Neuro - Strokes

Question 1

Describe the main causes of stroke.

Answer 1

1. Ischaemic (85%)
   a) thrombosis
   - atherosclerosis
   b) embolism
   - AF
   - carotid atherosclerosis
   - valvular disease
   - septic emboli
   - intracardiac thrombi
2. Intracranial haemorrhage (10%)

Question 2

Name the main risk factors for strokes.

Answer 2

1. Ischaemic
   - increasing age
   - HTN
   - AF
   - hyperlipidaemia
   - PFO
   - thrombophilia
2. Haemorrhagic
   - increasing age
   - HTN
   - AVM
   - anticoagulation treatment

Question 3

A 56yo man is brought to ED with a ?stroke. What is your differential diagnosis?

Answer 3

1. DKA/hypoglycaemia
2. hemiplegic migraine
3. previous CVA + systemic illness (functional decompensation)
4. post-ictal

Question 4

A 56yo man is brought to ED with a ?stroke. How would you assess/investigate him?

Answer 4

1. blood glucose to rule out hypoglycaemia
2. ROSIER score
3. non-contrast CT brain (look for effacement, loss of grey/white matter distinction, increased intensity of BV)
4. CT angiography if thrombectomy might be indicated

Question 5

A 56yo man is brought to ED with a ?stroke. CTB supports the diagnosis and rules out an intracranial haemorrhage. Symptom onset was 3hrs ago.
What is your initial and short-term management?

Answer 5

1. Admit to stroke unit
2. ALTEPLASE IV (as within 4.5hrs)
   or if large vessel disease and according to imaging: thrombectomy (as within 6hrs)
3. optimise physiology e.g. BP
4. 300mg ASPIRIN OD for 14/7 (start 48hrs post-thrombolysis)
5. support nutrition e.g. NGT
6. monitor for complications
7. carotid doppler, ECG/24hr tape, echo

Question 6

A 56yo man is admitted to hospital and treated with IV alteplase for an ischaemic TACS. On discharge, which secondary prevention measures should he be on?

Answer 6

1. CLOPIDOGREL 75mg OD PO (if contra-indicated: ASPIRIN + DYPIRIDAMOLE)
2. ATORVASTATIN 80mg OD PO
3. ensure BP + glycaemic control
4. lifestyle measures e.g. stop smoking + cardiac rehabilitation

Question 7

When would a carotid endarterectomy be indicated?

Answer 7

In a fit patient with symptomatic carotid stenosis >50% e.g. post-stroke or TIA.

Question 8

Name the 3 criteria for a TACS. Which vessel is likely affected?

Answer 8

1. homonymous hemianopia AND
2. hemiparesis AND
3. higher cortical dysfunction

ICA or proximal MCA

Question 9

Which features suggest a PACS? Which vessel is likely affected?

Answer 9

1. isolated higher cortical dysfunction OR
2. any 2 of: higher cortical dysfunction, homonymous hemianopia, hemiparesis

Branch MCA

Question 10

Which features suggest a LACS? Which vessels are likely affected?

Answer 10

1. pure motor or sensory stroke OR
2. ataxic hemiparesis OR
3. clumsy hand-dysarthria

Usually small lenticulostriate arteries.

Question 11

Which features suggest a POCS? Which vessels are likely affected?

Answer 11

1. isolated homonymous hemianopia OR
2. brainstem syndromes OR
3. cerebellar syndromes

PCA, vertebral or cerebellar vessels.

Question 12

A patient presents to the GP with a suspected TIA 2hrs ago. How should the he be managed?

Answer 12

1. 300mg ASPIRIN stat.
2. refer for urgent assessment by specialist within 24hrs
3. Ix: carotid doppler, ECG
4. clopidogrel 75mg PO OD (or aspirin + dipyridamole)
5. atorvastatin 80mg OD
6. consider carotid endarterectomy
7. advise cannot drive for 1/12