Ischaemia stroke

Question 1

Paramedics inform you that a 65y right handed male presents with RS weakness, dysarthria, loss of vision and difficulty speaking. Symptoms started at 1:30 and now it is 3pm
Stroke is likely, but what type of stroke?
What is important in the history and what do we do next?

Answer 1

Left MCA Ischaemia stroke

• Right sided, dysarthria, loss of vision, difficulty speaking - left MCA stroke
• 1.5h so blue light ambulance and perform CT scan to rule out bleed, proceed to thrombolysis and thrombectomy if no contraindications.

Question 2

These symptoms correlate to a stroke in which area of the brain?

• Leg weakness
• Sensory disturbance in the legs
• Gait apraxia - common, especially truncal ataxia
• Incontinence
• Drowsiness
• Akinetic mutism - decrease in spontaneous speech and stuporus state

Answer 2

ACA territory stroke

Question 3

Which area of the brain would cause the most devastating stroke? What symptoms would you suspect in this type of stroke?

Answer 3

MCA as it would mean a large amount of brain tissue are infarcted

• contra-lateral arm and leg weakness, contra-lateral sensory loss
• hemianopia
• aphasia as wernickes and brooks area are affected
• dysphasia as motor supply to tongue can be affected
• facial droop

Question 4

What effects would you expect from a PCA territory stroke?

Answer 4

• Damage to the occipital lobe: cortical blindness with bilateral involvement of the occipital lobe branches
• Visual agnosia - lack of ability to interpret visual information (difference between persons face and plant)
• Prosopagnosia - inability to distinguish one persons face from another persons face
• Dyslexia, anomic aphasia, colour naming and discrimination problems
• Headaches unilateral - otherwise headaches in ischaemic strokes are uncommon

Question 5

What symptoms would you expect in a posterior circulation stroke?

Answer 5

• Motor deficits such as meniparesis or tetraparesis and facial paresis - 40-60% cases
• Dysarthria and speech impairment as bulbar muscles are affected - 30-60%
• Vertigo, nausea and vomiting as CN nuclei controlling balance are affected in 50-70%
• Visual disturbances 20-30%
• Altered consciousness especially if reticular formation is affected - 15-30%

Question 6

Treatment for acute Ischaemia stroke?

Answer 6

Time is key

• image straight away for CT
• alteplase (breaks up clot)
• only used in first 4 hrs so need to know onset

Thrombolysis - up to 4.5hrs post onset of symptoms

Clot retrieval - thrombectomy (highly skilled technique)

Decompressive craniotomy

Question 7

Secondary prevention after strokes

Answer 7

Platelet treatment - aspirin 300mg or clop
Cholesterol treatment - statins for those with cholesterol 4 or above
AF treatments - warfarin, DOAC
Blood pressure treatment - antihypertensives
Manage diabetes