Stroke

Question 1

Causes of stroke/TIA in young people?

Answer 1

Vasculitis
Thrombophilia/Thrombosis
Subarachnoid haemorrhage (head injury)
Venous sinus

Question 2

Causes of stroke/TIA in older people?

Answer 2

Vasculitis e.g. giant cell arteritis 
Athero-thromboembolism (carotids)
Heart emboli - AF, MI, infective endocarditis
CNS bleed
Venous sinus thombosis

Question 3

Risk factors for stroke

Answer 3

HTN
Smoking
Heart conditions - AF, ACS, valvular
DM
Excessive alcohol
Previous TIA
Hyperlipidaemia
Contraceptive pill
carotid occlusion
Polycythaemia vera, clotting disorders

Question 4

Symptoms of cerebellar stroke?

Answer 4

Contralateral hemiplegia (flaccid –> spastic) and sensory loss
Homonymous hemianopia
Dysphasia

Question 5

Symptoms of brainstem stroke?

Answer 5

Quadriplegia
Locked in syndrome
Disturbances in gaze and vision
Lateral medullary syndrome - PICU, vertebral a.

Question 6

Symptoms of lacunar infarcts?

Answer 6

Small infarcts –> motor, sensory or mixed signs
ATAXIA
Intact cognition

Question 7

Management of suspected stroke in GP

Answer 7

1. Emergency admission to specialist stroke unit via ambulance
2. Do not start antiplatelet treatment until haemorrhagic stroke has been ruled out –> MRI
3. Hospital
   - Oxygen
   - Aspirin 300mg (+/- PPI)
   - Thombolytic - Alteplase
   - BM control (4-11)
   - BP control

Question 8

How can the risk of a stroke after a TIA be screened for?

Answer 8

ABCD2

A = age (60+ = 1 point)
B = BP (>140/90 = 1 point)
C = clinical 
- unilateral weakness = 2 points
- speech disturbance with no weakness = 1 point
D 
= DM (1 point)
= Duration (60+ mins = 2 points, 10-59 = 1 point)

Low risk = <3 or if they present more than a week after their TIA has resolved

High risk = 4+, AF, >1 TIA in a week, TIA whilst on anticoagulation

Question 9

Management of TIA in GP

Answer 9

Assess:

• BP
• AF (ECG)
• Blood sugar
• HX - symptoms of TIA in last 7 days?
• ABCD2

Question 10

Management of high risk TIA patients?

Answer 10

Refer to specialist stroke until within 24 hours of symptoms onset
If taking oral anticoagulation admit for brain imaging (haemorrhagic stroke) and carotid imaging

Question 11

Management of low risk TIA patients?

Answer 11

Refer to specialist assessment within 1 week of symptoms onset
- MRI + carotid imaging

Question 12

What immediate treatment should be given to TIA patients?

Answer 12

Simvastatin 40mg
Aspirin/clopidrogrel 300mg (then 75mg daily)
-unless high risk or already taking anticoagulants

Question 13

Primary care follow up at GP for confirmed stroke?

Answer 13

within 6 months:

• Lifestyle - advice about driving
• CV risk
• Assess medications
• Annual BP and Lipid profile
• Annual pre winter influenza

Question 14

Neurological problems after stoke and their management?

Answer 14

Impaired balance - balance training and walking aids

Falls - bone profile, falls and injury prevention

Reduced movement/weakness - physiotherapy

Spasticity - Physio, botox, drugs (baclofen, gabapentin, tizanidine)

Question 15

Pain management after stroke

Answer 15

Neuropathic pain - amitriptyline, gabapentin

Shoulder and musculoskeletal pain - pain ladder

Question 16

Cognitive impairments management

Answer 16

MMSE

Question 17

GP management of confirmed TIA

Answer 17

Follow up within 1 month - then annualy:

• Lifestyle
• CV risk
• Assess medications - clopidogrel 75mg daily, simvastatin 40mg
• Driving - should not drive 4 weeks, >1 TIA then 3 months (truckers can’t drive for 1 year)
• Annual BP and lipid profile
• Annual pre-winter influenza

Question 18

Contraindications for thrombolysis?

Answer 18

BP>185/110
Recent MI, stroke, head injury
Recent LP
Pregnancy
Seizures at onset
INR<1.7

Question 19

Important differentials to rule out for stroke?

Answer 19

Hypoglycaemia 
Seizures (todd's paresis)
Trauma
Infection
Malignancy
Migraine
GCA

Question 20

Anterior circulation strokes

Answer 20

40%
Limb weakness with visual field loss +/- corticol dysfunction (aphasia/apraxia) suggests partial or complete infarct

If dominant hemisphere - apraxia/aphasia more pronounced

Question 21

Lacunar infarct

Answer 21

30% - internal capsule
Motor sensort loss affedting 2+ of:
-Face
-Arm
-leg
Do not have visual or speech distubance

Question 22

Posterior circulation

Answer 22

15%

Visual problems +/- cerebellar (ataxia, N+V)
Cranial nerve deficits

Question 23

Haemorrhage

Answer 23

10% intracerebral
5% subarachnoid

Early vomiting, severe headache, drowsiness
HTN and warfarin

Question 24

ROSIER score

Answer 24

LOC/syncope = -1
Seizure = -1

1 point:
Asymmetric face weakness
Asymmetric arm weakness
Asymmetric leg weakness
Speech disturbance
Visual field defect

1+ = stroke likely
<1 = stroke unlikely

Question 25

Acute management of stroke

Answer 25

ABCDE
Blood glucose
ECG + BP
IV access and bloods (FBC, U+E, LFT, clotting, ESR and CRP, Ca2+
CXR

Immediate CT/MRI within thrombolysis window (4.5 hrs) to exclude haemorrhagic stroke
IV alteplase if <4.5 hrs since onset
>4.5 hrs - 300 mg aspirin, carotid doppler

Question 26

Management of haemorrhagic stroke?

Answer 26

FFP
Vitamin K
Surgical intervention