Stroke

Question 1

What are the 2 main types of stroke?

Answer 1

Ischaemic

Haemorrhagic

Question 2

What is ischaemic stroke caused by? (5)

HINT: there are two main categories.

Give examples of each process.

Answer 2

EMBOLISM:
Cardiac, e.g.
-AF
-MI
-Patent foramen ovale
Aortic, e.g.
-Atheroma
Arterial, e.g.
-Atheroma
-Dissection

THROMBOSIS:
Large vessel disease, e.g.
-Atherosclerosis
Small vessel disease, e.g.
-Lipohyalinosis
-Atherosclerosis

Question 3

Describe the pathophysiology of ischaemic stroke. (5)

Answer 3

1. Blockage of cranial arteries causes ischaemia
2. Anaerobic respiration produces less ATP
   a. Therefore ATP depletion
3. Loss of Na+/K+ ATPase
   a. Na+ builds up in cell
   b. This causes cytotoxic oedema
4. Loss of Na+/Ca2+ ATPase
   a. Ca2+ builds up in cell
   b. This causes excitotoxicity
   c. Also causes activation of proteases/lipases
   d. Also causes ROS and free radical production
5. This causes tissue death (infarction)

Question 4

What is the ischaemic penumbra?

Answer 4

Area of ischaemic tissue around a core of infarction in ischaemic stroke

Can be saved if blood supply is restored!

Question 5

List 8 risk factors for ischaemic stroke.

Answer 5

Age
Hypertension
Heart disease (e.g. AF)
Smoking
Diabetes
Hypercholesterolaemia
Previous stroke/TIA
Family history

Question 6

What is haemorrhagic stroke caused by? (2)

Answer 6

Intracerebral haemorrhage

Anti-coagulation drugs

Question 7

List 12 risk factors for haemorrhagic stroke.

Answer 7

Hypertension
Cerebral amyloid angiopathy
Anti-coagulants
Anti-platelets
Dementia
Age
Gender (males > females)
Alcohol
Smoking
Drugs
HypOcholesterolaemia
Vascular lesions (e.g. aneurysms)

Question 8

How do you differentiate between ischaemic and haemorrhagic stroke?

Answer 8

CT scan

Haemorrhagic - white area
Ischaemic - grey area BUT may look normal!!

Question 9

What investigations would you do for stroke? (12)

Answer 9

CT scan

Bloods:

• FBC
• Troponin
• Glucose
• Coagulation assays
• Other standard tests

Cardiac investigations:

• BP
• ECGs
• Echocardiogram

Vascular investigations:

• CT angiogram
• MR angiogram
• Doppler ultrasound

Question 10

How would you manage ischaemic stroke? (4)

Answer 10

Thrombolysis (alteplase, ONLY if <4.5 hours since onset)
Anti-platelet drugs (aspirin, AFTER 24 hour scan)
Endovascular procedures (ICA/proximal MCA occlusion)
Secondary prevention

Question 11

What would you do for secondary prevention of ischaemic stroke? (5)

Answer 11

Aspirin/clopidogrel
BP control
Statins
Warfarin/DOACs (in AF)
Carotid endarterctomy

Question 12

When would you do a carotid endarterectomy for secondary stroke prevention?

Answer 12

Carotid artery stenosis 70+%

Question 13

Describe the typical discharge drugs after ischaemic stroke. (5)

Answer 13

Clopidogrel (or apixaban)
Simvastatin
Perindopril
Bendrofluazide
Smoking cessation tools

Question 14

What advice about driving would you give patients after suffering a stroke? (2)

Answer 14

If no/minimal neuro deficit: wait 30 days

If significant deficit: do NOT drive until further assessment is carried out

Question 15

How would you manage haemorrhagic stroke? (8)

Answer 15

ABCDs

Admission to stroke unit

Prevent haematoma expansion:

• Prothrombin complex concentrate
• Reverse anticoagulants
• Fresh frozen plasma

Neurosurgery

Treat fever

DVT prophylaxis:
-Compression stockings

Nutrition

Rehabilitation

Question 16

How would you prevent haematoma expansion in haemorrhagic stroke? (3)

Answer 16

Prothrombin complex concentrate
Fresh frozen plasma
Reversal agents for anticoagulant drugs

Question 17

When would you do neurosurgery for a haemorrhagic stroke? (3)

Answer 17

Haematoma is <1cm from cortical surface
Posterior fossa haematoma
Patient is rapidly deteriorating

Question 18

Describe the clinical features of stroke.

Answer 18

CEREBRAL STROKE:
Contralateral sensory loss/hemiplegia
Dysphasia
Homonymous hemianopia
Visuospatial deficit

BRAINSTEM STROKE:
Quadriplegia
Locked-in syndrome

CEREBELLAR STROKE:
Cerebellar ataxia
Dysdochodiakinesis

Question 19

List 3 clinical features of stroke which might suggest haemorrhagic stroke.

NOTE: this is very unreliable; don’t use it to actually diagnose one!

Answer 19

Meningism
Severe headache
Coma

Question 20

List 3 clinical features of stroke which might suggest ischaemic stroke.

Answer 20

Carotid bruit
AF
Previous TIA
Ischaemic heart disease

Question 21

How would you classify stroke? (4)

Answer 21

Total anterior circulation syndrome (TACS)
Partial anterior circulation syndrome (PACS)
Posterior circulation syndrome (POCS)
Lacunar syndrome (LACS)

Question 22

Describe the features of a TACS stroke. (3)

What can cause a TACS stroke? (2)

Answer 22

CLINICAL FEATURES:
Hemiparesis
Higher cortical dysfunction
Hemianopia

CAUSED BY:
MCA occlusion
Internal carotid a. occlusion

Question 23

Describe the clinical features of a PACS stroke. (4)

Answer 23

Isolated higher cortical dysfunction

OR

Any 2 of:

• Hemiparesis
• Higher cortical dysfunction
• Hemianopia

Question 24

Describe the clinical features of a POCS stroke. (7)

Answer 24

Isolated hemianopia

OR

Cranial nerve abnormalities
Brainstem syndrome:
-Nystagmus
-Past-pointing
-Dysdiadochokinesis 
-Ataxia

Question 25

Describe the clinical features of a LACS stroke. (5)

Answer 25

Pure motor stroke
Pure sensory stroke
Sensorimotor stroke
Ataxic hemiparesis
"Clumsy hand" dysarthria

Question 26

What can cause a POCS stroke? (3)

Answer 26

Perforating artery disease
Posterior cerebral artery occlusion
Cerebellar artery occlusion

Question 27

What can cause a LACS stroke? (2)

Answer 27

Small vessel disease

Perforating artery disease