Stroke

Question 1

Define stroke

Answer 1

Rapidly developing clinical signs of focal (or global) disturbance of cerebral function + lasting > 24h

Question 2

What are the 3 main aetiological causes of stroke caused by ischaemia?

Answer 2

Thrombosis: MCA branch point, ICA bifurcation
Emboli: AF, rheumatic heart disease
Hypoperfusion

Question 3

Give the incidence of each type of stroke

Answer 3

Ischaemic 85%
Intracerebral Haemorrhage 10%
SAH 5%

Question 4

What might cause an emboli leading to stroke caused by ischaemia?

Answer 4

Carotid atherosclerotic plaque breaking off
Atheromatous plaques from heart (ie. AF)
Break off of intima from carotid dissection.
Rarely: venous emboli which passes through the ASD/ VSD

Question 5

How can hypotension lead to a stroke caused by ischaemia?

Answer 5

If BP below autoregulatory range required to maintain cerebral blood flow, leads to ischaemia in the watershed zones between different cerebral artery territories

Question 6

List 2 less common causes of stroke caused by ischaemia

Answer 6

Cocaine
Vasculitis

Question 7

What are the 3 main causes of haemorrhagic stroke?

Answer 7

HTN
Cerebral Amyloid angiopathy
Arteriovenous malformations

Question 8

List 3 less common causes of haemorrhagic stroke?

Answer 8

Trauma
Tumours
Vasculitis

Question 9

Summarise the epidemiology of stroke

Answer 9

COMMON
Largest cause of disability
3rd most common cause of death in UK
Usual age of stroke patients: 70+

Question 10

List 6 presenting symptoms of stroke

Answer 10

SUDDEN-ONSET
Weakness
Sensory, visual or cognitive impairment
Impaired coordination
Impaired consciousness
Head or neck pain (carotid/ vertebral artery dissection)

Question 11

In a potential stroke patient what do you enquire about?

Answer 11

Time of onset (for emergency Mx if < 4.5h)

Hx of AF, MI, valvular heart disease, carotid artery stenosis, recent neck trauma or pain

Question 12

What do you look for in a potential stroke patient?

Answer 12

Signs of the underlying cause e.g. AF

Question 13

Describe the signs seen in lacunar infarct strokes affecting the internal capsule or pons, the thalamus and the basal ganglia

Answer 13

Internal capsule/ pons: pure sensory/ motor deficit (or both)
Thalamus: loss of consciousness, hemisensory deficit
Basal ganglia: hemichorea, hemiballismus, parkinsonism

Question 14

Describe 2 signs seen in anterior cerebral artery ischaemic strokes

Answer 14

Lower limb weakness

Confusion

Question 15

Describe the signs seen in middle cerebral artery ischaemic strokes

Answer 15

Facial weakness
Hemiparesis (motor cortex)
Hemisensory loss (sensory cortex)
Apraxia
Hemineglect (parietal lobe)
Receptive or expressive dysphasia (involvement of Wernicke’s + Broca’s areas)
Quadrantopia (if superior or inferior optic radiations are affected)

Question 16

Describe a sign seen in posterior cerebral artery ischaemic strokes

Answer 16

Hemianopia

Question 17

Describe 6 signs seen in Posterior Inferior Cerebellar artery ischaemic stroke. In which syndrome is this artery affected?

Answer 17

Vertigo
Ipsilateral ataxia
Ipsilateral Horner's syndrome
Ipsilateral hemisensory loss
Dysarthria
Contralateral spinothalamic sensory loss
Lateral medullary syndrome

Question 18

Describe 4 signs seen in anterior inferior cerebellar ischaemic strokes

Answer 18

Vertigo
Ipsilateral ataxia
Ipsilateral deafness
Ipsilateral facial weakness

Question 19

Describe 2 signs seen in basilar artery ischaemic strokes

Answer 19

Cranial nerve pathology

Impaired consciousness

Question 20

List 5 signs that are seen in multiple lacunar infarct strokes

Answer 20

Vascular dementia
Urinary incontinence
Gait apraxia
Shuffling gait
Normal or excessive arm-swing

Question 21

Describe 6 signs seen in intracerebral haemorrhage strokes

Answer 21

Headache
Meningism
Focal neurological signs
N+V
Signs of raised ICP
Seizures

Question 22

What non-imaging investigations do you perform in suspected stroke?

Answer 22

Bloods: FBC. UE, glucose, lipid profile. Clotting profile - check if thrombophilia (esp. in young patients)
ECG: to detect arrhythmias which predispose to emboli

Question 23

What 5 imaging investigations can you perform in suspected stroke?

Answer 23

Echo: to see cardiac emboli / endocarditis
Doppler carotid US: to exclude carotid artery disease
CT Head: Rapid detection of haemorrhages
MRI-Brain: Higher sensitivity for infarction but less available
CT Cerebral Angiogram: Detect dissections or intracranial stenosis

Question 24

Describe the management plan for hyperacute stroke

Answer 24

If < 4.5h from onset  
Exclude haemorrhage using CT-head   
Thrombolysis IV
No aspirin for 24h
Monitor on GCS

Question 25

Describe the management plan for acute ischaemic stroke

Answer 25

Aspirin + Clopidogrel to prevent further thrombosis (once haemorrhage excluded on CT head)
Heparin anticoagulation considered if a high risk of emboli recurrence or stroke progression
Swallow assessment (NG tube may be needed)
GCS monitoring
Thromboprophylaxis

Question 26

Describe the secondary prevention plan for stroke

Answer 26

Aspirin + dipyridamole
Warfarin anticoagulation (AF)
Control risk factors: HTN, hyperlipidaemia, treat carotid artery disease, smoking

Question 27

What surgical treatment option is available for stroke?

Answer 27

Carotid endarterectomy

Question 28

Describe the management plan for intracerebral haemorrhagic stroke

Answer 28

IV mannitol to reduce ICP
Control HTN + seizures
Hyperventilation lowers ICP
Evacuation of haematoma may be required

Question 29

List 6 potential complications of stroke

Answer 29

Cerebral oedema (increased ICP) 
Immobility  
Infections  
DVT  
Cardiovascular events  
Death

Question 30

Describe the prognosis of a stroke patient

Answer 30

10% mortality in first month
50% of survivors become dependent
10% recurrence within 1 year

Question 31

Which type of stroke has a worse prognosis?

Answer 31

Haemorrhagic

Question 32

How does a stroke differ to a TIA?

Answer 32

TIA Sx are similar to stroke but last < 24h.
Due to a temporary lack of blood to a part of the brain. Mostly caused by tiny blood clots
Affected part of brain is without O2 for just a few minutes + soon recovers as the clot either breaks up quickly or nearby blood vessels are able to compensate.