Stroke

Question 1

Stroke

Answer 1

sudden onset of focal neurological deficit of presumed vascular aetiology lasting >24 hours
Also referred to as cerebrovascular accident CVA
changes on CT

Question 2

TIA

Answer 2

same except < 24 hours (90% last < 2 hours)
transient neurological dysfunction secondary to ischaemia without infarction
Caused by sudden reduction in blood supply to brain
No changes on CT

Question 3

crescendo TIA

Answer 3

two or more TIAs within a week
high risk of developing in to a stroke

Question 4

Cerebrovascular accidents are either:

Answer 4

Ischaemic (87%)
Intracranial haemorrhage (13%)

Question 5

Stroke/TIA RF

Answer 5

Smoking
Alcohol misuse and drug abuse (for example cocaine, methamphetamine)
Physical inactivity
Poor diet
HTN
AF
IE
Vascular disease
Congestive HF
MI Hx
Migraine
Sickle cell
Haemophilia
CKD
Connective tissue disease
PCKD
OSA
Anticoagulation ( haemorrhagic stroke)

Question 6

Ischaemic stroke RF in young people

Answer 6

carotid/ vertebral Dissection
Cardioembolism eg PFO, endocarditis
Vasculitis
antiphospholipid syndrome
inherited thrombophilia
Genetic eg CADASIL, Fabrys, MELAS

Question 7

Aetiology intracranial haemorrhage

Answer 7

HTN
Cerebral amyloid angiopathy
Tumours,
AVMs
aneurysms
Oral anticoagulants

Question 8

Stroke history taking

Answer 8

Onset
Seizure or hypoglycaemia
Vision
Weakness of face/limbs
Speech
which hand is dominant
Do they drive
Context/risk factors/comorbidity

Question 9

Oxford/bamford main criteria points

Answer 9

1. Hemiparesis (weakness on one side) and/or hemisensory loss of the face, arm & leg
2. contralateral homonymous hemianopia (person sees only one side )
3. higher cognitive dysfunction e.g. dysphasia, visuospatial disorder

Question 10

TACI (total anterior circulatory infarct)

Answer 10

15%
involves middle and anterior cerebral arteries
All 3 criteria

Question 11

PACI (partial anterior circulatory infarct)

Answer 11

25%
Any 2 of the above or isolated cortical dysfunction
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
A PACI involves the anterior OR middle cerebral artery on the affected side

Question 12

Anterior cerebral artery

Answer 12

legs, behaviour

Question 13

Middle cerebral artery

Answer 13

arms, speech

Question 14

LACI (lacunar circulatory infarct)

Answer 14

25%
involves small deep perforating arteries around the internal capsule, thalamus and basal ganglia
no complex features, presents with 1 of the following:
- 1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
- 2. pure sensory stroke.
- 3. ataxic hemiparesis

strong association with hypertension

Question 15

POCI (posterior circulatory infarct)

Answer 15

25%
involves damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem).
involves vertebrobasilar arteries
presents with 1 of the following:
- 1. cerebellar or brainstem syndromes
- 2. loss of consciousness
- 3. isolated homonymous hemianopia

Symptoms like: Vertigo, diplopia,ipsilateral ataxia and nystagmus from cerebellar damage

Question 16

Posterior cerebral artery

Answer 16

vision, ataxia

Question 17

Basilar artery occlusion

Answer 17

locked in quadriparesis with preserved consciousness and ocular movements), loss of consciousness, or sudden death

Question 18

lateral pontine syndrome

Answer 18

Anterior inferior cerebellar artery
condition similar to the lateral medullary syndrome but with additional involvement of pontine cranial nerve nuclei eg deafness,facial paralysis

Question 19

What is Wallenberg’s sydnrome/lateral medullary syndrome

Answer 19

caused by occlusion of the posterior inferior cerebellar artery leading to infarction of the lateral medulla.

Question 20

Clinical presentation of Wallenberg’s sydnrome

Answer 20

DANVAH
Dysphagia, ipsilateral Ataxia, ipsilateral Nystagmus, Vertigo, Anaesthesia(Ipsilateral facial numbness and contralateral pain loss on the body) and ipsilateral Horner’s syndrome

Question 21

What is Weber’s syndrome

Answer 21

Caused by lesions to the Medial midbrain/cerebral peduncle.
(paramedian branches of the upper basilar and proximal posterior cerebral arteries)

Question 22

Clinical presentation of webers syndrome

Answer 22

ipsilateral oculomotor CN III palsy and contralateral hemiparesis (motor)

Question 23

Clinical presentation TIA

Answer 23

focal neurological deficit (such as speech difficulty or arm/leg weakness/sensory changes).
most symptoms resolve within 1 hour
absence of positive symptoms suggestive of differentials (e.g. shaking preceding the weakness, suggestive of a focal motor seizure)
absence of headache, which would suggest a differential e.g. migraine or intracranial bleeding.

Question 24

Investigations

Answer 24

CT
FBC / PV or ESR
U&Es, lipids, glucose, ESR, TFTs, clotting and vasculitis screen
Glucose / cholesterol / renal function
ECG eg af,mi
Carotid ultrasound can be used to assess for carotid stenosis
24 hour ecg tape for paroxysmal af
ECHO for infected heart valves, endocarditis,PFO and septal defects
vasculitis eg ANA
thrombophilia screen

Question 25

Ischaemic stroke management

Answer 25

1. Thrombolysis eg alteplase
   If <4.5 hours from onset and
   the patient has not had a previous intracranial haemorrhage, uncontrolled hypertension, pregnant etc
2. thrombectomy within 6h
3. aspirin 300mg for 2 weeks (reduce risk of recurrence)

Question 26

Haemorrhagic stroke management

Answer 26

Anticoagulants (e.g. warfarin) and antithrombotic medications (e.g. clopidogrel) should be stopped to minimise further bleeding
BP management <140/80
Neurosurgical and neurocritical care evaluation due to the potential for surgical intervention

Question 27

TIA within the last week Mx

Answer 27

aspirin 300 mg
urgent assessment (within 24 hours) by a specialist stroke physician

Question 28

TIA more than 7 days ago Mx

Answer 28

300mg aspirin
Refer for specialist assessment as soon as possible within 7 days

Question 29

dysphagia management

Answer 29

Everyone who has a stroke should have their swallowing assessed within four hours of arriving at the hospital, and you shouldn’t have any food, drink or medications by mouth until your swallowing has been assessed

Question 30

Secondary prevention for stroke or TIA without AF

Answer 30

aspirin 300mg for 2 weeks, and then switched to clopidogrel long-term, 75 mg daily.
Aspirin 75 mg daily with modified-release dipyridamole 200 mg twice daily may be used if clopidogrel cannot be tolerated

Atorvastatin 80mg
Treat modifiable risk factors such as hypertension and diabetes

Question 31

Secondary prevention for stroke due to AF

Answer 31

warfarin (target INR 2-3 or a direct oral anticoagulant (such as Rivaroxaban or Apixiban) is initiated 2 weeks post-stroke

Question 32

Stroke differentials

Answer 32

B- brain - space occupying lesions
E- epilepsy
H- Hypoglycaemia/ hyponatraemia
I- infection ( meningitis)
N- neuro ( MS, hemiplegic migraine)
D- disc prolapse ( if weakness in their legs)

Question 33

People who have had a single TIA or stroke must not drive for

Answer 33

1 month but need not notify DVLA.

Question 34

People who have multiple TIAs must not drive for

Answer 34

3 months and must notify DVLA. Driving may resume after 3 months if there have been no further TIAs.

Question 35

Midbrain Cranial nerves

Answer 35

CN 1, 2, 3, 4

Question 36

Pons cranial nerves

Answer 36

CN 5, 6, 7, 8

Question 37

medulla cranial nerves

Answer 37

CN 9, 10, 11, 12