Cerebral Infarction (Clinical)

Question 1

What is the definition of stroke?

Answer 1

The sudden onset of focal or global neurological symptoms caused by ischaemia or haemorrhage and lasting more than 24 hours

Question 2

What proportion of strokes are ischaemic?

Answer 2

85%

Question 3

What term is given to when stroke symptoms last less than 24 hours?

Answer 3

Transient ischaemic attack

Question 4

What are the risk factors for stroke?

Answer 4

Non-modifiable:
-Male sex
-Previous stroke
-Old age
-Family history
-Diabetes mellitus
Modifiable:
-Hypertension (most important modifiable risk factor)
-Diabetes mellitus
-Smoking
-Cholesterol
-Diet
-High BMI
-Sedentary lifestyle
-Oral contraceptives with a high oestrogen content

Question 5

What are the symptoms of anterior cerebral artery occlusion?

Answer 5

Contralateral:
Paralysis of foot and leg
Sensory loss over foot and leg
Impairment of gait and stance

Question 6

What are the symptoms of middle cerebral artery occlusion?

Answer 6

Contralateral:

• Paralysis of face/arm/leg
• Sensory loss of face/arm/leg
• Homonymous hemianopia

Gaze paralysis to opposite side
Aphasia if stroke on dominant (left) side
Unilateral neglect and agnosia for half of external space if non-dominant stroke (usually right side)

Question 7

What are the symptoms of a left hemisphere MCA stroke?

Answer 7

Hemiplegia

Homonymous hemianopia

Question 8

What are the symptoms of a right hemisphere MCA stroke?

Answer 8

Left hemiplegia
Homonymous hemianopia
Neglect syndromes (agnosias):
Visual agnosia
Sensory agnosia
Anosagnosia (denial of hemiplegia)
Prosopagnosia (failure to recognise faces)

Question 9

What are the symptoms of posterior circulation syndromes?

Answer 9

Coma
Vertigo
Nausea
Vomiting
Cranial nerve palsies
Ataxia
Hemiparesis
Hemisensory loss
Crossed sensori-motor deficits
Visual field deficits

Question 10

When can tissue plasminogen activator (TPA) be used?

Answer 10

When it is <4.5hrs since onset of symptoms
Disabling neurological deficit
Symptoms present >60mins
Consent obtained

Question 11

What are the exclusion criteria for IV TPA?

Answer 11

Anything that increases the possibility of haemorrhage (blood on CT scan, recent surgery, recent episodes of bleeding, coagulation problems)
BP >185 systolic or >110 diastolic
Glucose <2.8 or >22mmol/L

Question 12

What percentage of people with TIAs will have a stroke within two weeks?

Answer 12

10%

Question 13

What investigations can be done in cases of stroke?

Answer 13

Routine blood tests
CT or MRI head scan
ECG
Echocardiogram
Carotid doppler ultrasound
Cerebral angiogram/venogram
Hyper-coagulable blood screen

Question 14

What medication can be given as secondary prevention of strokes?

Answer 14

Anti-hypertensives
Anti-platelets
Lipid lowering agents
Warfarin for AF
Carotid endarterectomy

Question 15

What are the objectives of stroke care?

Answer 15

Reduce mortality
Reduce residual disability amongst survivors
Improve psychological status of patients and care-givers
Improve patient/care giver knowledge
Maximise quality of life

Question 16

What should be the immediate management for a patient presenting with an ischaemic stroke within 4.5 hours?

Answer 16

Give alteplase (rTPA)
Give aspirin 24hrs after rTPA
Give andovascular intervention (stent)

Question 17

What should be the immediate management for a patient presenting with an ischaemic stroke outwith 4.5 hours?

Answer 17

Give aspirin

Question 18

How should an ischaemic stroke that presents with cerebral venous sinus thrombosis be immediately managed?

Answer 18

Give anticoagulation