Stroke

Question 1

What is the definition of a stroke

Answer 1

An acute neurological deficit last more than 24 hours caused by cerebrovascular aetiology

Question 2

What is the definition of a TIA

Answer 2

Stroke signs and symptoms that resolve within 24 hours

Question 3

What percentage of strokes are ischaemic

Answer 3

Roughly 85%

Question 4

What are the causes of an ischaemic stroke

Answer 4

Cerebral vessel thrombosis Arterial emboli (AF, endocarditis, MI) Atherthromboembolism (from carotids)

Question 5

What are some causes of a haemorrhagic stroke

Answer 5

High BP Trauma Aneurysm rupture

Question 6

What is the time window for thrombolysis for an ischaemic stroke

Answer 6

3-4.5 hours

Question 7

What medication is used in thrombolysis

Answer 7

Alteplase - recombinant tissue plasminogen activator

Question 8

What is the time window for endovascular intervention for ischaemic strokes

Answer 8

Within 6 hours from onset

Question 9

Give 3 contraindications for thrombolysis in acute stroke

Answer 9

Haemorrhage Past CNS bleed Anticoagulants or INR >1.7 BP >220/130

Question 10

A 70 year old man presented with right sided weakness and dysphasia. These symptoms lasted for 2 hours then resolved. The patient has a BP of 135/85 and no other co-morbidities. What is this patients ABCD2 score and what does this suggest

Answer 10

Age - >65 (1 pt) BP - >140/90 (1 pt) Clinical features - unilateral weakness (2 pts), speech disturbance w/o weakness (1 pt) Duration of symptoms - >60 mins (2 pts), 10-59 mins (1 pt) Diabetes (1 pt) This patient has a score of 5. Patients with a score of 4 or above should be assessed by a specialist within 24 hrs. A score of 6 or above strongly predicts a stroke

Question 11

What is Hoffman’s sign?

Answer 11

Equivalent of Babinski in the upper limbs- elicit by flicking the DIP of the middle finger and watching (especially the thumb) for finger flexion

Question 12

What suggests a lacunar stroke vs large vessel stroke?

Answer 12

Lacunar- classically involves only motor or sensory hemideficit.

Large vessel-both

Question 13

What should you look for in patients with a right hemiparesis?

Answer 13

Speech abnormalities

Question 14

How would you like to complete an examination of a patient with signs suggestive of a stroke?

Answer 14

Complete neuro exam Assess visual field defects (homonymous hemianopia) Assess speech Fundoscopy for papilloedema (SOL) Measure BP Assess pulse (AF) Auscultate for carotid bruits Check urinalysis (glycosuria) Ask patient which is their dominant hand

Question 15

How would you differentiate a cerebral from a brainstem stroke?

Answer 15

Higher cerebral function abnormalities –> cerebral stroke

Cerebellar abnormalities, eye movement abnormalities or Horner’s syndrome –> brainstem

Also “crossed signs (i.e. pathology on both signs of the body) –> brainstem stroke

Question 16

A patient with unilateral arm weakness > leg weakness is suggestive of a stroke in which artery?

Answer 16

MCA- predominantly affects the arms and face due to supply of motor homunculus

Question 17

A patient with unilateral leg weakness > arm weakness is suggestive of a stroke in which artery?

Answer 17

ACA- predominantly affects the legs due to supply of motor homunculus

Question 18

What visual field deficit is most likely after a stroke?

Answer 18

Homonymous hemianopia

Question 19

What is the most sensitive imaging for an acute infarct?

Answer 19

Diffusion-weighted MRI

Question 20

What is the medical management of acute stroke?

Answer 20

Thrombolysis within 4.5 hours (alteplase) Aspirin 300mg PO/PRr once haemorrhagic stroke excluded

Question 21

What further work up would you do on a patient who has had a stroke?

Answer 21

ECG ± 24 hour tape Thrombophilia screen Imaging- including echo for mural thrombus

Question 22

What secondary prevention measures can you take in a patient who has had a stroke?

Answer 22

• Risk factor management:
  
  • Statin- start after 48 hour
• Anticoagulants:
  
  • Aspirin/clopidogrel 300mg for 2 weeks
    
    • Then clopidogrel 75mg OD (preferred)
    • Or aspirin 75mg + dipyramidole 200mg
  • Warfarin instead if:
    
    • Cardioembolic stroke
    • Chronic AF
    • Start from 2 weeks post stroke (INR 2-3)
  • NB not aspirin and warfarin together
• Carotid endarterectomy if good recovery + ipsilateral stenosis

Question 23

What rehabilitation is important to consider?

Answer 23

Requires a dedicated stroke unit

MENDS:

• MDT:
• Eating: Swallow and malnutrition screening
• Neurorehab: Physio and speech
• DVT prophylaxis
• Sores- avoid at all costs

Question 24

What classification system is used for strokes?

Answer 24

Bamford classification of stroke (based on symptoms, gives prognosis)

• TACS: Total anterior circulation stroke: Hemiplegia, homonymous hemianopia, higher cortical dysfunction. Worse prognosis
• PACS: Partial anterior circulation. 2/3rds of the above
• LACS: Lacunar infarct. Pure hemi-motor or sensory loss. Best prognosis