhage - Oval or circular clots in the subcortical white matter - 50% idiopathic, 50% pathological like - AVM, Anticoagulation, tumour, amyloid
3) Putamen hemorrhage - most common. Eye deviated to contralateral side and contralateral hemiplegia
4) Thalamic haemorrhages - contralateral hemiplegia, Eye down and in. Unequal pupils and absent light reflex. Ipsilateral Horners syndrome and aphasia
5) Pontine bleed - deep coma with quadriplegia, pinpoint pupils, decerebrate rigidity, hyperpnoea, hypertension
6) Cerebellar bleed - repeated vomiting and vertigo, eyes deviate to contralateral side , no paralysis - may be amenable to surgery

Question 16

Outline your management of Hemorrhagic stroke

Answer 16

1) Reverse coagulopathy
2) Reduce ICP
3) Blood pressure control
4) Other measures
- glycemic control
- thermal protection
- Seizure control and prophylaxis
- pressure care
- Urinary cathter
- antiemetic
5) Neurosurgical consult