Stroke

Question 1

Definition of stroke

Answer 1

Rapid onset neurological deficit of vascular origin lasting >24h

Question 2

Pathogenesis of stroke

Answer 2

80% ischaemic: atheroma or embolism (cardiac or atherothromboembolism)
20% hamorrhagic

Question 3

Classification system for strokes

Answer 3

Bamford classification AKA Oxford Stroke classification:
TACS (total anterior circulation stroke) - carotid/MCA/ACA
PACS (partial anterior circulation stroke) - carotid/MCA/ACA
POCS (posterior circulation syndrome) - vertebrobasilar
LACS (lacunar syndrome) - infarct around basal ganglia/internal capsule/thalamus/pons

Question 4

Features of TACS stroke

Answer 4

Carotid/MCA/ACA territory.

1. Hemiparesis and/or hemisensory deficit.
2. Homonymous hemianopia.
3. Higher cortical dysfunction: dominant side - aphasia, non-dominant - neglect, apraxia.

Question 5

Features of PACS stroke

Answer 5

2 out of 3 of TACS features, usually: homonymous hemianopia + higher cortical dysfunction.

Question 6

Features of POCS stroke

Answer 6

Vertebrobasilar territory.
Any of:
1. Cerebellar syndrome
2. Brainstem syndrome
3. Homonymous hemianopia.

Question 7

Features of LACS stroke

Answer 7

Pure motor: posterior limb of internal capsule
Pure sensory: posterior thalamus (VPL)
Mixed sensorimotor: internal capsule
Dysarthria/clumsy hand
Ataxic hemiparesis: posterior limb of internal capsule

Question 8

Differential for acute stroke

Answer 8

Head injury
High or low glucose
SOL
Infection
Drugs e.g. opiate OD

Question 9

Acute management of stroke

Answer 9

1. Resuscitate:
   Airway - consider NGT. NBM until assessed by SALT. Don’t over hydrate - risk of cerebral oedema. BM to exclude hypoglycaemia.
2. Monitor: glucose 4-11mM (sliding scale if DM). BP: Rx of HTN can decrease cerebral perfusion. Neuro obs.
3. Bloods
4. Imaging
5. Medical:
   Aspirin 300mg PO/PR once haemorrhage stroke excluded by CT, then continue 75mg OD indefinitely, + clopidogrel 75mg OD, ± PPI.
   Thrombolysis with alteplase if within 4.5h and haemorrhage excluded. Pause antiplatelets. Re-image 24h afterwards to check for haemorrhage.

Question 10

Blood tests in acute stroke

Answer 10

FBC: infection. sepsis may cause stroke.
U+E: electrolyte disturbance may mimic stroke.
Glucose: exclude hypoglycaemia.
Clotting: high or low INR may indicate cause.

Question 11

Imaging in acute stroke

Answer 11

Urgent CT/MRI
Diffusion-weighted MRI is most sensitive for acute infarct
CT will exclude primary haemorrhage

Question 12

Surgical tx in acute stroke

Answer 12

Neurosurgical opinion if intracranial haemorrhage
May coil bleeding aneurysms
Decompressive hemicraniotomy for some forms of MCA infarction

Question 13

Main functions of a stroke unit

Answer 13

Specialist nursing and physiology
Early mobilisation
DVT prophylaxis

Question 14

Post-acute management of stroke

Answer 14

Secondary prevention

Rehabilitation

Question 15

Non-acute stroke work-up investigations

Answer 15

ECG ± 24h tape: arrhythmia, old ischaemia.
Bloods: FBC (high or low Hb), U+E (association with renovascular disease), glucose (exclude DM), lipids (CV risk), clotting and thrombophilia screen, vasculitis (ESR, ANA),
Imaging: CXR (cardiomegaly, aspiration), carotid doppler, echo (mural thrombus, RWMA, ASD/VSD (paradoxical emboli)).

Question 16

Components of a thrombophilia screen

Answer 16

FBC, clotting, fibrinogen concentration.
APC resistance AKA factor V Leiden.
Lupus anticoagulant.
Anti-cardiolipin antibodies.
Assays for protein C and S and AT3 activity.
PCR for prothrombin gene mutation.

Question 17

Secondary prevention of stroke

Answer 17

AABCDEE
Antiaggregants and anticoagulants.
Blood pressure drugs.
Cigarette smoking cessation.
Diet
Exercise
Endarterectomy of carotids if stable and stenosis >50%.

Question 18

Rehabilitation after stroke

Answer 18

MENDS
MDT
Eating: screen swallowing and screen malnutrition (MUST tool). NG/PEG and nutritional supplements as needed.
Neurorehab: physiology and speech therapy. Botulinum for spasticity.
DVT prophylaxis.
Sores must be avoided.

Question 19

Tool for assessing malnutrition

Answer 19

MUST tool (malnutrition universal screening tool)

Question 20

Prognosis for stroke @ 1 year

Answer 20

10% recurrence
PACS: 20% mortality, 1/3 survivors independent.
TACS much worse: 60% mortality, 5% independent.