Clinical Management of Stroke

Question 1

How many new strokes occur in the UK every year?

Answer 1

150,000

Question 2

Define acute stroke

Answer 2

An acute-onset focal neurological deficit caused by vascular disorder

Question 3

What percentage of strokes are caused by ischaemia?

Answer 3

80%

Question 4

What percentage of strokes are caused by cerebral haemorrhage?

Answer 4

10-15%

Question 5

What percentage of strokes are caused by subarachnoid haemorrhage?

Answer 5

5%

Question 6

What percentage of strokes are caused by sinus and venous thrombosis?

Answer 6

2%

Question 7

Which area of ischaemia is targeted in acute ischaemic stroke intervention?

Answer 7

The ischaemic penumbra - the area around the core ischaemia which receieves some blood from the blocked vessel but some blood from other vessels

Question 8

Why is a CT scan necessary in all strokes?

Answer 8

To exclude haemorrhage

Question 9

Within what time after onset can IV thrombolysis or mechanical thrombectomy be offered?

Answer 9

4 hours

Question 10

Describe IV thrombolysis

Answer 10

An IV bolus of 0.9mg/kg recombinant tissue plasminogen activator over 60 minutes

Question 11

The modified Rankin scale for stroke outcome goes from 0-6. What is a 2?

Answer 11

Independent with slight disability - can self-care but unable to perform all previous activities

Question 12

The modified Rankin scale for stroke outcome goes from 0-6. What is a 4?

Answer 12

Needs help to mobilise and to attend to own bodily needs

Question 13

What percentage of stroke patients will have their blood vessels unblock (recanalise) spontaneously?

Answer 13

24.1%

Question 14

In what percentage of patients is vessel unblocking successful with IV rTPA and mechanical thrombectomy respectively?

Answer 14

IV rTPA: 46.2%

Mechanical thrombectomy: 83.6%

Question 15

Describe the process of mechanical thrombectomy

Answer 15

A catheter is inserted into the vessel, then a stent is unfolded. The thrombus goes into the holes of the stent, which is then retracted to remove the thrombus

Question 16

Give a piece of evidence for using mechanical thrombectomy after the 4h time window

Answer 16

1) DEFUSE-3 trial - thrombectomy in the 6-16h time window increased likelihood of a functionally independent outcome 3x
2) DAWN trial - mechanical thrombectomy in the 6-24h time window is effective in certain carefully selected patients

Question 17

Define basilar artery thrombosis

Answer 17

Atherothrombotic or embolic occlusion of the basilar artery, which supplies the brainstem

Question 18

State the typical symptoms of basilar artery thrombosis

Answer 18

Fluctuating vertigo and loss of consciousness

Question 19

State the prognosis after basilar artery thrombosis

Answer 19

50-90% mortality with severe morbidity including locked-in syndrome

Question 20

Describe the symptom progression of a space-occupying middle cerebral artery infarct

Answer 20

Severe neurological deficit, with oedema leading to midline shift and brainstem compression, eventually inhibiting cardiorespiratory signals

Question 21

What is the standard treatment for a space-occupying middle cerebral artery infarct?

Answer 21

Hemicraniectomy

Question 22

Give a piece of evidence supporting the use of hemicraniectomy for space-occupying middle cerebral artery infarcts

Answer 22

DESIRE trial - hemicraniectomy reduces mortality, increases the number of patients with lower-level disability, and produces no increase in patients in a vegetative state

Question 23

Describe how a stroke unit reduces morbidity and mortality (Cochrane review, 2004)

Answer 23

Monitor patients with acute stroke in the sub-stable phase, carry out immediate diagnostic workup for cause, immediate specific therapy and secondary prevention (e.g. heparin), continuous vital sign monitoring

Question 24

What is the 1 year mortality of intracerebral haemorrhage?

Answer 24

37-47%

Question 25

What is the most common cause of non-traumatic intracerebral haemorrhage?

Answer 25

Hypertensive arteriolopathy

Question 26

State 4 causes of intracerebral haemorrhage other than hypertensive arteriolopathy

Answer 26

Trauma, anticoagulants, cerebral amyloid angiopathy, tumours, vascular malformations

Question 27

How are cerebral amyloid angiopathy haemorrhages different to those caused by hypertensive arteriolopathy?

Answer 27

Hypertensive haemorrhages are more likely to be deep, CAA haemorrhages more likely to be superficial

Question 28

State, in order of commonality, the sites for intracerebral haemorrhages

Answer 28

Lobar, basal ganglia and thalamus, cerebellum and brainstem

Question 29

Name the sign on MRI that predicts haematoma enlargement

Answer 29

The spot sign

Question 30

Describe the results of trials into using recombinant factor VIIa to treat intracerebral haemorrhage

Answer 30

Reduction in haematoma volume but no improvement in death or disability rates at 90 days. Increased risk of thromboembolic events

Question 31

Describe the results of the UK TICH-2 trial (Sprigg et al, 2018) into intracerebral haemorrhage

Answer 31

Tranexamic acid had no impact on intracerebral haemorrhage disability or death

Question 32

State 3 factors associated with haematoma growth

Answer 32

Deep location, high systolic blood pressure, high INR level on first measurement

Question 33

State the inclusion criteria for intensive blood pressure lowering to treat intracerebral haemorrhage

Answer 33

Spontaneous haemorrhage, within 6 hours of symptom onset, blood pressure 150-220mmHg

Question 34

State the exclusion criteria for intensive blood pressure lowering to treat intracerebral haemorrhage

Answer 34

Structural cause of haematoma, GCS 3-5, massive haematoma with poor prognosis, planned early surgery

Question 35

Give a piece of evidence against using surgery to treat intracerebral haemorrhage

Answer 35

The STICH-II trial found surgery had only a minimal effect on outcome