Investigations in Stroke

Question 1

What basic obs and bedside tests can be done to start the investigation into a stroke?

Answer 1

BP - check for HTN

ECG - check for ventricular hypertrophy, AF

Question 2

What basic bloods can we do to investigate a stroke?

Answer 2

FBC for thrombocytopenia or polycythemia
ESR for ?giant cell arteritis
Ceck for:
-Hypoglycaemia
-Hyperglycaemia
-Hyperlipidaemia

Question 3

A young pt (under 40) has a stroke. What extra bloods would you want to do to investigate possible causes in this case?

Answer 3

• Coagulation screen for clotting disorders (antithrombin, factor V Leiden, prothrombin gene mutations)
• Protein S and Protein C for deficiencies
• ?tumour markers if cancer indicated
• Blood film for sickle cell
• Antiphospholipid antibodies

Question 4

What scoring systems can we use to assess risk of strokes or other thromboembolic events?

Answer 4

ABCD2 score

Question 5

What is the ABCD2 score?

Answer 5

Scoring system designed to predict the likelihood of another CVA event i.e. having a stroke after a TIA.

Question 6

Tell me about the ABCD2 score.

Answer 6

Age over 60 - 1
BP over 140/90 - 1
Clinical features:
-Unilateral weakness - 2
-Speech disturbance, no weakness - 1
Duration:
-Over 60 mins - 2
-10-60 mins -1
-0-10 mins - 0
Diabetes - 1

If greater than or equal to 4, pt is high risk of a subsequent CVA and should start 300mg aspirin immediately and go for further investigation.

Question 7

What is the ROSIER score?

Answer 7

Stroke assessment tool to distinguish stroke/TIA from nonstroke event.

Question 8

Describe the ROSIER score for me.

Answer 8

0 or less means nonstroke:
-LoC/syncope = -1
-Seizure activity = -1
New acute onset of:
-asymmetric facial weakness = +1
-asymmetric arm weakness = +1
-asymmetric leg weakness = +1
-speech disturbance =	+1
-visual field defect =	+1

Question 9

What can we use to assess AF in a pt to see if they need anticoagulation?

Answer 9

CHA2DS2-VASc score

Question 10

Describe the CHA2DS2-VASc score.

Answer 10

Congestive HF (1)
HTN (treated or untreated) (1)
Age over 75 (2) or over 65 (1)
Diabetes (1)
Stroke (previous stroke or TIA) (2)
Vascular disease (1)
Sex female (1) (only if score on anything else)

0 = no Rx
1 = consider anticoag
2 = anticoag needed

Question 11

How can we assess someones risk of bleeding if we want to start them on anticoagulation e.g. warfarin?

Answer 11

Using HASBLED score

Question 12

What is the HASBLED score?

Answer 12

Risk assessment for bleeding:
HTN (uncontrolled over 160 systolic) - 1
Abnormal renal/liver function - 1 for each
Stroke (Hx of) - 1
Bleeding (hx or tendancy) - 1
Labiles INRs - 1
Elderly (over 65) - 1
Drugs increasing bleed risk or alcohol - 1 for each

3 or more indicates high risk for bleeding.

Question 13

When should brain imaging be done in a stroke pt?

Answer 13

ASAP, especially if they are within the treatment window for thrombolysis.

Everyone should be imaged within 24 hours of admission at the very longest.

Question 14

What imaging is used for acute phase of stroke?

Answer 14

CT

Question 15

Why is CT great?

Answer 15

It is sensitive, widely available, practical, quick, and easy to use in ill patients.

Question 16

What is MRI better for than CT in a stroke pt?

Answer 16

• Chronic haemorrhage
• Determining site and extent of ischaemic damage
• Small lesions or posterior fossa lesions

Question 17

A stroke pt has signs of infective endocarditis. How should we investigate after acute phase?

Answer 17

Echo

Question 18

What can we use to look at the carotids if we suspect they are the origin of a clot for a stroke?

Answer 18

Carotid duplex ultrasound.

Question 19

What imaging modality can be used to look for AV malformations?

Answer 19

MRI angiogram/venogram