Neuro - Stroke/TIA

Question 1

As a quick exam to check for stroke/TIA, what (2) do you get patients to do?

Answer 1

Facial Droop: Have Patient Smile

Arm Drift: Close Eyes & Hold Out Both Arms

Question 2

Emergency Rx for stroke (Code Stroke)

Answer 2

1. Urgent triage and high priority for stroke patient
2. Mobilise the stroke team
3. IV - glucose, routine biochemistry, FBE
4. ECG
5. Accurate clinical diagnosis – exclude mimics 6. Urgent CT

Question 3

(4) Clinical features that help predict stroke

Answer 3

• exact time of onset
• patient could recall exactly what they were doing at symptom onset
• well in the last week
• definite focal symptoms or signs, worse NIHSS

Question 4

(5) clinical features that help predict mimics of stroke

Answer 4

• known cognitive impairment
• lost consciousness or seizure at onset
• patient could still walk
• no lateralising symptoms
• confusion, non-vascular or no neurological signs

Question 5

3 major stroke types

Answer 5

• Ischemic stroke (cerebral infarction)
• Intracerebral hemorrhage (ICH)
• Subarachnoid hemorrhage (SAH)

Question 6

5 subtypes of ischaemic stroke

Answer 6

1. Large artery thromboembolism
2. Cardiogenic embolism (e.g. AF)
3. Small vessel (lacunar) infarction
4. Rarer causes
5. Unclassified or cryptogenic

Question 7

2 subtypes of intracerebral haemorrhage

Answer 7

1. Deep hypertensive location

2. Lobar

Question 8

3 subtypes of subarachnoid haemorrhage

Answer 8

1. Aneurysm
2. Arteriovenous malformation
3. Other

Question 9

(4) Areas commonly affected in deep ICH

Answer 9

Putamen, thalamus, brainstem, cerebellum

• Usually due to hypertension and rupture of deep penetrating arteries

Question 10

General area commonly affected in lobar ICH

- Causes?

Answer 10

Superficial

• Often secondary to amyloid angiopathy, tumour, arteriovenous malformation, aneurysm

Question 11

Describe primary prevention of stroke

Answer 11

In those who have never had strokes before

• Main modifiable risk factors are smoking, hypertension, diabetes and obesity
• Encourage smoking cessation, weight loss, increased physical activity and a healthy diet
• Antihypertensive drugs reduce the risk of primary stroke by up to 40%
• There is NO clear indication for antiplatelet treatment in low risk, or intermediate risk (uncomplicated diabetes, hypertension or hypercholestrolaemia) of stroke
• In high risk of cardiovascular disease consider aspirin

Question 12

What is dabigatran?

Answer 12

A Direct Thrombin Inhibitor (NOAC)

Question 13

What is Rivaroxaban?

Answer 13

Factor Xa Inhibitors (NOAC)

Question 14

What is Apixaban?

Answer 14

Factor Xa Inhibitors (NOAC)

Question 15

How do you assess stroke risk in non-valvular AF?

Answer 15

CHADS2 score

(score 1 for each risk factor of heart failure, hypertension, age >75, and diabetes, score 2 for previous stroke of TIA).

• If score zero, can undertake a more comprehensive risk assessment e.g. VASc
• CHADS2 score of one or more recommends an oral anticoagulant
• Oral anticoagulants reduce the risk of stroke by about 60% in people with AF

Question 16

Describe secondary prevention of stroke

Answer 16

In those who have had a previous stroke

• Blood pressure lowering
• Cholesterol and statins
• Antiplatelet therapy – which strategy?
• Atrial fibrillation and anticoagulation
• Carotid revascularization endarterectomy and stenting

Lowering blood pressure and cholesterol at any level equally effective in secondary stroke prevention

High-risk patients benefit from BP, cholesterol lowering regardless of baseline

Antiplatelet therapy routine if patient not anticoagulated

Question 17

How do you assess the risk of having another stroke in stroke patients?

Answer 17

ABCD2 score

• Age >60
• BP: SBP >140, DBP>90
• Clinical: e.g. focal weakness, speech impaired w/o focal weakness
• Duration
• Diabetes

Total out of 7