Stroke

Question 1

Two main pathological processes which lead to stroke?

Answer 1

Infarction

Haemorrhage

Question 2

Aetiology of infarction?

Answer 2

Emboli (cardiac or carotid)
Thrombosis
Hypotension, e.g. in sepsis

Question 3

Main cause/risk factor for haemorrhagic stroke?

Answer 3

Hypertension

Question 4

Which functional areas of the brain are affected infarctions in the territory of:

a) anterior cerebral
b) middle cerebral
c) posterior circulation
d) small vessel

Answer 4

a) motor cortex, frontal lobe
b) motor cortex, somatosensory cortex, parietal lobe, optic radiations (causing quadrantanopia)
c) occipital lobe, cerebellum, cranial nerves
d) pons, internal capsule, thalamus, basal ganglia

Question 5

Signs which indicate intracerebral haemorrhage rather than infarction? (4)

Answer 5

Headache, meningism, nausea and vomiting, seizures

Question 6

Main investigation in suspected stroke?

Answer 6

Urgent brain imaging (CT or MRI) to exclude haemorrhage

Question 7

Indications for thrombolysis?

Answer 7

Patient is within 4.5hrs of symptoms onset, aged 18-80 years and no contraindication exists (e.g. haemorrhage on CT)

Question 8

Agent used for thrombolysis, and dose?

Answer 8

recombinant tissue plasminogen activator e.g. alteplase 0.9mg/kg over one hour

Question 9

When should antiplatelets be used? What agent?

Answer 9

In acute ischaemic stroke where haemorrhage has been excluded. Aspirin 300mg

Question 10

Which investigation is essential to carry out as soon as possible?

Answer 10

Formal swallow assessment

Question 11

Who should be considered for carotid endarctectomy?

Answer 11

Patients with non-disabling stroke/TIA, if carotid artery is found to be stenosed on carotid Doppler ultrasound +/- CT/MRI angiography

Question 12

Tool which can be used to assess suspected stroke?

Answer 12

ROSIER

Question 13

Stroke mimics? (7)

Answer 13

Hypoglycaemia
Migraine
Space occupying lesion
Post-ictal
Intracerebral haemorrhage
Bell's palsy
Non-organic/functional

Question 14

Which antiplatelets are used in secondary prevention?

Answer 14

Aspirin and dipyridamole

Question 15

When should warfarin be used for anticoagulation?

Answer 15

In patients with risk of venous embolism e.g. with persistent/paroxysmal AF, prosthetic valves

Question 16

Prognosis of a stroke which presents with loss of consciousness?

Answer 16

Poor prognosis, however LOC is an uncommon presentation of stroke

Question 17

Contraindications to thrombolyis? (2)

Answer 17

Recent stroke within 3 months

Current haemorrhagic stroke

Question 18

Gait abnormality in stroke?

Answer 18

Hemiplegic gait- steps are slower and leg is dragged in an arc

Question 19

What clinically defines large vessel occlusion in stroke?

Answer 19

Loss of higher cortical functions e.g. speech, personality

Question 20

Investigations aimed towards finding the underlying cause of a stroke? (5)

Answer 20

Basic bloods esp lipids and glucose
ECG- atrial fibrillation, signs of previous ischaemia, left ventricular hypertrophy
Carotid artery Doppler
Holter monitoring
Echocardiogram- atrial dilatation if longstanding A fib

Question 21

Definition of stroke?

Answer 21

Acute onset of a focal neurological deficit due to obstruction of blood flow to the brain

Question 22

Small vessel (lacunar) stroke is usually caused by what process?

Answer 22

Thrombosis (rather than emboli)

Question 23

Symptoms which should raise suspicion of stroke?

Answer 23

Unilateral weakness which is initially flaccid
Unilateral sensory loss
Homonymous hemianopia
Dysphasia

Question 24

Definition of TIA?

Answer 24

Sudden onset of focal neurological deficit lasting less than 24 hours

Question 25

What score is used to stratify stroke risk in patients who have had a TIA?

Answer 25

ABCD2 score

A= age
B= blood pressure
C= clinical features
D= diabetes mellitus
D(2)= duration of symptoms

Question 26

Prevention of stroke in patients with TIA? (2)

Answer 26

Clopidogrel 300mg loading dose, followed by 75mg daily

Control of BP/lipids/diabetes

Question 27

In cardio-embolic stroke, when should anticoagulation be commenced and what is the rationale behind the delay?

Answer 27

14 days. Reduces risk of haemorrhagic transformation