Neurology/neurosurgery - stroke

Question 1

How might stroke present?

Answer 1

Focal neurology
Numbness/tingling
Sudden death
Unconscious patient

Question 2

How does stroke normally develop?

Answer 2

Rapidly developing

Can include loss of global function

Question 3

How does stroke differ from TIA?

Answer 3

By definition, symptoms must last longer than 24hours or lead to death. If neither of these are present, this is TIA.

Question 4

What are the two broad classes of stroke?

Answer 4

Ischaemic

Haemorrhagic

Question 5

What is the incidence of stroke?

Answer 5

2/1000 population (1/500 or 0.2%)

Question 6

Where do the majority of strokes occur?

Answer 6

Cerebrum

Question 7

Where can a stroke affect in theory?

Answer 7

It can affect the cerebrum, cerebellum, brainstem or spinal cord

Question 8

Ischaemic strokes can be due to thrombosis - what causes thrombosis?

Answer 8

Virchow’s triad: vessel wall abnormalities e.g. vasculitis, inflammation or trauma, abnormalities of blood e.g. hypercoagulability, polycythaemia, disturbances of blood flow e.g. stasis or turbulence

Question 9

Ischaemic strokes can be be caused by embolus - list some things that might cause embolus?

Answer 9

Valvular disease
Atrial fibrillation
Recent MI

Question 10

if an artery is occluded, the area will infarct if no adequate collateral supply. There is a central zone of necrosis and an ischaemic penumbra - explain the ischaemic penumbra

Answer 10

This is a zone that is ischaemic but may recover function if blood flow is restored within a reasonable time frame

Question 11

Give two reasons why CNS ischaemia is often accompanied by swelling

Answer 11

Cytotoxic oedema - accumulation of water in damaged glial cells and neurones
Vasogenic oedema - ECF accumulation due to breakdown of blood brain barrier

Question 12

Swelling may cause major clinical deterioration in the days following major stroke - why and what can we do to help prevent this?

Answer 12

Swelling could compress major structure (Munro-kelly hypothesis).
Dexamethasone may counteract this.

Question 13

What forms the anterior circulation of the brain?

Answer 13

The internal carotid arteries

Question 14

What type of stroke will occlusion of the carotid artery cause?

Answer 14

Total anterior circulatory syndrome/infarct (TACS/TACI)

Question 15

What would you expect to see in TACS/TACI?

Answer 15

All three of:

• Unilateral hemiparesis +/- sensory deficit of the face, arm or leg
• Homonymous hemianopia
• higher dysfunction such as dysphasia or visuospatial disorder

Question 16

Where would you expect the occlusion to be in a partial anterior circulatory sydrome/infarct?

Answer 16

In the circle of willis distal to the internal carotid on that side e.g. anterior cerebral artery, middle cerebral artery

Question 17

What symptoms would you see in a PACS/PACI?

Answer 17

2/3 of:

• Unilateral hemiparesis +/- sensory deficit of the face, arm or leg
• Homonymous hemianopia
• higher dysfunction such as dysphasia or visuospatial disorder

Question 18

Where is the occlusion in a lacunar syndrome/infarct (LACS/LACI?)

Answer 18

The occlusion is in one of the small arterial branches that penetrate the deep structures of the brain

Question 19

What would you see in a LACS/LACI?

Answer 19

1/3 of:

• Unilateral hemiparesis +/- sensory deficit of the face, arm or leg
• Homonymous hemianopia
• higher dysfunction such as dysphasia or visuospatial disorder

Usually produce a characteristic syndrome such as pure motor, pure sensory or ataxic hemiparesis.

Question 20

Where does the posterior circulation arise from?

Answer 20

The vertebral/basilar arteries

Question 21

What would you see in a posterior circulatory syndrome/infarct (POCS/POCI?)

Answer 21

Evidence of brainstem lesion such as vertigo, diplopia, altered consciousness +/- homonymous hemianopia.

Question 22

Stroke is a clinical diagnosis - true/false

Answer 22

True - investigation is to find the cause and prevent recurrence rather than to diagnose

Question 23

What investigations should you do in suspected stroke?

Answer 23

FBC, ESR, U+E, glucose, lipid, CXR, ECG, CTB.

Question 24

What is the purpose of CTB in a stroke?

Answer 24

Distinguish between haemorrhage and ischaemic stroke and therefore decide on initial management; to thrombolyse or not to thrombolyse. Will rule out other important diagnoses such as intracranial neoplasm and subdural haematoma.

Question 25

Initial management of a stroke should include:

Answer 25

• admission to stroke unit
• 300mg aspirin 2x daily.
• 15% of patients eligible for thrombolysis with alteplase
  within 3hrs of onset for maximum benefit
• do not thrombolyse until CTB shows no bleeding

Question 26

Secondary prevention for stroke should include:

Answer 26

• reduce risk factors e.g. smoking/diet/statins/BP control
• dont start anti-HTN within 2 weeks unless malignant hypertension
• 300mg aspirin daily for 4weeks then 75mg daily life long
• Warfarin if in AF

Question 27

Who should be involved in rehabilitation?

Answer 27

Stroke specialists
Physiotherapy
Speech and language 
Occupational therapy
?Social work