Stroke

Question 1

Definition of stroke?

Answer 1

ACUTE (sudden) onset of FOCAL neurological symptoms and signs, due to disruption of blood supply

ALSO

An end-organ complication of poor vascular health

Question 2

2 types of stroke?

Answer 2

Haemorrhagic - blood vessel bursts or bleeds

Ischaemia (most common) - blockage of blood flow

Question 3

Causes of haemorrhagic stroke?

Answer 3

HYPERTENSION (in stroke, this is the BIGGEST RISK FACTOR)

Weakened blood vessel wall due to:
Structural abnormalities like aneurysm, arteriovenous malformation (AVM)
Inflammation of vessel walls (vasculitis)

Question 4

Main causes of ischaemic stroke?

Answer 4

Thrombotic

Embolic

Hypoperfusion - narrowed blood vessels depend on a certain pressure for perfusion but, in this, blood flow is disturbed by a lack of forward flow due to a systemic problem

Question 5

How is Virchow’s triad related to thrombosis?

Answer 5

Circulatory stasis
Endothelial injury
Hypercoagulable state

Question 6

Mechanisms of atherothrombotic stroke?

Answer 6

Atherogenesis leads to plaque (at this stage, risk factor control can help)

Plaque can lead to:
Vessel stenosis (leads to low blood flow and ischaemia) OR
Plaque rupture

Both lead to platelet aggregation as well, then to thrombosis and ischaemia

Question 7

Non-modifiable risk factors for stroke?

Answer 7

Age
Family history of stroke
Gender
Race
Previous stroke

Question 8

Potentially modifiable risk factors of stroke?

Answer 8

Hypertension, hyperlipidaemia and smoking make the most difference; if a person had a TIA and they correct these lifestyle factors, they reduce their risk dramatically

Diabetes
AF
Congestive HF
Alcohol excess
Obesity
Physical inactivity
Poor socio-economic status

Question 9

When is statin therapy used in stroke?

Answer 9

Recommended in all patients with ischaemic stroke

Not recommended in haemorrhagic stroke

Question 10

Causes of stroke in youngsters?

Answer 10

Homocysteinemia 
Vasculitis
Protein C/S deficiency
Antithrombin III deficiency
Cervical artery dissection

Question 11

6 essential questions when dealing with a stroke patient?

Answer 11

Is this a stroke?

What kind of stroke is this?

What caused this stroke/TIA?

Have I tried my best to answer the above question?

Is the patient on the appropriate secondary prevention following investigations?

Have I answered any questions the patient has?

Question 12

What conditions can mimic stroke?

Answer 12

Hypoglycaemia
Seizure
Migraine (some can have neurological symptoms)
Space occupying lesions like brain tumours
Functional hemiparesis - somebody putting on stroke symptoms

Question 13

What is a TIA and diagnosis?

Answer 13

Transient Ischaemic Attack (mini-stroke)
No different to a stroke but shorter (symptoms last less than 24 hours) - blood vessels have mechanisms of dealing with clots, e.g: Tissue Plasminogen Activator, so symptoms disappear

MRI changes can occur if symptoms last over 1 hour

Question 14

Usefulness of a TIA diagnosis?

Answer 14

WARNING SIGN to modify risk factors and prevent stroke

If a person has a TIA, there is a high risk of a subsequent stroke within the next week (so a diagnosis must be made but people do not often present)

Question 15

Why is brain imaging used?

Answer 15

Only way of differentiating between an ischaemic and haemorrhagic stroke:
CT brain scan +/- angiography
MRI with DWI +/- angiography

MRI with GRE can be used to look for old haemosiderin deposits (old bleeds and strokes)

Question 16

Investigations that can be used to determine cause of ischaemic stroke?

Answer 16

Glucose, lipids, thrombophilia screen in young patients

For atheroembolism - can use carotid scanning, CT/MR

Ambulatory ECG monitoring for AF, LVH (uncontrolled hypertension)

ECHO

Question 17

Difference between an atheroembolic and cardioembolic stroke?

Answer 17

Atheroembolism - infarcts in the same side as the affected carotid artery

Cardioembolism - infarcts in more than one arterial territory (bilateral - can go either direction)

Question 18

Causes of haemorrhagic stroke in elderly and young patients?

Answer 18

Elderly - hypertension
Young - if no hypertension and it is a lobar (superficial bleed) haemorrhage, investigate for an underlying aneurysm and AVM (Arteriovenous Malformation)

Question 19

Causes of multiple bleeds in haemorrhagic stroke?

Answer 19

Vasculitis
Moya Moya disease
Cerebral amyloid angiopathy

Question 20

Evidence for thombolysis use in stroke patients?

Answer 20

NOT IN HAEMORRHAGIC STROKE
Despite increased risk of symptomatic bleed within 36 hours, there is a better functional outcome in thrombolysed patients

Question 21

Medical management of ischaemic stroke?

Answer 21

Aspirin (75 mg) + Dipyridamole MR (200 mg BD) or Clopidogrel (75 mg daily) - all are anti-platelets

If in AF - anti-coagulation

Anti-hypertensives

Question 22

Surgical management of stroke?

Answer 22

Haematoma evacuation

Relief of raised intra-cranial pressure; in an older person, the brain is shrunken so there is less risk of brain compression

Carotic endarectomy