Neurology - stroke

Question 1

What are strokes caused by?

Answer 1

Ischaemia or infarction due to inadequate blood supply

Intracranial haemorrhage

Question 2

What can cause disruption of blood supply?

Answer 2

Thrombus formation or embolus, for example in patients with atrial fibrillation

Atherosclerosis

Shock

Vasculitis

Question 3

Presentation

Answer 3

Sudden onset of neurological symptoms.

Symptoms are typically asymmetrical:

Sudden weakness of limbs

Sudden facial weakness

Sudden onset dysphasia (speech disturbance)

Sudden onset visual or sensory loss

Question 4

RFs for stroke

Answer 4

Cardiovascular disease such as angina, myocardial infarction and peripheral vascular disease

Previous stroke or TIA

Atrial fibrillation

Carotid artery disease

Hypertension

Diabetes

Smoking

Vasculitis

Thrombophilia

Combined contraceptive pill

Question 5

Investigations in suspected stroke

Answer 5

CT head - to exclude intracerebral haemorrhage

Exclude hypoglycaemia and other stroke mimics - but don’t delay the CT head if stroke is likely

Could consider carotid ultrasound (not in the acute scenario so much) - to assess for carotid stenosis

Question 6

What are some stroke mimics?

Answer 6

Seizure (e.g. Todd’s paresis following seizure)

Hypoglycaemia

Migraine (particularly hemiplegic migraine)

Syncope

Question 7

Initial management of stroke

Answer 7

Aspirin 300mg stat (after CT excluded haemorrhage) - for 2 weeks

Thrombolysis with alteplase (after haemorrhage excluded) - can be offered within 4.5h of symptom onset

Thrombectomy is also an option if an occlusion is confirmed on imaging and within 24h of symptom onset.

Generally, blood pressure should not be lowered during a stroke because this risks reducing the perfusion to the brain.

Question 8

How does alteplase work?

Answer 8

It is a tissue plasminogen activator that rapidly breaks down clots

Question 9

What are some absolute contraindications to thrombolysis?

Answer 9

• Previous intracranial haemorrhage
• Seizure at onset of stroke
• Intracranial neoplasm
• Suspected subarachnoid haemorrhage
• Stroke or traumatic brain injury in preceding 3 months
• Lumbar puncture in preceding 7 days
• Gastrointestinal haemorrhage in preceding 3 weeks
• Active bleeding
• Pregnancy
• Oesophageal varices
• Uncontrolled hypertension >200/120mmHg

Question 10

Management of TIA

Answer 10

Start aspirin 300mg daily. Start secondary prevention measures for cardiovascular disease.

Stroke specialist review within 24h

Question 11

What is the secondary prevention of stroke?

Answer 11

Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily)

Atorvastatin 80mg should be started but not immediately

Carotid endarterectomy or stenting in patients with carotid artery disease

Treat modifiable risk factors such as hypertension and diabetes

Question 12

Further long term stroke management

Answer 12

MDT involvement including:

• SALT
• Dieticians
• Physio
• Nurses
• OT
• Ophthalmology
• Orthotics