Medicine: Cerebrovascular disease

Question 1

New definition of TIA

Answer 1

* even short periods of ischaemia can lead to permanent changes → therefore a new ‘tissue-based’ definition rather than a ‘time-based’

‘Tissue-based’ definition: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

Question 2

New definition of stroke

Answer 2

Sudden onset of a focal neurological deficit, lasting more than 24 hours (or leading to death) due to either infarction (85%) or haemorrhage (15%)

Question 3

What’s ROSIER score?

Describe it

Answer 3

ROSIER it’s a variant of FACE used by medical professionals

• Total Score > 0 (1-6) = Acute Stroke is likely
• Total Score 0, -1 or -2 = Stroke unlikely (Discuss with Stroke Team)

Question 4

First-line investigation for a suspected stroke

Answer 4

A non-contrast CT head scan is the first-line radiological investigation for suspected stroke

Question 5

Anatomy of circle of Willis

Answer 5

Question 6

What’ total anterior circulation stroke

Answer 6

Total Anterior Circulation Stroke (TACS)

•Hemiparesis +/- hemisensory loss

AND

•Homonymous hemianopia

AND

•Cortical dysfunction (dysphasia /perceptual problem)

Question 7

What’s that?

Answer 7

Total Anterior Circulation Stroke

Question 8

What’s that?

Answer 8

Clot in left middle cerebral artery (MCA)

Question 9

What’s partial circulation stroke?

Answer 9

• 2 of the 3 below:
• Hemiparesis +/- hemisensory loss
• Homonymous hemianopia
• Cortical dysfunction (dysphasia / perceptual problem)
• OR
• Cortical dysfunction alone

Question 10

What’s that?

Answer 10

Partial anterior circulation stroke

Question 11

What’s a lacunar stroke? (criteria)

Answer 11

LACUNAR STROKE (LACS)

• Hemiparesis

OR

• Hemisensory loss

OR

• Hemisensorymotor loss

OR

•Ataxic hemiparesis

* No cortical dysfunction or hemianopia *

Question 12

What’s that?

Answer 12

Lacunar stroke

Question 13

Signs and symptoms of Posterior Circulation Stroke

Answer 13

Posterior Circulation Stroke (POCS)

• Brainstem nuclei or cerebellar signs & symptoms
• Occipital signs

Presentation:

•Diplopia, vertigo, ataxia, bilateral limb problems, hemianopia, cortical blindness

Question 14

What’s that?

Answer 14

Posterior circulation stroke

Question 15

Acute Mx of stroke

Answer 15

• CT Brain
• Bloods
• ECG
• CXR
• Aspirin 300mg ASAP (PO/PR/NG) – if no bleed on scan
• Stroke Unit

Question 16

Mx of a stroke at stroke unit

Answer 16

• Careful monitoring and correction of physiological parameters
• Hypoxia / Glucose / Blood pressure / Pyrexia
• Early SALT input
• Early feeding
• Physiotherapy and rehab
• Psychology input

Question 17

What’s the Modified Rankin Scale?

Answer 17

Commonly used measure of disability / dependence in people who have suffered a stroke or other causes of neurological disability

0 - No symptoms

1 - No significant disability. Able to carry out all usual activities, despite some symptoms

2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.

3 - Moderate disability. Requires some help, but able to walk unassisted.

4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted

5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent

6 - Dead

Question 18

Power grading in neurological examination

Answer 18

Question 19

Secondary prevention of stroke

Answer 19

• Clopidogrel 75mg od, after 2 weeks of Aspirin 300mg od
• Cholesterol control (target < 4.0) - Statin
• BP Control (target < 130/80)
• Screen for and treat diabetes
• Smoking cessation
• Screen for and treat carotid stenosis
• Screen for and manage AF (anticoagulation)
• Echocardiogram

Question 20

What’s the driving restriction post-stroke?

Answer 20

Driving restrictions (DVLA): Car – 1 month off driving if good functional recovery

Question 22

What’s the ischaemic core?

Answer 22

ISCHAEMIC CORE (irreversible damage) :

Area of brain tissue local to the blood vessel occlusion, whose blood supply is entirely supplied by this vessel, dies.

Question 23

What’s Ischaemic Penumbra?

Answer 23

ISCHAEMIC PENUMBRA (SALVAGEABLE TISSUE):

• Surrounding the ischaemic core is an area with some collateral blood supply (blood flow is reduced)
• Without intervention much of this will also die
• Over subsequent hours this area either becomes viable again, or forms part of the ischaemic core.

Question 24

Role/considerations in the hyperacute treatment of stroke

Answer 24

• Earlier treatment = better outcomes
• Ischaemic penumbra is likely to be larger
• As the penumbra disappears, stroke therapy such as thrombolysis becomes ineffective
• Most patients no longer have a penumbra beyond 4.5 hours
• Ischaemic core becomes more friable
• Risk of bleeding is higher & usually outweighs benefits of thrombolysis

Question 25

Management of stroke with thrombolysis ## Footnote - drug used - timeframe - what must be done before treatment - possible complications - when to repeat CT

Answer 25

* **IV Alteplase** * Bolus – 10% of total dose (0.9mg/kg) * Infusion over 1 hour (remainder of drug) * Given within 4.5 hours of symptom onset * Urgent CT brain to exclude bleed prior to treatment * Complications include bleeding & angio-oedema * Repeat CT Brain at 24 hours

Question 26

What's **thrombectomy**? - timeframe - complications

Answer 26

**Thrombectomy = Mechanical Clot Retrieval** ## Footnote **•** offered up to 6 hours post symptom onset * Can be as 1st line but usually as 2nd line treatment after failed thrombolysis * Risk of serious complications: Intracranial haemorrhage / access site complications / vessel perforation / distal emboli

Question 27

Thrombectomy procedure - describe

Answer 27

Procedure: * Under sedation (Local or General anaesthesia) * Initially, patient undergoes conventional cerebral angiography: demonstrates presence & location of arterial occlusion * Delivery catheter inserted (usually through femoral artery) & advanced using X-ray guidance to occluded vessel * Clot retrieval device attached to a guidewire is introduced through the delivery catheter to the occlusion site

Question 28

Ix in deteriorating stroke patient

Answer 28

* ABCDE * Blood glucose * GCS and Neurological examination * Bloods - Consider aspiration / infection * Urgent CT Brain

Question 29

What's the scan present?

Answer 29

Intracerebral haemorrhage with surrounding oedema and midline shift

Question 30

What's the scan present?

Answer 30

Malignant MCA Syndrome

Question 31

ABCD2 scoring system

Answer 31

* Age \> 60 = 1 * BP \> 140/90 = 1 * Clinical – speech disturbance (1), unilateral weakness (2) * Duration – 10 mins to 59 mins (1), 1hr + (2) * Diabetes = 1 1-3 = 2-day risk of 1%, 7 day risk of 1.2% 4-5 = 2-day risk of 4%, 7 day risk of 6% \>5 = 2-day risk of 8%, 7 day risk of 12%

Question 32

Why seizures and transient LOC are not usually indicative of a stroke?

Answer 32

* stroke does not cause seizures ACUTELY → however possible to cause seizures later on due to fibrosis of the dead tissue etc * stroke does not cause transient LOC/syncope → if stroke causes LOC it would be more long-term like

Question 33

What do we with high BP in acute **ischaemic** stroke?

Answer 33

* do not lower BP → sometimes high BP needed to maintain perfusion * lower BP → if thrombolysis is indicated

Question 34

What to do with high BP in acute **haemorrhagic** stroke?

Answer 34

lower BP gradually

Question 35

Stroke differentials

Answer 35

* post- seizure **Todd Paresis** → is a focal weakness in a part or all of the body after a seizure. This weakness typically affects appendages and is localized to either the left or right side of the body. It usually subsides completely within 48 hours * Bell's Palsy * migraine

Question 36

How to differentiate between stroke vs Bell's Palsy

Answer 36

* Bell's Palsy is LMN → therefore both, forehead + face affected * Stroke is UMN → forehead sparing

Question 37

How to differentiate between haemorrhagic and ischaemic stroke on CT scan?

Answer 37