Cerebrovascular Disease

Question 1

Define a TIA

Answer 1

A sudden onset focal neurological deficit, resolving in under 24 hours

Question 2

Modifiable risk factors for a stroke

Answer 2

Diabetes, raised cholesterol, hypertension, smoking, alcohol, obesity, drug abuse, infections

Question 3

Pathophysiology of an ischaemic stroke

Answer 3

Blood clot stopping blood flow to an area of the brain
Can de due to:
- a thrombus in situ (small vessel disease)
- an embolism from the heart/aortic arch/carotid artery
- vasculitis
- cryptogenic (no cause identified)

Question 4

Pathophysiology of a haemorrhagic stroke

Answer 4

Bleed in to the brain after rupture of diseased/weakened blood vessels
Primary bleed - usually due to hypertension
Secondary bleed - underlying cause eg. vascular abnormality/tumour/iatrogenic eg. Anticoagulants

Question 5

Unmodifiable risk factors for stroke

Answer 5

Male, age, family history, previous stroke/TIA

Question 6

Describe blood supply of the anterior cerebral artery

Answer 6

Supplies the anteromedial cerebrum

Part of the frontal and parietal lobes

Question 7

Describe blood supply of the middle cerebral artery

Answer 7

Lateral cerebrum

Parts of the frontal, parietal, and temporal lobes

Question 8

Describe blood supply of the posterior cerebral artery

Answer 8

Supplies the medial and lateral parts of the posterior cerebrum
Supplies the temporal and occipital lobes and the midbrain and thalamus

Question 9

Which blood vessel is most commonly involved in a stroke?

Answer 9

Middle cerebral artery

Question 10

Describe a Total Anterior Circulation Stroke (TACS)

Answer 10

Occlusion occurs in the ICA or the proximal MCA
Causes hemiparesis, hemisensory loss, hemianopia, higher cortical dysfunction (eg. Dysphasia, visuospatial disorders)

Usually due to a cardiac emboli
Poor prognosis - 50% mortality

Question 11

Describe a Partial Anterior Circulation Stroke

Answer 11

Occlusion of MCA, usually due to large vessel disease eg. Carotids/arch of aorta

Causes 2 of hemiparesis/hemisensory loss/hemianopia or higher cortical dysfunction

Question 12

Describe a Lacunar Stroke

Answer 12

Occlusion of a single perforating artery, due to small vessel disease ie. Atheroma in situ
Gives a pure motor or pure sensory deficit

Question 13

Describe a Posterior Circulation Stroke

Answer 13

Leads to cranial nerve palsies, motor and sensory loss, cerebellar dysfunction, visual field defects

Can have any cause

Question 14

Define stroke

Answer 14

A sudden onset focal neurological deficit, lasting over 24 hours

Question 15

Symptoms of a stroke in the frontal lobe region

Answer 15

Muscle weakness (hemiparesis)
Expressive dysphasia (brocas)
Personality/behaviour changes

Question 16

Symptoms of a stroke in parietal lobe

Answer 16

Hemisensory loss (primary sensory cortex) 
Visuospatial deficit
Inferior quadrantanopia (superior optic radiation)

Question 17

Symptoms of stroke in temporal lobe

Answer 17

Loss of auditory/vestibular function
Taste and smell dysfunction
Receptive dysphasia (wernickes)
Memory loss
Superior quadrantanopia (inferior optic radiation)

Question 18

Symptoms of stroke in occipital lobe

Answer 18

Loss of vision

Question 19

Symptoms of stroke affecting the cerebellum

Answer 19

Dysdiadokokinesia
Ataxia 
Nystagmus 
Intention tremor 
Scanning speech
Hypotonia

Question 20

Stroke differential diagnosis

Answer 20

Hypoglycaemia
Epilepsy
SOL
MS

Question 21

Investigations of stroke

Answer 21

CT head - to look for bleeding/infarct
Carotid ultrasound/cardiac investigations
Coagulation profile

Question 22

Management of ischaemic stroke

Answer 22

Thrombolysis - give rTPA, give <3hrs of symptom onset (<4.5hrs if patient <80yrs), only if INR<1.7

Thrombectomy/craniotomy

Carotid endarterectomy (if carotid embolus suspected)

Secondary prevention: Aspirin, risk factor reduction

Question 23

Management of haemorrhagic stroke

Answer 23

Reverse any anticoagulation
Craniotomy
Secondary prevention: control of BP

Question 24

Mechanism of action of rTPAs

Give some examples

Answer 24

rTPAs = recombinant Tissue plasminogen activator
Convert plasminogen to plasmin, which acts to cleave fibrin and break down blood clot.

Eg. Alteplase, Reteplase

Question 25

Give some contraindications for thrombolysis

Answer 25

History of haemorrhagic stroke
Active peptic ulcer 
Recent trauma or surgery
CNS neoplasm
Uncontrolled hypertension
Coagulopathies