Stroke

Question 1

What is the definition of a stroke?

Answer 1

Is sudden onset of focal or global neurological symptoms caused by ischaemia or haemorrhage and lasts more than 24hrs

Question 2

What is a TIA?

Answer 2

Transient ischaemic attack
Is if symptoms resolve within 24hrs

Question 3

What are the main causes of an ischaemic stroke?

Answer 3

Carotid plaque with arteriogenic emboli
Cardiogenic emboli - AF, valve disease and left ventricle thrombosis
Small artery disease
Carotid dissection

Question 4

What are the risk factors of a stroke?

Answer 4

Previous stroke, age, male and FH
Smoking, Oestrogen pills, obesity, diabetes, alcohol, cocaine, high BP and cholesterol

Question 5

What is the most important modifiable risk factor?

Answer 5

Hypertension
Esp. lacunar ischaemic strokes and small vessel haemorrhages esp. in brainstem, basal ganglia and subcortical areas

Question 6

Describe AF and strokes

Answer 6

5 x increased risk of emboli with atrial fibrillation
More severe strokes
Anticoagulants reduce risk of ischaemic stroke

Question 7

What is the anterior circulation of the brain?

Answer 7

2 x internal carotid arteries - 2 x anterior cerebral arteries and 2 x middle cerebral arteries

Question 8

What is the posterior circulation of the brain?

Answer 8

2 vertebral arteries - 1 basilar artery
3 pairs of cerebellar arteries
2 posterior cerebellar arteries

Question 9

Where are Borderzone anastomoses?

Answer 9

Between peripheral branches of anterior, middle and posterior cerebral arteries

Question 10

Where does the carotid system supply?

Answer 10

Most of hemispheres and cortical deep white matter

Question 11

Where does vertebro-basilar system supply?

Answer 11

Brainstem, cerebellum and occipital lobes

Question 12

What are the functions of the frontal lobe?

Answer 12

High level cognitive functions
Memory
Motor control of speech
Motor cortex
Urinary continence
Emotion and personality

Question 13

What are the functions of the parietal lobe?

Answer 13

Sensory cortex, sensation, awareness of parts of body, spatial orientation and ability to perform learned motor tasks

Question 14

What are the functions of the temporal lobe?

Answer 14

Primary auditory area, comprehension of speech, visual, auditory and olfactory perception, learning and memory

Question 15

What does an ACA and MCA more cause?

Answer 15

ACA - more leg than arm weakness
MCA - face and arm more than leg weakness

Question 16

What is the function of the occipital lobe?

Answer 16

Primary visual cortex, visual perception and involuntary smooth eye movement

Question 17

What are the clinical presentations of a stroke?

Answer 17

Sudden onset loss of function - motor, sensory, dysphasia, neglect, vision affected and gaze palsy
Ataxia, vertigo, and nystagmus

Question 18

What classifies strokes?

Answer 18

Oxford Community Stroke Project Classification OCSP

Question 19

What are the subtypes of strokes?

Answer 19

TACS - total anterior circulation stroke
PACS - partial anterior circulation stroke
LACS - lacunar stroke
POCS - posterior circulation stroke

Question 20

Describe a total anterior circulation stroke (TACS)

Answer 20

Main artery to one hemisphere
Has 3 symptoms - complete hemiparesis/ numbness, loss of vision on one side and loss of awareness on non-dominant side or dysphasia dominant
Blocked carotid or middle artery

Question 21

Describe a partial anterior circulation stroke

Answer 21

Branch of main artery
In between TACS and LACS
Has 2/3 of TACS criteria or one higher cortical defect (inattention or dysphasia) or monoparesis

Question 22

Describe a lacunar stroke

Answer 22

Small perforating artery
Movement and sensation pathways
Weakness and numbness of face, arm and leg
May have dysarthria
Ataxic hemiparesis
No effect on higher function

Question 23

Describe posterior circulation stroke (POCS)

Answer 23

Any posterior artery
Combination of symptoms - loss of balance, vertigo, double vision, dysarthria and visual loss

Question 24

Describe a basilar artery occlusion

Answer 24

Ischaemia in pons, predominantly motor signs, bilateral but asymmetrical
Alteration of consciousness common
May present with reduced consciousness

Question 25

What are some things which can mimic a stroke?

Answer 25

Seizures, syncope, sugar, sepsis, severe migraine, space occupying lesions, vestibular disorders, demyelination and mononeuropathy

Question 26

What type of symptoms are more present in strokes?

Answer 26

Negative
Loss or reduction in CNS function
Loss of vision, sensation and limb power

Question 27

Describe a migraine aura

Answer 27

Is due to cortical spreading depression
Classical spreading onset and causes visual disturbances
Can be sensory, motor and speech disturbance too

Question 28

What is Hoover’s sign?

Answer 28

Test hip extension - weak
Test contralateral hip flexion against resistance - hip extension has become strong

Question 29

What are the investigations used for a stoke?

Answer 29

Routine blood tests, CT/MRI, ECG and Holter, and carotid doppler US
Some patients may need Echo, cerebral angiogram and hyper-coagulable blood screen

Question 30

What acute stroke treatment has biggest effect on individual?

Answer 30

Thrombolysis and thrombectomy
Thrombolysis by TPA

Question 31

What stroke treatment has the biggest effect on most patients?

Answer 31

Stroke unit admission

Question 32

What is the criteria for TPA use?

Answer 32

Use under 4.5hrs from symptom onset
Disabling neurological deficit
Symptoms more than 60 mins
Consent is obtained

Question 33

What is the exclusion criteria for IV TPA?

Answer 33

Anything which increases risk of haemorrhage - blood on CT, recent surgery, recent episode of bleeding and coagulation problems
BP more than 185 systolic and 110 diastolic
Glucose more than 2.8 or less than 22mmol/l

Question 34

What is used for secondary prevention of stroke?

Answer 34

Anti-hypertensives, anti-platelets, lipid lowering agents, warfarin for AF and carotid endarterectomy in ICA stenosis