Stroke

Question 1

what is a stroke?

Answer 1

sudden onset of focal or global neurological symptoms caused by ischaemia or haemorrhage and lasting more than 24 hours

Question 2

what is a transient ischaemic attack?

Answer 2

symptoms of a stroke but resolves within 24 hours and often precedes a full stroke

Question 3

what are the causes of an ischaemic stroke?

Answer 3

large artery atherosclerosis eg carotid, cardioembolid eg AF, small artery occlusion, undetermined

Question 4

what are the causes of a haemorrhagic stroke?

Answer 4

primary intracerebral commonly linked to age, high BP and amyloidosis and secondary haemorrhage if have structural abnormality eg SAH

Question 5

how does a stroke present?

Answer 5

symptoms are typically asymmetrical: sudden weakness of limbs, sudden facial weakness, sudden onset dysphasia, sudden onset visual or sensory loss

Question 6

what are the risk factors for a stroke?

Answer 6

cardiovascular disease, previous stroke or TIA, AF, carotid artery disease, hypertension, diabetes, smoking, vasculitis, thrombophilila

Question 7

what tool is used for identifying stroke in the community?

Answer 7

FAST - face, arm, speech, time to call 999

Question 8

what tool is used for identifying stroke in the ER?

Answer 8

ROSIER tool based on clinical features and duration- any score above 0 means a stroke is likely

Question 9

how is a stroke managed?

Answer 9

admit to specialist stroke centre, exclude hypoglycaemia, immediate head CT to exclude primary intracerebral haemorrhage and aspirin start after CT and continued for 2 weeks

Question 10

what treatment can then be given after the CT has excluded an intracranial haemorrhage?

Answer 10

thrombolysis with alteplase which is a tissue plasminogen activator (TPA) which rapidly breaks down clots and can reverse the effects of a stroke but needs to be given within 4.5 hours of symptoms onset and the quicker it is given the better it will work

Question 11

what are the possible complications of thrombolysis and so how to we avoid this?

Answer 11

intracranial or systemic haemorrhages which can be monitored by repeated CT scans

Question 12

why should BP not be lowered during a stroke?

Answer 12

this risks reducing perfusion to the brain

Question 13

what is the Oxford community stroke project classification (OCSP)?

Answer 13

total anterior circulation stroke (TACS), partial anterior circulation stroke (PACS), lacunar stroke (LACS) and posterior circulation stroke (POCS)

Question 14

what is a TACS?

Answer 14

main artery to one hemisphere affected so get 3/3 effects= complete hemiparesis/numbness, loss of vision on one side (hemianopia) and loss of awareness on one side (inattention) non-dominant or dysphasia dominant- often due to blocked carotid or MCA

Question 15

what is a PACS?

Answer 15

branch of the main artery affects, in between LACS and TACS- 2/3 RACS criteria or one higher cortical deficit (inattention or dysphasia) or monoparesis

Question 16

what is a LACS?

Answer 16

small perforating arteries affected, movement and sensation pathways, weakness/numbness of face + arm + leg or face + arm or arm + leg, may have dysarthria, ataxic hemiparesis, no effect on higher function so will not have dysphasia, inattention or hemianopia as not damaging the cortex, only damaging the white matter tracts deep in the brain so tends to be pure sensory or pure motor

Question 17

what is a POCS?

Answer 17

any posterior artery, get a combination of symptoms including loss of balance/coordiation, vertigo, double vision, dysarthria, hemianopia

Question 18

why is a basilar artery occlusion one of the worst strokes to have?

Answer 18

it supplies the brainstem which helps you breathe and keeps you conscious so blocking it can cause locked in syndrome or a coma and can cause ischaemia in the pons and predominantly motor/oculomotor signs/symptoms, reduced consciousness is common and may progress over 12-24 hours

Question 19

what is the gold-standard imaging for strokes?

Answer 19

diffusion-weighted MRI but CT is an alternative and is used to establish the vascular territory that is affected

Question 20

what is used instead of TPA if excluded the required criteria?

Answer 20

thrombectomy which is used for large vessel occlusion and involves stents

Question 21

what are the secondary prevention of strokes?

Answer 21

clopidogrel, atorvastatin, carotid endarectomy or stunting in patients with carotid artery disease, warfarin for AF and treat modifiable risk factors like hypertension and diabetes