Stroke

Question 1

What is a stroke?

Answer 1

Acute and sudden onset of symptoms.
Focal neurological deficit not global.
Pattern of symptoms and signs attributable to one part of the brain and a particular vascular system.

Question 2

What is a TIA?

Explain

Answer 2

Transient Ischaemic Attack (TIA)

It is a brief episode of neurologic dysfunction caused by focal brain or retinal ischaemia:
symptoms typically less than an hour, without evidence of infarction.

Question 3

How does a TIA differ from a stroke?

Answer 3

It differs only in duration.

Question 4

How long does a TIA last?

Answer 4

Typically less than an hour.
Many patients with TIA’s lasting more than 2 hrs will have infarction on MRI scan.
Requires urgent assessment as many high risk for full CVE (full cardiovascular events).

Question 5

What are transient focal neurological events?

Answer 5

Focal fit/partial seizure, transient global amnesia, demyelination, hypoglycaemia, peripheral nerve compressions migraine.

Question 6

When should TIA patients be assessed?

Answer 6

Within 1 week,
24 hrs if high risk.

23% strokes preceded by TIA, 17% same day, 9% day before, 40% in 7 days prior to stroke.

Question 7

What is the most severe form of stroke?

Answer 7

TACS > PACS > LACS

TACS >50% dead at 90 days.

Question 8

What is TACS?

which artery?

Answer 8

Total anterior circulating syndrome

Extensive middle cerebral artery infarct

Question 9

What are the signs of TACS?

Answer 9

All of:

1. Unilateral weakness (+/or sensory deficit) or face, arm and leg.
2. Homonymous hemianopia
3. Higher cerebral dysfunction (dysphasia, visuospatial disorder).

Question 10

What is PACS?

Answer 10

Partial anterior circulating syndrome

Branch of middle cerebral area infarct

Question 11

What are the signs and symptoms of TACS?

Answer 11

Any 2 of the 3 components of TACS:

1. Unilateral weakness (+/or sensory deficit) of face, arm and leg.
2. Homonymous hemianopia
3. Higher cerebral dysfunction (dysphasia, visuospatial disorder)

DYSPHASIA ALONE

Question 12

What is LACS?

Answer 12

Lacunar syndrome

Tiny deep infarcts usually silent (80%)

Question 13

What are the signs and symptoms of LACs?

Answer 13

One of:

a. unilateral weakness of face and arm, arm and leg or all three
b. pure sensory stroke
c. ataxic hemiparesis

Question 14

What is POCS?

Answer 14

Posterior circulating syndrome

Question 15

What are the signs and symptoms of POCS?

Answer 15

One of:

1. Cerebellar or brainstem syndromes.
2. Loss of consciousness.
3. Isolated homonymous hemianopia.

Question 16

What is ABCD^2 score?

Answer 16

Age, BP, Clinical symptoms, Duration, Diabetes

It predicts stroke at 2 days

Age >60 yrs
SBP >1400 mmHg or DBP >90mmHg
speech impairment
unilateral weakness
duration 10-59 mins
duration > 60 mins
diabetes

Question 17

What are the risk factors of stroke?

Answer 17

• hypertension
• diabetes
• smoking
• hyperlipidaemia
• carotid stenosis
• atrial fibrillation

Question 18

What is the single most important modifiable risk for stroke?

Answer 18

Hypertension. 
risk of stroke 2-4x risk. 
risk doubles every 7.5mmHg
Small reduction in BP results in large reductions in recurrence of stroke. 
aim 140/85. diabetic 130/80

Question 19

How do you treat a stoke?

Answer 19

Thrombolysis:
IV tPA within 4.5hrs of ischaemic stroke.
IV tPA = Intravenous tissue plasminogen activator.
Requires CT to exclude haemorrhage.

Acute treatment:
General medical care of STROKE UNIT.
if infarct aspirin 300mg OD.
pressure sore prevention/TED stockings. Hydration and nutrition. Antipyretic. Active glucose monitor.

Question 20

What is a stroke unit?

Answer 20

Hydration, nutrition, handling, pressure, continence, early mobilisation, fever (<38) glucose (<10mmols/L), oxygen, TED stockings, vigilant observations for complication.
> prevents complications e.g. pneumonia, infections and early recurrence (aspirin)
> control blood glucose and body temp
> avoid aggressive BP lowering

Question 21

What is secondary prevention of a stroke?

Answer 21

Thromboprophylaxis
Hypertension
Cholesterol management, 
Glucose management
Rhythm
Carotid stenosis

Antiplatelet therapy:

• clopidogrel
• aspirin combined with dipyridamole.

warfarin and NOACs - secondary prevention if AF or PAF

Question 22

What are the oral manifestations related to stroke?

Answer 22

Related to antihypertensive drugs

• xerostomia
• gingival hyperplasia
• lichenoid reaction
• cough and/or loss/alteration of taste (aguesia/dysgeusia)

most antihypertensive drugs have drug interactions with LA and analgesics,

Question 23

What is the most important modifiable risk factor for stroke?

Answer 23

Hypertension

Question 24

What scoring system is used to predict stroke risk?

Answer 24

ABCD^2

Question 25

Regarding Bamford classification of strokes, which type of stoke would result from an extensive middle cerebral artery infarction?

Answer 25

TACS

Question 26

Using Bamford classification of strokes, which is the most common type of stroke?

Answer 26

PACS

PACS>LACS>POCS>TACS

Question 27

Using Bamford classification of strokes, which type of stoke would be associated with nystagmus, unsteady gaits and acute visual loss?

Answer 27

POCS

Question 28

Regarding Bamford Classification, which stroke has the highest mortality rate at 90 days?

Answer 28

TACS