Ischemic/Hemorrhagic stroke, TIA, Bells Palsy, Ramsay Hunt

Question 1

Stroke
-subtypes

Answer 1

Sudden interruption of blood supply in brain
Ischemic (85%)
-thrombosis of large vessels (carotid)
-embolic from clot/fat/air/septic

Haemorrhagic (15%)
-intracerebral
-subarachnoid

Question 2

Risk factors for stroke and TIA
-ischemic
-hemorrhagic

Answer 2

General
-HTN
-age
-hypercoagulability - APS, migraine with aura, postpartum, sickle cell

Ischemic
-smoking
-hyperlipidemia, carotid artery disease
-DM
-AF, infective endocarditis

Hemorrhagic
-AVM
-ADOKD
-AC

Question 3

Symptoms of stroke

Answer 3

ACUTE SUDDEN FOCAL NEURO LOSS
-unilateral weakness/paraesthesia in face, arm, leg
-dysarthria, expressive/receptive dysphasia
-vision problems
-headache (sudden, severe, unusual)
-ataxia
-vertigo/loss of balance

Question 4

Symptoms of stroke mimics

Answer 4

Neuro symptoms that are gradual in onset, progressive, migratory
-POSITIVE neurological symptoms (flashing lights, tingling, jerking, shaking limbs)
-cognitive impairment
-resp, abdominal or other abnormal signs

Question 5

Stroke and TIA mimics

Answer 5

Migraine with aura - positive marching in minutes

Epilepsy - focal, acute, positive sensorimotor spread in minutes.
Stereotypic attacks

TGA - short term acute anteroretrograde amnesia, resolves in hours

Bells palsy

Facial palsy

Question 6

Facial palsy/Bells palsy
-presentation
-how does this differ from a stroke

Answer 6

Weakness/paralysis of facial muscles

Forehead sparing in UMN/stroke
Forehead not spared in facial palsy

Question 7

Bells palsy
-presentation
-investigations
-management

Answer 7

Idiopathic, but related to recent viral infections/stress

Painless unilateral LMN facial weakness, in hours
-cannot close eyes or cry
-increased sensitivity to sound
-metallic taste

Clinical diagnosis
-serology to rule out RHS

Supportive eye care - eye pathc, lubricating drops
Medical - PO steroids within 72hrs + antivirals
Surgical if no change or not Bells

If no change within 3wks => urgent neuro referral

Question 8

Ramsay Hunt Syndrome
-pathophysiology
-presentation
-investigations
-management

Answer 8

Reactivitation of HZV

Ear pain => facial palsy, ipsilateral vertigo, increased sensitivity to sound, blisters on VII region

Clinical diagnosis

Medical - PO pred (5 days) + aciclovir (7 days)

Question 9

Stroke patterns - Anterior cerebral artery

Answer 9

CL M+S loss
L limbs > U limbs

Question 10

Stroke patterns - Middle cerebral artery

Answer 10

CL M+S loss
U limb > L limbs

CL HH
Aphasia if dominant hemisphere affected
Spatial neglect if non dominant hemisphere affected

Question 11

Stroke patterns - Posterior cerebral artery

Answer 11

CL HH with macular sparing
Visual agnosia

Question 12

Stroke patterns - Branches of PCA that supply midbrain

Answer 12

Weber’s syndrome

IL CN3 palsy
CL UL, LL weakness

Question 13

Stroke patterns - Posterior inferior cerebellar artery

Answer 13

Lateral medullary syndrome
Wallenburg syndrome

Spinothalamic - temp/pain loss
IL facial
CL limb/torso

Ataxia, nystagmus

Question 14

Stroke patterns - Anterior inferior cerebellar artery

Answer 14

Lateral pontine syndrome

Spinothalamic - temp/pain loss
IL facial
CL limb/torso

IL FACIAL PARALYSIS and DEAFNESS

Question 15

Stroke patterns - retinal artery

Answer 15

Amaurosis fugax

Question 16

Stroke patterns - basilar artery

Answer 16

Locked in syndrome

Question 17

Difference between TIA and stroke

Answer 17

TIA - brief neurological deficit due to focal brain, spinal cord, retinal ischemia without acute infarction

Stroke - acute infarction of focal, brain, spinal cord, retinal ischemia => neurological deficit

Question 18

Management of suspected ischemic stroke
-secondary management

Answer 18

Carotid endarterectomy if
-stroke/TIA in carotid region and not severely disabled
-stenosis 50 or 70%+ depending on criteria used

Question 19

Presentation of hemorrhagic strokes (SAH)

Answer 19

Thunderclap occipital headache
-peak severe pain almost instantly
-may be history of less severe headaches leading up to presentation

N+V

Meningism - photophobia, neck stiffness

Seizures

May have ST elevation on ECG
-from autonomic neural stimulation from hypothalamus/elevated levels of circulating catecholamines

Question 20

TIA
-what is it

Answer 20

Transient neurological deficit caused by focal cerebral ischemia without CT evidence of infarction

Symptoms last U24hrs, bit similar to stroke

Question 21

Bamford and Oxford classification of strokes
POCS

Answer 21

Posterior circulation infarct - cerebellum and brainstem

-homonymous hemianopia
-dizzy
-drowsy
-dysarthria
-diplopia
-dysphagia

Question 22

Bamford and Oxford classification of strokes
TACS vs PACS

Answer 22

Total anterior circulation infarct - ACA + MCA

INVOLVEMENT OF WEAKNESS/SENSORY LOSS + VISION + SPEECH

All 3 of
-unilateral weakness/sensory deficit of face, arm, leg
-homonymous hemianopia
-higher cerebral dysfunction (aphasia or spatial neglect)

PACS - smaller arteries of anterior circulation involved

2 of the 3 criteria from above

Question 23

Bamford and Oxford classification of strokes
Lacunar

Answer 23

Lacunar infarct - no loss of higher cerebral function

1 of
-pure sensory
-pure motor
-sensorimotor
-ataxic hemiparesis

Question 24

Stroke differentials
-acute
-chronic

Answer 24

Acute
-seizure
-migraine + aura
-peripheral neuropathy - Bells
-trauma
-hypoglycemia, hypoxia
-syncope
-meningitis, encephalitis, vasculitis
-delirium
-drug, alcohol, Wernicke’s

Chronic
-tumour
-subdural
-asbcess

Question 25

Initial investigations for suspected stroke or TIA

Answer 25

History Clinical examination -neuro -cardiovascular -RULE OUT HYPOXIA AND HYPOGLYCEMIA Quick screening tools -FAST -ROSIER Suspect stroke if -sudden onset focal neurological deficit, ongoing/persisted for longer than 24hrs Suspect TIA if -sudden onset neurological deficit has resolved within 24hrs Blood glucose ECG - AF? CT HEAD TO ASSESS FOR HEMORRHAGE

Question 26

Managament of ischemic stroke -immediate -secondary prevention

Answer 26

A-E stabilisation ASPIRIN 300mg for 2 weeks Non contrast CT head -may not see anything -may have hypodense tissue + (hyperdense artery sign from clot) U4.5hrs since onset - alteplase thrombolysis U6hrs since onset - mechanical thrombectomy for proximal anterior circulation -can use with thrombolysis if applicable 6-24hrs => thrombectomy if there is potential to salvage brain tissue -Yes = proximal anterior circ -Maybe = proximal posterior circ 2 week follow up 1st line - long term clopidogrel 75mg + PPI 2nd line - aspirin 75mg + MR dipyridamole 200mg BD 3rd line - aspirin 75mg OD 4th line - MR dipyridamole 200mg BD Lifestyle changes -smoking cessation -reduce alcohol -increase physical activity -diet modification

Question 27

Management of hemorrhagic stroke

Answer 27

STOP AC, AP Rapid reduction in high BP => target 130-140 within 1 hour of treatment, maintain for 7 days UNLESS -underlying structural cause - tumour, AVM, aneurysm -GCS U6 -early neurosurgery to evacuate hematoma -massive hematoma with poor prognosis Surgery SAH - coil, craniectomy and clipping ICH - craniotomy/craniectomy with evacuation of hematoma Hydrocephalus - temporary ext ventricular drain or long term ventriculoperitoneal shunt LowNa from SIADH Seizures

Question 28

Investigations and management -subarachnoid hemorrhages

Answer 28

Non contrast CT head immediately to assess for ischemic or haemorrhagic If U6hrs + normal => alt diagnosis If 6hrs+ + normal => LP at least 12hrs from onset -xanthochromia = identify true SAH from traumatic tap -normal/high opening pressure Evidence of hemorrhagic stroke -hyperdense blood surrounded by hypodense edema => NEUROSURGERY REFERRAL and CT intracranial angio to identify cause Fluid resuscitation PO nimodipine => prevent vasospasm Reduce BP!

Question 29

Management of TIA -initial -ongoing

Answer 29

Referrals -Current => emergency admission, imaging to exclude hemorrhagic -Multiple TIAs => discuss admission with stroke specialist -Within week => assessment within 24hrs -More than 1 week => assessment within the week Immediate 300mg aspirin unless -has bleeding disorder or on AC/AP => immediate admission for imaging to exclude haemorrhage -can't take aspirin -TIA caused by AF => take DOAC/warfarin Imaging - MRI -determine ischemic area/hemorrhage Aspirin for 2 weeks => clopidogrel 75mg Statin 40mg Lifestyle modification Do not drive until driving advice given by specialist team Carotid doppler - if candidate for carotid endarterectomy (stenosis 70%+) If U55 -thrombophilia and AI screening (ANA, APL. ACL, LA) -coagulation factors -ESR -homocysteine -syphilis