Different types of strokes

Question 1

What signs would you expect to see in a stroke affecting the Anterior cerebral artery

Answer 1

Contralateral hemiparesis and sensory loss - mainly of the leg
E.g the leg may feel weaker and numb
There may be arm symptoms but these are often milder

This is due to the homunculus theory and the fat that the anterior cerebellar artery supplies the frontal and medial part of the cerebrum

Question 2

What signs would you expect to see in a stroke affecting the Middle cerebral artery

Answer 2

Contralateral hemiparesis and sensory loss - where the arm is affected more than the leg
Contralateral homonymous heminopia (due to the fact that it supplies the optic radiation)
Aphasia (an inability to comprehend or formulate language) - with dominant lesions
Visuospatial disturbance with non-dominant lesions

Question 3

What signs would you expect to see in a stroke affecting the Posterior cerebral artery

Answer 3

Contralateral homonymous hemianopia with macular sparing

Visual agnosia

Question 4

What signs would you expect to see in a stroke affecting the Posterior inferior cerebellar artery
What is this otherwise known as?

Answer 4

Lateral medullary syndrome
There is infarction of the lateral medulla and the inferior cerebellar surface
This leads to vertigo, vomiting, dysphagia, nystagmus, ataxia and:
Ipsilateral: facial pain (on pin prick) and temperature loss
Contralateral: limb/torso pain (on pin prick) and temperature loss

Question 5

What signs would you expect to see in a stroke affecting the Anterior inferior cerebellar artery

Answer 5

Symptoms are similar to Wallenberg’s but:

Ipsilateral: facial paralysis and deafness

Question 6

What signs would you expect to see in a stroke affecting the Retinal/ophthalmic artery

Answer 6

Amaurosis fugax (painless temporary loss of vision in one or both eyes

Question 7

What signs would you expect to see in a stroke affecting the Basilar artery

Answer 7

Locked in syndrome

Patient is aware but cannot move or communicate verbally due to complete paralysis of nearly all voluntary muscles

Question 8

What signs would you expect to see in a stroke affecting branches of the posterior cerebral artery that supply the midbrain?
What is this otherwise known as?

Answer 8

Known as Weber’s syndrome
Ipsilateral CN3 palsy
Contralateral weakness of upper and lower extremity

Question 9

How do lacunar strokes present?

Answer 9

With either isolated:
Hemiparesis
Hemisensory loss
Hemiparesis with limb ataxia

Question 10

What is your INR target for patients with recurrent PE or those that have suffered from DVTs whilst anticoagulated?

Answer 10

3.5

Question 11

What is your INR target for patients with AF/PE/DVT? How long do you initially anticoagulated for/

Answer 11

2-3

Initially anticoagulated for 3 months

Question 12

What is your target INR for patients with a prosthetic aortic valve?

Answer 12

2-3

Question 13

What is your target INR for a patient with a prosthetic mitral valve?

Answer 13

2.5-3.5

Question 14

What are the steps you would carry our if a patient has a severely raised INR due to warfarin and is have a major bleed?

Answer 14

Stop warfarin, vitamin K IV and PCC.

Question 15

Once a haemorrhagic stroke has been excluded what antiplatelet agent can be given? For how long?
What long term antiplatelet is given? What are the exceptions?

Answer 15

Aspirin 300mg. For 2 weeks
Long term = clopidogrel
If CI: Low dose aspirin plus slow released dipyramidole

Question 16

When should thrombolysis be carried out? (Within what time period)
What medication is commonly used?
What follow up should be carried out?

Answer 16

Within 4.5 hours of onset of symptoms
Alteplase
A CT must ALWAYS be done 24 hours post-lysis to identify any bleeds

Question 17

What are some risk factors for stroke?

Answer 17

7 raised things and 6 conditions/lifestyles:
7 up to heaven. RAISED:
- BP
- Lipids
- Clotting (fibrinogen)
- Homocysteine
- Alcohol
- PCV
- Sugar
6 other:
- Smoker
- Syphylis
- CHD
- PVD
- COCP
- Carotid bruit

Question 18

What are some investigations you may carry out to look into the cause of the stroke? (Think about different causes)

Answer 18

• BP (you may look
• Dyslipidaemia, hyperhomocysteinaemia, hyperglycaemia (look for on blood tests), PCV
• Investigate pro-thrombotic states e.g thrombophilia, antiphospholipid syndrome, thrombocytopaenia
• Look for active, untreated syphylis
• CHD (look for a cardiac source of emboli using ECHO)
• Look for hyperviscotic states e.g polycythaemia or sickle cell disease
• Carotid artery stenosis - do a carotid doppler US +/- CT/MRI

Question 19

What is the mechanism of action of aspirin?

Answer 19

Inhibits COX-1, therefore suppressing prostaglandin and thromboxane synthesis

Question 20

What is the mechanism of action of clopidogrel?

Answer 20

Inhibits platelet aggregation by modifying platelet ADP receptors, preventing further strokes and MIs

Question 21

What is the mechanism of action of dipyramidole?

Answer 21

Increases cAMP and decreases thromboxane production

Question 22

In the oxford classification of strokes what are the 3 components that make up a TACS?

Answer 22

1. Contralateral hemiparesis
2. Contralateral hemianopia
3. Higher cortical dysfunction

Question 23

In the oxford classification of strokes what is meant by higher cortical dysfunction?

Answer 23

Visuo-spatial deficit
Dysphasia
Dyspraxia

Question 24

What are the ABCD2 criteria?

Answer 24

Is tells you the risk of patients who have had a TIA having a stroke. It is age, Blood pressure, Clinical features (unilateral weakness/speech disturbance without weakness), Duration of symptoms, Diabetes