Stroke

Question 1

What are the risk factors of a stroke?

Answer 1

• High blood pressure
• Smoking
• Atrial fibrillation
• Diabetes
• Hypercholesterolaemia

Question 2

What are the main stroke types (2)

Answer 2

• Ischaemic - blockage of blood vessel

* haemorrhagic

Question 3

What are the signs of a large vessel stroke?

Answer 3

Cortical signs due to cortex damage
•If right brain: right gaze preference and neglect of left side
•If left brain then left gaze preference and aphasia

Question 4

What are the signs of a stroke in the posterior circulation?

Answer 4

• Crossed signs
• Cranial nerve findings
• Cerebellar features

Question 5

Which is the most common large vessel stroke?

Answer 5

MCA

Question 6

Describe the signs of a stroke involving the MCA

Answer 6

• Arm>leg weakness
• Left MCA: aphasia
• Right MCA: neglect, topographical difficulty, apraxia, constructional impairment, anosognosia (not aware of the deficit)

Question 7

Describe the signs of a stroke involving the ACA

Answer 7

• Leg>arm weakness, problems with grasp
• Cognitive signs: muteness, perseveration, abulia
• Personality changes (frontal lobe)

Question 8

Describe the signs of a stroke involving the PCA

Answer 8

• Hemianopia (lose field of the contralateral side)

* Cognitive: memory loss/confusion, Alexia

Question 9

What are the risk factors of a stroke involving the small vessels?

Answer 9

• Hypertension
• Hyperlipidaemia
• Diabetes mellitus
• Tobacco/smoking
• sleep apnoea

Question 10

What are the symptoms of a lacunar stroke?

Answer 10

Either:
•Pure motor
•Pure sensory
•Sensori-motor

Question 11

What are the signs of a brainstem stroke?

Answer 11

•Usually a combination of cranial nerve abnormalities
•Crossed motor/sensory findings: 
 - Double vision 
 - facial numbness and/or weakness
 - slurred speech 
 - difficulty swallowing 
 - ataxia 
 - vertigo  
 - nausea and vomiting 
 - hoarseness

Question 12

Where do haemorrhagic strokes due to hypertension typically happen?

Answer 12

In the basal ganglia (also cerebellum and pons)

Question 13

What is the typical presentation of a haemorrhagic stroke due to hypertension?

Answer 13

• Patient is typically awake
• Often stressed
• Abrupt onset of symptoms with acute decompensation and smooth progression

Question 14

Describe initial management of someone presenting with a stroke

Answer 14

• If GCS<8 then intubate - avoid hypo and hyperventilation
• NBM until swallow assessment
• Non contrast CT head (but may take a few hours to show up on CT)
• CT with contrast may help to identify aneurysms, AVMs or tumours
• MRI is superior for showing underlying structural lesions but does have contraindications

Question 15

What is the acute treatment of ischaemic stroke?

Answer 15

• Tissue plasminogen activator (alteplase)
• IV window is 4.5 hours
• Mechanical retrieval often used in conjunction (stentrievers)

Question 16

What are the contraindications of tPA?

Answer 16

• Haemorrhage
• Systolic BP>185
• Diastolic BP >110
• Recent surgery, trauma or stroke
• coagulopathy
• Seizures at onset of symptoms
• Glucose <2.2
• NIHSS>21