Station 3.16: Stroke

Question 1

Clinical signs

What are the clinical signs of Stroke?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 1

• Inspection: walking aids, nasogastric tube or PEG tube, posture (flexed upper limbs
  and extended lower limbs), wasted or oedematous on affected side.
• Tone: spastic rigidity, ‘clasp knife’ (resistance to movement, then sudden release).
  Ankles may demonstrate clonus (>4 beats).
• Power: reduced.

MRC graded:
0, none
1, flicker
2, moves with gravity neutralized
3, moves against gravity
4, reduced power against resistance
5, normal
Extensors are usually weaker than flexors in the upper limbs and vice versa in the lower limbs.

• Coordination: sometimes reduced. Usually impaired due to weakness but may reflect cerebellar involvement in posterior circulation stroke.
• Reflexes: brisk with extensor plantars

Question 2

Clinical signs - offer to

What should you offer to do for this patient?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 2

• Walk the patient if they are able to, to demonstrate the flexed posture of the upper limb and ‘tip toeing’ of the lower limb.
• Test sensation (this is tricky and should be avoided if possible!). Proprioception is important for rehabilitation.

Question 3

Clinical signs - other signs

What are other signs of Stroke?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 3

• Upper motor neurone unilateral facial weakness (spares frontalis due to its dual innervation).
• Gag reflex and swallow to minimize aspiration.
• Visual fields and higher cortical functions, e.g. neglect helps determine a Bamford classification.
• Cause: irregular pulse (AF), blood pressure, cardiac murmurs or carotid bruits (anterior circulation stroke).

Question 4

Clinical signs - other signs

What are other signs of Stroke?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 4

• Upper motor neurone unilateral facial weakness (spares frontalis due to its dual innervation).
• Gag reflex and swallow to minimize aspiration.
• Visual fields and higher cortical functions, e.g. neglect helps determine a Bamford classification.
• Cause: irregular pulse (AF), blood pressure, cardiac murmurs or carotid bruits (anterior circulation stroke).

Question 5

Discussion - Definitions

Provide the definition of Stroke ?
Provide the definition of Transient ischaemic attack (TIA)?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 5

• Stroke: rapid onset, focal neurological deficit due to a vascular lesion lasting > 24 hours.
• Transient ischaemic attack (TIA): focal neurological deficit lasting < 24 hours.

Question 6

Discussion - Definitions

Provide the definition of Stroke ?
Provide the definition of Transient ischaemic attack (TIA)?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 6

• Stroke: rapid onset, focal neurological deficit due to a vascular lesion lasting > 24 hours.
• Transient ischaemic attack (TIA): focal neurological deficit lasting < 24 hours.

Question 7

Discussion - Investigation

What investigations do you prescribe for Stroke?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 7

• Bloods: FBC, CRP/ESR (young CVA may be due to arteritis), glucose and renal function
• ECG: AF or previous infarction
• CXR: cardiomegaly or aspiration
• CT head: infarct or bleed, territory
• Consider echocardiogram, carotid Doppler, MRI/A/V (dissection or venous sinus thrombosis in young patient), clotting screen (thrombophilia), vasulitis screen in young CVA

Question 8

Discussion - Acute Stroke Management

What management do you prescribe for Acute Stroke?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 8

• Thrombolysis with tPA (within 4.5 hours of acute ischaemic stroke)
• Clopidogrel (or aspirin + dipyridamole)
• Referral to a specialist stroke unit: multidisciplinary approach: physiotherapy, occupational therapy, speech and language therapy and specialist stroke rehabilitation nurses
• DVT prophylaxis

Question 9

Discussion - Chronic Stroke Management

What management do you prescribe for Chronic Stroke?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 9

• Carotid endarterectomy in patients who have made a good recovery, e.g. in PACS (if >70% stenosis of the ipsilateral internal carotid artery)
• Anticoagulation for cardiac thromboembolism
• Address cardiovascular risk factors
• Nursing +/− social care.

Question 10

Bamford classification of stroke (Lancet 1991) Management

What management do you prescribe for Bamford classification of stroke (Lancet 1991) ?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 10

Total anterior circulation stroke (TACS)
* Hemiplegia (contra‐lateral to the lesion)
* Homonomous hemianopia (contra‐lateral to the lesion)
* Higher cortical dysfunction, e.g. dysphasia, dyspraxia and neglect

Partial anterior circulation (PACS)
* 2/3 of the above

Lacunar (LACS)
* Pure hemi‐motor or sensory loss

Prognosis at 1 year (%)

—————-TACS ———- PACS —– LACS
Dead ————-60 ————–15 ———- 10
Dependent —–35 ———— 30 ———- 30
Independent —5 ————-55 ———- 60

Question 11

Dominant parietal‐lobe cortical signs

What are the Dominant parietal‐lobe cortical signs ?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 11

• Dysphasia: receptive, expressive or global
• Gerstmann’s syndrome
  ⚬ Dysgraphia, dyslexia and dyscalculia
  ⚬ L‐R disorientation
  ⚬ Finger agnosia

Question 12

Non-Dominant parietal‐lobe cortical signs

What are the Non-Dominant parietal‐lobe cortical signs ?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 12

• Dressing and constructional apraxia
• Spatial neglect

Question 13

Either Dominat or Non-Dominant parietal‐lobe cortical signs

What affectst either Dominant or Non-Dominant parietal‐lobe cortical signs ?

Stroke

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Answer 13

Either
* Sensory and visual inattention
* Astereognosis
* Graphaesthesia

Visual Field Defects