Stroke

Question 1

Cerebrovascular accidents are either:

Answer 1

Ischaemia or infarction of brain tissue secondary to inadequate blood supply

Intracranial haemorrhage

Question 2

Disruption of blood supply can be caused by:

Answer 2

Thrombus formation or embolus, for example in patients with atrial fibrillation
Atherosclerosis
Shock
Vasculitis

Question 3

Transient ischaemic attack (TIA)?

Answer 3

was originally defined as symptoms of a stroke that resolve within 24 hours. It has been updated based on advanced imaging to now be defined as transient neurological dysfunction secondary to ischaemia without infarction.

Transient ischaemic attacks often precede a full stroke. A crescendo TIA is where there are two or more TIAs within a week. This carries a high risk of developing in to a stroke.

Question 4

Presentation of strokes?

Answer 4

In neurology, suspect a vascular cause where there is a sudden onset of neurological symptoms.

Stoke symptoms are typically asymmetrical:

Sudden weakness of limbs
Sudden facial weakness
Sudden onset dysphasia (speech disturbance)
Sudden onset visual or sensory loss

Question 5

Risk factors of stroke

Answer 5

Cardiovascular disease such as angina, myocardial infarction and peripheral vascular disease
Previous stroke or TIA
Atrial fibrillation
Carotid artery disease
Hypertension
Diabetes
Smoking
Vasculitis
Thrombophilia (increased clotting)
Combined contraceptive pill

Question 6

FAST Tool for Identifying a Stroke in the Community

Answer 6

F – Face
A – Arm
S – Speech
T – Time (act fast and call 999)

Question 7

ROSIER Tool for Recognition Of Stroke In Emergency Room

Answer 7

ROSIER is a clinical scoring tool based on clinical features and duration. Stroke is likely if the patient scores anything above 0.

Question 8

Management of Stroke

Answer 8

This is adapted from the NICE guidelines updated in 2017 to help your learning. See the full guidelines before treating patients.

• Admit patients to a specialist stroke centre
• Exclude hypoglycaemia
• Immediate CT brain to exclude primary intracerebral haemorrhage
• Aspirin 300mg stat (after the CT) and continued for 2 weeks

Thrombolysis with alteplase can be used after the CT brain scan has excluded an intracranial haemorrhage. Alteplase is a tissue plasminogen activator that rapidly breaks down clots and can reverse the effects of a stroke if given in time. It is given based on local protocols by an experienced physician. It needs to be given within a defined window of opportunity, for example 4.5 hours. Patients need monitoring for post thrombolysis complications such as intracranial or systemic haemorrhage. This includes using repeated CT scans of the brain.

Thrombectomy (mechanical removal of the clot) may be offered if an occlusion is confirmed on imaging, depending on the location and the time since the symptoms started. It is not used after 24 hours since the onset of symptoms.

Generally, blood pressure should not be lowered during a stroke because this risks reducing the perfusion to the brain.

Question 9

Management of TIA

Answer 9

Start aspirin 300mg daily. Start secondary prevention measures for cardiovascular disease. They should be referred and seen within 24 hours by a stroke specialist.

Question 10

Specialist Imaging for strokes

Answer 10

The aim of imaging is to establish the vascular territory that is affected. It is guided by specialist assessment.

Diffusion-weighted MRI is the gold standard imaging technique. CT is an alternative.

Carotid ultrasound can be used to assess for carotid stenosis. Endarterectomy to remove plaques or carotid stenting to widen the lumen should be considered if there is carotid stenosis.

Question 11

Secondary Prevention of Stroke

Answer 11

Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily)

Atorvastatin 80mg should be started but not immediately

Carotid endarterectomy or stenting in patients with carotid artery disease

Treat modifiable risk factors such as hypertension and diabetes

Question 12

Stroke Rehabilitation

Answer 12

Once patients have had a stroke they require a period of adjustment and rehabilitation. This is essential and central to stroke care. It involves a multidisciplinary team including:

Nurses
Speech and language (SALT)
Dieticians
Physiotherapy
Occupational therapy
Social services
Optometry and ophthalmology
Psychology
Orthotics

Question 13

Differential diagnoses for stroke presentation?

Answer 13

Ischaemic stroke
Haemorrhagic stroke
TIA
Hypoglycaemia
Seizure with Todd’s paresis
Migraine
SOLs
Psychosomatic

Question 14

Complications few days after a stroke?

Answer 14

UTI, urinary incontinence, sepsis, pneumonia

Question 15

Scoring used used for risk of a stroke and what do you do if it comes back high?

Answer 15

QRISK 3 score

• Age
• BP
• BMI
• Smoking
• Cholesterol

10 is the cut-off, anything more give statins!!

Only help with hypertension and cholesterol aspect (25% reduction in risk)

Question 16

Side effects of statins?

Answer 16

Causes muscle pain (achy muscles for most patients)

check kinase if severe muscle pain - rhabdomyolysis

Rhabdomyolysis is a syndrome characterized by muscle necrosis and the release of intracellular muscle constituents into the circulation. Creatine kinase (CK) levels are typically markedly elevated, and muscle pain and myoglobinuria may be present

Question 17

Patients with high cholesterol what should you ask if they eat and especially cut down?

Answer 17

Chocolate and cheese

consider low fat cheese, consider other options that are low in sugar and fat.

Question 18

If the QRISK score is high options are?

Answer 18

lifestyle measures for 6 months and recheck cholesterol and QRISK, if stable can give another 6 months or if not ask if they want to go on statins.

go on statins straight away