Cerebrovascular Disease

Question 1

What is ischaemic stroke?

Answer 1

-Acute focal neurological dysfunction due to focal infarction at single or multiple sites of the brain or retina
=Symptoms lasting >24hrs
=Imaging findings in the clinically relevant area of the brain

Question 2

What is an intracerebral haemorrhage?

Answer 2

Acute neurological dysfunction from haemorrhage in brain parenchyma or ventricular system

Question 3

What is a TIA?

Answer 3

-Transient focal neurological symptoms due to cerebral ischaemia without evidence of infarction

Question 4

What is infarction

Answer 4

Positive imaging or symptoms at 24hr follow up

Question 5

What are focal symptoms?

Answer 5

-Weakness, clumsiness, sensory alteration in limb(s) on the same side
-Speech or language disturbance
-Loss of vision in eye/part of eye/ homonymous hemianopsia
-Sensory alteration, ataxia, imbalance, unsteadiness not associated with vertigo
-2 or more diplopia, dysphagia, dysarthria, or vertigo

Question 6

Symptoms less likely to be TIA

Answer 6

-Disturbances of vision with flashes, objects, distorted-view tunnel vision or image moving
-Tiredness/ heavy sensation in limb(s)
-Sensory symptoms or gradual spread of sensory symptoms
-Isolated disorder of swallowing or articulation, double vision, dizziness, or uncoordinated movements
-Unconsciousness, limb jerking, tingling of limbs/lips, disorientation

Question 7

Treatment of carotid stenosis

Answer 7

Endarterectomy
=Atheroma removal

Question 8

Primary and secondary prevention of stroke

Answer 8

-DOAC= more convenient than warfarin (monitoring, slow onset of action, bridging, and multiple drug interactions)
=Reduce risk of stroke or systemic embolic events compared with warfarin and reduce bleeding
=Warfarin has role in renal failure and mechanical heart valves
-Antiplatelet (clopidogrel)/ aspirin 300mg
-Blood pressure lowering
-LDL-cholesterol lowering
-Look for AF
-Look for carotid stenosis
-Stopping smoking advice
-Diet advice
-Look for PFO (patent foramen Ovale)

Question 9

Presentation of subarachnoid haemorrhage

Answer 9

-Sudden-onset thunderclap headache, severe, occipital, peaking in intensity 1-5 minutes
=Maybe history of less-severe ‘sentinel’ headache in weeks prior
-Nausea and vomiting
-Meningism
-Coma
-Seizures

Question 10

Diagnosis of subarachnoid haemorrhage

Answer 10

-Non-contrast CT head= hyperdense/ bright on CT
-If CT done more than 6 hours after symptom onset and is normal= LP
-CT angiography to identify cause

Question 11

Management of subarachnoid haemorrhage

Answer 11

-Pain relief
-Enteral nimodipine for ruptured aneurysm
-Endovascular coiling, or neurosurgical clipping

Question 12

Presentation of subdural haemorrhage

Answer 12

-Acute/ subacute/ chronic.
-Headache
-Nausea and vomiting
-Diminished GCS
-Confusion
-Loss of bowel and bladder continence
-Localised weakness
-Seizure.

-ACUTE= high impact trauma, incidental finding vs severe coma and coning due to herniation.

-CHRONIC= weeks to months, rupture of small bridging veins causing slow bleeding, elderly and alcoholic (brain atrophy), progressive history of confusion, reduced consciousness, neurological deficit.

Question 13

Investigation of subdural haemorrhage

Answer 13

-Non-contrast CT imaging (crescentic collection not limited by suture lines, large= mass effect= midline shift or herniation).
-ACUTE= hyperdense
-CHRONIC= hypodense

Question 14

Management of subdural haemorrhage

Answer 14

-Prophylactic antiepileptic
-Correction of coagulopathy
-ICP lowering.
-ACUTE= conservative/ surgical decompressive craniectomy, monitoring of ICP.
-Surgical decompression with burr holes= chronic, confusion, neurological deficit.

Question 15

Presentation of extradural haemorrhage

Answer 15

-Trauma (low impact)
-Often in temporal-parietal region (middle meningeal artery).
-Initially loses, briefly regains, then loses again consciousness (lucid interval).
-Lost when expands and herniation= fixed and dilated pupil due to compression of third cranial nerve.
-Fracture of temporal bone, headache.

Question 16

Investigations of extradural haemorrhage

Answer 16

-Non-contrast CT= biconvex/ lentiform, hyperdense collection limited by the suture lines of the skull.

Question 17

Management of extradural haemorrhage

Answer 17

-Clinical and radiological observation in patients with no neurological deficit
-Craniotomy and evacuation of haematoma.

Question 18

Presentation and investigation of cerebral arterial dissection

Answer 18

-Presentation: haematoma in wall of cervical or intracranial artery. Leads to brain infarction, stroke, and subarachnoid haemorrhage. Head and neck pain

-Investigation: Angiography (catheter cerebral), CT, MRI

Question 19

Presentation and investigation of cerebral venous thrombosis

Answer 19

-Presentation
=Raised ICP
=Seizures
=Focal neurological symptoms.
=CORTICAL= aphasia, hemiparesis, epilepsy.
=CAVERNOUS= eye symptoms, headache, reduced sensation in trigeminal first division.
=SUPERIOR SAGITTAL SINUS= headache, papilledema, seizures, resemble idiopathic intracranial hypertension.
=TRANSVERSE= hemiparesis, seizures, papilledema.
=Causes= dehydration, pregnancy, idiopathic, infection of cranial sinuses, thrombophilia.

-Diagnosis: MR venography= filling defect in affected vessel.

Question 20

Presentation of TIA

Answer 20

-Brief period of sudden onset neurological deficit typically lasting less than an hour/ completely resolved within 24hrs- ischaemia without acute infarction.
-Unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, loss of balance, visual problems (amaurosis fugax, diplopia, homonymous hemianopia)

Question 21

Investigation of TIA

Answer 21

-MRI to determine territory of ischaemia or detect haemorrhage.
-Carotid doppler= atherosclerosis can be source of emboli, carotid endarterectomy of carotid stenosis >70%.
-CT if bleeding disorder or taking anticoagulation: exclude haemorrhage.

Question 22

Management of TIA

Answer 22

-Immediate antithrombotic therapy (aspirin 300mg unless anticoagulated, already taking low-dose aspirin, contraindicated)

Question 23

Presentation of anterior cerebral stroke

Answer 23

-Contralateral hemiparesis and sensory loss, lower extremity > upper

Question 24

Presentation of middle cerebral stroke

Answer 24

-Sudden onset contralateral hemiparesis
-Homonymous hemianopia with eye deviation
-Altered speech (aphasia)
-Difficulty answering questions or naming objects.
-Upper > lower.

Question 25

Presentation of posterior cerebral stroke

Answer 25

-Acute vestibular syndrome (acute, persistent, continuous vertigo or dizziness with nystagmus, nausea, vomiting, head motion intolerance, new gait unsteadiness).
-Contralateral homonymous hemianopia with macular sparing.

Question 26

Presentation of lacunar stroke

Answer 26

-Isolated hemiparesis
-Hemisensory loss or hemiparesis with limb ataxia
-Hypertension.

Question 27

Presentation of basilar artery stroke

Answer 27

Locked in syndrome

Question 28

Diagnosis of stroke

Answer 28

-ECG to exclude arrhythmia
-Non-contrast CT head (hypoattenuation of brain parenchyma, sulcal effacement, loss of grey matter-white matter differentiation, hyperattenuating indicates clot in artery)
-Routine bloods
-CT angiography or MRI in patients with suspected large vessel occlusion candidates for thrombectomy.
-MRI if diagnosis uncertain.
-Carotid ultrasound, echo.

Question 29

Management of stroke

Answer 29

-Within 4.5 hours and thrombolysis not contraindicated: alteplase/ mechanical thrombectomy (proximal anterior circulation).
-Otherwise, aspirin 300mg orally one haemorrhagic stroke excluded, antiplatelet therapy, VTE prophylaxis, high-intensity statin.
-Blood pressure not lowered in acute phase unless complications (hypertensive encephalopathy)