Neurology

Question 1

Causes of ischaemic stroke

Answer 1

• atheroma
• embolism
  1. cardiac - AF, endocarditis, MI, valve vegetations
  2. atherothromboembolism

Question 2

Causes of haemorrhagic stroke

Answer 2

HTN, aneurysm rupture, anticoagulation, thrombolysis, trauma, dissection

Question 3

Rarer causes of stroke

Answer 3

watershed stroke, vasculitis (HIV, PAN), carotid artery dissection, anti-phospholipid syndrome

Question 4

Stroke risk factors

Answer 4

Modifiable - HTN, smoking, high cholesterol

Non-modifiable - previous history, AF, valve disease, Black/Asian, DM, PVD

Question 5

TACS (Total anterior circulation)

Answer 5

Large infarct in carotid, MCA, ACA. All 3 of:

1. Contralateral hemiparesis and/or sensory (2 face, arm, leg)
2. Contralateral homonymous hemianopia
3. higher cortical dysfunction (dysphagia, hemispatial neglect)

Question 6

PACS (Partial anterior circulation)

Answer 6

Carotid / MCA /ACA

- 2/3 TACS criteria (less dense / incomplete deficit)

Question 7

POCS (posterior circulations stroke)

Answer 7

Vertebrobasilar territory. Any of:

1. Cerebellar syndrome
2. Brainstem syndrome
3. Contralateral homonymous hemianopia

Question 8

LACS (lacunar)

Answer 8

Small infarcts around basal ganglia / internal capsule / thalamus / pons. 5 syndromes:

1. Pure motor (post limb of internal capsule
2. Pure sensory (post thalamus)
3. Sensorimotor (internal capsule)
4. Dysarthria
5. Ataxic hemiparesis (ant limb of internal capsule)

Question 9

DDx for stroke

Answer 9

Head injury +/- haemorrhage
Glucose high or low
hemiplegic migraine
Todd's palsy
TIA
infections - encephalitis, abscess, HIV, toxoplasmosis
druge - opiate overdose

Question 10

Acute stroke management

Answer 10

1. Protect airway (consider NGT), NBM until swallow screen
2. Monitor: glucose (4-11), BP (<185/110), neuro obs
3. Exclude haemorrhage CT/MRI: within 1 hour if urgent, within 24 hours otherwise
4. treat as either ischaemic or haemorrhagic accordingly

Question 11

When would a CT/MRI be needed in 1 hour in stroke?

Answer 11

• if eligible for thrombolysis (<4.5hr)
• high haemorrhage risk (meningism, high ICP, reduced GCS)
• anticoagulants
• fluctuating consciousness

Question 12

Whats the best imaging for acute stroke?

Answer 12

Diffusion weighted MRI is the most sensitive for acute infarct but CT excludes primary haemorrhage

Question 13

Treatment for ischaemic stroke

Answer 13

1. Antiplatelets - aspirin 300mg or Clopidogrel if aspirin sensitive
2. Thrombolysis if <4.5hrs and 18-80yrs - Alteplase, 24hr CT to check for bleeds
3. Thrombectomy if eligible (large artery)
4. Surgery - consider decompressive hemicraniectomy (MCA)
5. Stroke unit - MDT, physio, DVT prophylaxis

Question 14

Treatment for haemorrhagic stroke

Answer 14

1. Neurosurgical opinion / coil aneurysms
2. Stop / reverse blood thinners
3. Treatment depending which type of haemorrhage

Question 15

Primary stroke prevention

Answer 15

1. Control risk - HTN, lipids, DM, smoking…
2. Consider anticoagulation in AF (CHADS2)
3. Carotid endarterectomy if Sx + 70% stenosis
4. Exercise

Question 16

Secondary stroke prevention

Answer 16

1. Control risk + statins after 48 hours
2. Antiplatelet therapy - Aspirin/Clopi 300mg 2 weeks then either one 75mg OD
3. Warfarin instead if cardioembolic stroke / AF
4. Carotid endarterectomy

Question 17

Stroke rehabilitation methods

Answer 17

MENDS
M - MDT
E - Eating - swallow, MUST
N - Neurorehab - physio and SALT
D - DVT prophylaxis
S - Sores (Avoid!)

Question 18

Stroke investigations

Answer 18

Cardiac emboli -