Stroke

Question 1

How does a middle cerebral a stroke usually present? (5)

Answer 1

Arm more affected than leg
Contralat paresis face and arm / leg
Contralat sensory loss
Aphasia (dominant hemisphere)
Contralateral neglect syndrome (non-dominant hemisphere)

Question 2

Clinical picture of lacunar infarctions? (4)

Answer 2

Dense motor hemiplegia (pure motor)
Hemihypoesthesia (pure sensory)
Dysarthria clumsy hand syndrome
Homolateral ataxia with crossed paresis ('ataxic hemiparesis)
No cortical signs

Question 3

Carotid TIA presentation (5)

Answer 3

Transient ipsilateral monocular blindness
Contralateral body weak or clumsy
Contralateral body sensory loss or paraesthesia
Aphasia (dominant hemisphere)
Contralat homonymous visual field defects

Question 4

Vertebro-basilar area ischaemia (post circulation) presentation (4)

Answer 4

Bilateral weak or clumsy (may be unilat or shifting)
Bilat shifting or crossed sensory loss or paraesthesiae
Bilat binocular visual defects
2 or more: vertigo, diplopia, dysphasia, dysarthria, ataxia
(Worse prognosis)

Question 5

What area of brain does cerebral haemorrhages most frequently occur?

Answer 5

Internal capsule

Question 6

How does a subarachnoid bleed present? (2)

Answer 6

Sudden onset severe headache

Neck stiff

Question 7

How does an intracerebral haemorrhage present? (3)

Answer 7

Sudden onset severe headache
Focal neurological deficit
Depression LOC

Question 8

8 risk factors for stroke

Answer 8

Hypertension most NB
Heart lesions or cardiac disease: Afib!, CAD
DM
Alcoholism
Oral contraceptive pill (oestrogen)
HIV
Hypenlipidaemia (→CAD)
Smoking

Question 9

Define stroke (4)

Answer 9

• Acute onset (minutes to hours) of
• focal neurological deficit (eg hemiparesis)
• of the CNS (above foramen magnum / excluding spinal cord) from vascular origin
• duration more than 24 hours

Question 10

Name 4 diagnostic criteria for transient ischaemic attacks

Answer 10

• Focal non - convulsive neurological deficit from ischaemic origin
• sudden onset (embolic phenomenon) reaching max intensity almost Immediately
• lasts 5-20 minutes usually ( < 24 h by definition)
• repeated attacks usually clinically stereotyped

Question 11

Name 3 criteria of total anterior circulation stroke (tacs)

Answer 11

All 3!

• unilateral weakness andor sensory deficit of the face, arm and leg
• homonymous hemianopia
• higher cerebral dysfunction (dysphasia, visuospatial disorder)

Question 12

Name 3 criteria of partial anterior circulation stroke (PACS)

Answer 12

Two of the following:

• unilateral weakness andor sensory deficit of the face, arm and leg
• homonymous hemianopia
• higher cerebral dysfunction (dysphasia, visuospatial disorder)

Question 13

How will ACA stroke present

Answer 13

Leg > arm

Question 14

How will MCA stroke present

Answer 14

Arm > leg

Question 15

How will lacunar stroke present

Answer 15

(Internal capsule),

Arm = leg

Question 16

Name 4 criteria lacunar syndrome (lacs)

Answer 16

One of the following:

• pure sensory stroke
• pure motor stroke
• sensori-motor stroke
• ataxic hemiparesis

Question 17

Name 5 criteria posterior circulation syndrome (pocs)

Answer 17

One of following:

• cranial nerve palsy and contralateral motor/sensory deficit
• bilateral motor/sensory deficit
• conjugate eye movement disorder eg gaze palsy
• cerebellar dysfunction eg ataxia, nystagmus, vertigo
• isolated homonymous hemi anopia or cortical blindness

Question 18

Management stroke?

Answer 18

BRAIN ATTACK

• blood pressure
• respiration
• airway
• imaging
• normoglycemia
• anti-platelets, anti-lipids
• thrombolysis with TPA for ischaemic stroke
• temperature
• assess swallow, nutrition, hydration
• Consult rehab team
• keep vigilant for complications: neuro deterioration ( haemorrhagic transformation), aspiration pneumonia, seizures, UTI, pressure injuries, DVT / PE

Question 19

How manage blood pressure in stroke (4)

Answer 19

• Permissive hypertension first 2-5 days
• then continue on chronic anti- ht treatment
• only treat if SBP > 220, DBP >120, map > 130
• target sbp reduction by 20% in first 24 hours
• candidates for thrombolysis: SBP >180 and DBP > 110
• If parenteral agents used, labetalol or nicardipine preferred because of ease of titration and limited effect on cerebral blood vessels. Don’t give sublingual nifedipine or nitroglycerin, can cause precipitous drop in bp → decreased cerebral perfusion + damage to penumbra.

Question 20

What type of Ct do for stroke

Answer 20

• Acute stroke <4,5 hours ago: non-contrast Ct head
• late presenting strokes (4,5 - 9 hours, wake up stroke, stroke of unknown time onset ): Ct perfusion scan

Question 21

Name 5 criteria for lyric for stroke

Answer 21

• Presentation <4,5 hours
• proven not haemorrhagic stroke by scan
• bp < 185/110
• 18-80 years old
• NIHS score < 23

Question 22

Post stroke best medical therapy to prevent recurrence? (7)

Answer 22

Aabbccd

• aspirin (anti-platelet)
• anticoagulant
• blood pressure: ace-i/ arb even if normal
• blood pressure! Goal <140 /90
• cholesterol (statin)
• carotid endarterectomy for selected patients
• diabetes control: keep bp <130/85. Put on SGLP2 (prevent vascular complications)