Stroke

Question 1

What are the general symptoms of a stroke?

Answer 1

Loss of:

• power
• sensation
• speech
• vision
• coordination

Question 2

What might be found on a neurological history/examination in stroke?

Answer 2

Clumsy or weak limb
Loss of sensation
Loss of speech
Neglect/visuospatial problems
Vision problems
Ataxia/vertigo/incoordination/nystagmus

Question 3

How is the neurovascular supply divided?

Answer 3

Carotid system supplies most of the hemispheres and cortical white matter

The vertebro-basilar system supplies the brainstem, cerebellum and occipital lobes

Question 4

What is the cause of a stroke?

Answer 4

Blockage of vessel (85%) or rupture of vessel (15%)

Blockage due to thrombus, disease, disturbance etc.

Of the 85% ischaemic

• 35% large artery atherosclerosis
• 25% cardioembolic (e.g. AF)
• 25% small artery occlusion
• rest idiopathic/rare

Carotid dissection is also a rarer cause

Question 5

What types of haemorrhagic stroke are there?

Answer 5

Primary intracerebral haemorrhage (70%)

Secondary haemorrhage (30%)

• subarachnoid
• arteriovenous malformation

Question 6

What are the various stroke subtypes, in terms of circulation affected?

Answer 6

TACS (20%) - total anterior circulation stroke
PACS (35%) - partial anterior circulation stroke
LACS (20%) - lacunar stroke
POCS (25%)- posterior circulation stroke

Question 7

What are some typical symptoms of each type of stroke?

Answer 7

TACS - weakness, sensory deficit, higher cerebral dysfunction, usually due to occlusion of proximal MCA or ICA

PACS - 2 of 3 of TACS criteria or restricted motor/sensory deficit

LACS - pure motor, one-sided weakness or pure sensory (or combination)

POCS - affecting vertebro-basilar supply
- bilateral symptoms, breathing effects, tinnitus/vertigo

Question 8

What are the terms given to the types of visual field defect?

Answer 8

Unilateral field loss
Bitemporal hemianopia
Homonymous hemianopia

Question 9

What are some risk factors for stroke? Modifiable and non-modifiable?

Answer 9

Modifiable:

• High blood pressure
• AF

Non:

• Age
• Race
• FH

Question 10

What investigations might you do in suspected stroke?

Answer 10

Blood tests - full
ECG

CT/MRI
Carotid doppler

Sometimes echo can be helpful to look for clots in the heart

Question 11

What are the pros/cons of CT vs MRI in stroke?

Answer 11

CT is quick and shows blood (haemorrhage)

MRI takes longer and is claustrophobic, but shows up ischaemia better than CT

Question 12

Why are stroke units important?

Answer 12

Mobilise ASAP
Concentrate on simple things like swallowing (50% affected)
Introduce early therapy assessment
- physio, OT
Specialist nursing input

Question 13

What is the first stroke treatment given and what is an ideal timescale for immediate therapy?

Answer 13

Ischaemic

• thrombolysis
• aims to restore perfusion before cell death occurs
• benefit declines with increasing delay
• no effect around 280-360 minutes

Recombinant Tissue Plasmingeon Activator given IV is main treatment
Streptokinase not used

Patients with suspected stroke should have ambulance priority, rapid triage, immediate access to specialist services, rapid imaging

Question 14

What treatments for stroke may also be used after the immediate treatment?

Answer 14

Clot retrieval

• Insera SHELTER device
• improves survival

Hemicraniectomy

• For <60s with MCA territory stroke and cerebral oedema
• should be offered within 48 hours of onset

Question 15

After a stroke, what is done to prevent further TIAs?

Answer 15

Clopidogrel or aspirin given
Statin
BP drugs, even if in normal range

Carotid endarterectomy, particularly in severe stenosis