Stroke

Question 1

Stroke - types

Answer 1

• Cerebrovascular accident – CVA
• Transient ischaemic attack – TIA – ministroke. Temporary disruption to cerebral blood supply with some neurologic manifestation which last only during first 24 hours then disappear if persist after 24 hours then it is a case of stroke.

Question 2

Stroke - causes

Answer 2

o Small vessels occlusion (thrombosis)
o Cardiac emboli (AF, endocarditis, MI)
o Atheroembolism (= cholesterol embolism)
o CNS bleeding (Bp high-trauma, anticoagulants, rupture aneurysm
o Younger patients:
 Sudden drop in BP below 40mm (watershed stroke)
 Vasculitis
 Subarachnoid haemorrhage

Question 3

Stroke - risk factors

Answer 3

o	High BP
o	DM
o	Heart disease (AF, peripheral vascular disease) 
o	Pills
o	Alcoholism 
o	Increased clotting factor 
o	Past TIA

Question 4

Stroke - types & locations

Answer 4

o Cerebral hemisphere infarct (50%)  Hemiplegia, sensory loss, dysphasia, hemianopia
o Brain stem infarct (25%)  Quadriplegia
o Lacunar infarct (25%) = Small infarct of basal ganglion and internal capsule  Sensory & motor manifestation

Question 5

Blood supply of the brain

Answer 5

Blood supply to the brain is derived entirely from the Internal carotid and vertebral arteries.

Question 6

What is haemorrhage? What is it due to?

Answer 6

= is sudden due to rupture of an artery, (aneurysm)

➤ tumours, abscess, anticoagulants and blood disease.

Question 7

What does hypertension predispose to?

Answer 7

haemorrhage

thrombosis

Question 8

What does thrombosis may follow?

Answer 8

Hypotension

Question 9

What is embolism due to?

Answer 9

➤ usually due to atrial fibrillation, complicating myocardial infarction & infective endocarditis.

Question 10

Clinical features of stroke in ant & middle cerebral + internal carotid arteries

Answer 10

• Hemiparesis
• Hemisensory loss
• Hemianopia
• Personality & behavioural changes
• Dyspraxia
• Agnosia
• Incontinence
• Seizure
• Anterior cerebral artery: leg affected more than arm. Also depends whether the occlusion is proximal or distal to the Heubner’s artery.
• Middle cerebral artery: arm & face affected more

Question 11

Clinical features of stroke in post cerebral artery

Answer 11

• Hemianopia
• Visual & visuospatial agnosia
• Seizures (uncommon)

Question 12

Clinical features of stroke in vertebral artery

Answer 12

• Pupillary abnormalities
• Eye movement disorder
• Cranial nerve signs
• Dysphagia (if dominant)
• Dysarthria
• Dysphagia
• Unilateral/bilateral motor sensory loss
• Cerebellar signs
• Tremor
• Extrapyramidal signs
• Hemianopia
• Visual & visuospatial agnosia

Question 13

What is dyspraxia?

Answer 13

Motor learning disability (or impairment of performance of complex motor function or movements despite intact individual specific motor actions). It is associated with problems of perception, language and thought. It is also called motor learning difficulty. The patient expresses difficulty in riding bicycle, driving a car, or simply buttoning up a shirt (= dressing dyspraxia) also constructional dyspraxia (=which is inability to assembling or drawing complex faces or shapes).
Could be due to congenital or damage to the cerebral cortex as a result of vascular damage.

Question 14

What is agnosia?

Answer 14

Loss of ability to interpret sensory stimuli, such as sound or images.
Could be due to congenital or damage to the cerebral cortex as a result of vascular damage.

Question 15

Stroke - Acute management

Answer 15

o	Ensure patent airways 
o	Monitor blood glucose 
o	Monitor BP
o	Urgent CT & MRI
o	Thrombolysis consider for age 18-80 and onset less than 4 hours
o	Nothing by mouth
o	Keep hydrated
o	Explain what has happened
o	Antiplatelet agent  aspirin 300 mgm - if no haemorrhage is diagnosed. 
o	Admission to stroke unit

Question 16

Stroke - Ddx

Answer 16

o	Head injury
o	Subdural haemorrhage
o	Hypoglycaemia
o	Hyperglycaemia
o	Tumours
o	Migraines
o	Drug overdose
o	Hepatic encephalopathy 
o	Encephalitis

Question 17

Primary prevention of stroke

Answer 17

o	Hypertension
o	DM
o	For lipids use statin
o	Treat cardiac conditions
o	Help quit smoking
o	Lifelong anticoagulant if Rheumatic and prosthetic heart involvement.

Question 18

Secondary prevention of future stroke

Answer 18

o Lower cholesterol and blood pressure:

o Antiplatelet & Anticoagulant agent (only in case of embolic stroke) after stroke.

Question 19

Stroke - investigate to identify risk factors

Answer 19

o Hypertension ➤ look for retinopathy& nephropathy.
o Cardiac source of emboli ➤ 24 hours ECG (AF), echo (mural thrombus)
o Carotid artery stenosis ➤ carotid doppler ultrasound & carotid angiography
o Hypoglycaemia
o Hyperglycaemia
o Hyperlipidaemia
o Vasculitis ➤ ESR high / VDRL for syphilis.
o Hyper-viscosity
o Polycythaemia
o Sickle cell anaemia
o Thrombocytopenia ➤ Genetic test

Question 20

Rehabilitation after stroke

Answer 20

o	Multidisciplinary teamwork 
o	Watch patient swallow
o	Avoid falls 
o	Ensure good bowel and bladder function
o	Position the patient to minimise spasticity 
o	Measure basic movement - how to improve?
o	Involve carer/spouse
o	Good lifestyle. 
o	Screen for depression
o	 Neurorehabilitation 
o	End-of life decision.