Cerebrovascular event (stroke)

Question 1

What is a stroke?

Answer 1

Sudden onset focal neurological deficit of vascular aetiology. Symptoms typically last >24 hours (or with evidence of infarction on imaging).

Question 2

Types of stroke?

Answer 2

Stroke can be categorised into 2 types:

Ischaemic stroke (85% of cases)

Haemorrhagic stroke (15% of cases)
- Intracerebral haemorrhages (75%)
- Subarachnoid haemorrhages (25%)

Question 3

Strong risk factors for ischaemic stroke?

Answer 3

Age

Male sex

Family history of ischaemic stroke

Haemophilia

Question 4

Weaker risk factors for ischaemic stroke?

Answer 4

Hypercholesterolaemia

Obesity

Poor diet

Migraine

Question 5

Strong risk factors for haemorrhagic stroke?

Answer 5

Older age

Male sex

Family history of haemorrhagic stroke

Haemophilia

Question 6

Weaker risk factors for haemorrhagic stroke?

Answer 6

NSAID’s

Thrombocytopenia

Heavy alcohol use

Question 7

How does an ischaemic stroke occur?

Answer 7

Occurs when blood supply in a cerebral vascular territory is reduced secondary to stenosis or complete occlusion of a cerebral artery.

Question 8

How does haemorrhagic stroke occur?

Answer 8

Bleeding occurs inside or around brain tissue due to the rupture of a blood vessel.

Question 9

What is a common cause of haemorrhagic stroke?

Answer 9

Hypertension

Question 10

Additional causes of haemorrhagic stroke?

Answer 10

Weakened blood vessel wall e.g. aneurysm, vasculitis

Question 11

Stroke symptoms are typically symmetrical. True/false?

Answer 11

False

Typically asymmetrical

Question 12

Typical symptoms of stroke?

Answer 12

• Sudden weakness of limbs
• Sudden facial weakness
• Sudden onset speech disturbance (dysphagia) - dysarthria (slurred speech), aphasia (expressive or receptive)
• Sudden onset visual or sensory loss

Question 13

Anterior or middle cerebral artery stroke symptoms?

Answer 13

Numbness, sudden muscle weakness

Question 14

Broca’s area (left frontal lobe) stroke symptoms?

Answer 14

expressive aphasia (difficulty producing speech)

Question 15

Wenicke’s area (left temporal lobe) stroke symptoms?

Answer 15

receptive aphasia (difficulty understanding speech - patient typically speaks in ‘word salad’)

Question 16

Posterior cerebral artery stroke symptoms?

Answer 16

affects vision

Question 17

What is a major cause of stroke?

Answer 17

AF (atrial fibrillation)

Question 18

Features of total anterior circulation syndrome?

Answer 18

• Involves the anterior AND middle cerebral arteries on the affected side
• Defined by:
  • Contralateral hemiplegia or hemiparesis, AND
  • Contralateral homonymous hemianopia, AND
  • Higher cerebral dysfunction (e.g. aphasia, neglect)

Question 19

Features of partial anterior circulation syndrome?

Answer 19

• Involves the anterior OR middle cerebral artery on the affected side
• Defined by:
  • 2 out of the 3 features present in a TACS OR
  • Higher cerebral dysfunction alone e.g. dysphagia

Question 20

Features of posterior circulation stroke?

Answer 20

• Involves the vertebrobasilar arteries and associated branches (supplying the cerebellum, brainstem, and occipital lobe)
• Defined by:
  • Cerebellar dysfunction, OR
  • Conjugate eye movement disorder, OR
  • Bilateral motor/sensory deficit, OR
  • Ipsilateral cranial nerve palsy with contralateral motor/sensory deficit, OR
  • Cortical blindness/isolated hemianopia

Question 21

Features of lacunar stroke?

Answer 21

• Small infarcts around the deeper parts of the brain (basal ganglia, internal capsule, thalamus and pons) caused by occlusion of a single deep single penetrating artery
• Defined as: a pure motor stroke, pure sensory stroke, sensorimotor stroke, or ataxic hemiparesis
• There should be NO: visual field defect, higher cerebral dysfunction, or brainstem dysfunction
• Best prognosis of all the strokes with 60% of patients alive and independent at 1 year

Question 22

Basilar artery occlusion features?

Answer 22

More likely to present with locked in syndrome (quadriparesis with preserved consciousness and ocular movements), loss of consciousness, or sudden death

In this, the person is completely paralysed however remains conscious and eye movement is preserved.

Question 23

Wallenberg’s syndrome (lateral medullary syndrome) features?

Answer 23

ipsilateral Horner’s syndrome,

ipsilateral loss of pain and temperature sensation on the face,

contralateral loss of pain and temperature sensation over the contralateral body

Question 24

Acute management of stroke?

Answer 24

• DR ABCDE approach
• Airway protection (in patients presenting with depressed consciousness) and aspiration precautions (in patients presenting with swallowing impairment) are very important

Question 25

When is aspirin given for stroke?

Answer 25

If hyper-acute treatments are not offered. Patients should receive aspirin 300mg orally once daily for 2 weeks.

If hyper-acute treatments are offered, aspirin is usually started 24 hours after the treatment following a repeat CT head that excludes any new hemorrhagic stroke.

Question 26

What can be given for stroke rehabilitation?

Answer 26

Physiotherapy to help prevent spasticity and contractures, and teach patients how to cope with their current functional level.

Speech therapy to help with dysphagia

Occupational therapist