Stroke

Question 1

How is stroke defined?

Answer 1

clinical syndrome of presumed vascular origin presenting with rapidly developing signs of focal or global disturbance of cerebral functions lasting more than 24 hours or leading to death.

Question 2

What are the RF for ischaemic stroke?

Answer 2

1. Thrombus: smoking, DM, HT, Hyperlipidaemia, Obesity,
2. Embolic: AF, Valvular defects, Patent Foramen Ovale, Infective Endocarditis,
3. TIA hx, Fhx, Arteriovenous malformations, The Pill / HRT, alcohol use

Question 3

What are the causes of stroke?

Answer 3

1. Thrombus
2. Embolus (cardiac or atherothromboembolism e.g. from carotid)
3. CNS Bleed i.e. haemorrhage due to aneurysm rupture, trauma, HT, anticoagulation T
4. Sepsis causing hypoperfusion
5. carotid artery dissection
6. Thrombophilia (disordered clotting)
7. Venous Sinus Thrombosis
8. Vasculitis

Question 4

What are the ddx for stroke?

Answer 4

1. Hyoglycaemia
2. Epilepsy: following a fit, some can develop Todd’s Paresis/Palsy which is a focal neurologic deficit which is characterised by persistent weakness - for several hours or longer - at the affected site. This usually recovers within mins- hours.
3. Subdural: may be longer time course, drowsiness, consider in people on e.g. warfarin or hx head injury.
4. Brain tumours: usually slower onset with progression. Headaches and vomitting are common.
5. Migraine: weakness can sometimes accompany but headache is the predominant feature and weakness is v transient.
6. Encephalitis: infective features sometimes, sometimes fitting and fluctuations.
7. Wernicke’s Encephalitis: triad of ataxia, opthalmoplegia- nystagmus, palsies of LR and confusion although rarely all are present. Acute Alcohol withdrawal induced and should respond to Pabrinex (IV Thiamine)
8. Cerebral Abscess: longer prodrome usually, headaches, fluctuating consciousness, and infective features.

Question 5

What are the Stroke S &S?

Answer 5

Cerebral: contralateral sensory loss/ hemiplegia which are initially flaccid and then become spastic, dysphasia, homonymous hemianopia, visuo-spatial deficit.
Brainstem: Disturbed gaze and vision, quadriplegia, locked in syndrome.
Lacunar: in basal ganglia, Internal Capsule, Thalamus and pons.

Question 6

What is a TIA?

Answer 6

Acute and transient i.e. lasting for less than 24h disturbance of focal or visual function. If repeated TIAs, or determined to be at high risk of subsequent stroke, NICE recommends MRI done urgently.

Question 7

What is dyphasia? Describe the two types.

Answer 7

Receptive: fluent and confident language but lacking in meaning/sense and unable to comprehend what is said to them. Wernicke’s Area is affected. Unable to follow simple commands.
Expressive: Hesitant speech with word finding difficulties but they understand what is said to them. May use neologisms- made up words to convey what they are trying to say.

Question 8

What is dysarthria?

Answer 8

Dysarthria is motor disturbance of speech: individuals know what they want to say, but cannot get the words out correctly, because of weakness to the tongue or facial muscles. Usually writing and reading is totally intact. Inability to Articulate.

Question 9

What is dysphagia?

Answer 9

Motor issue resulting in difficulty swallowing. Many patients with stroke are affected and this leads to risk of aspiration pneumonia.

Question 10

What is sensory neglect/ inattention?

Answer 10

the patient has intact sensation when tested unilaterally i.e. if you touch them on the L and then the R in turn they would identify both positively, but when confronted by bilateral stimuli, ignores the affected side

Question 11

What is dyspraxia?

Answer 11

the inability to perform tasks, despite having the necessary strength and sensation for example, unable to dress in the absence of a hemiparesis (‘dressing apraxia’). It is a problem with processing information.

Question 12

What is lost in homonymous hemianopia? What part of the visual pathway is disturbed?

Answer 12

Same side of both visual fields i.e. L visual field of both the L and R eyes (diff to e.g. bitemporal hemianopia).
The optic radiations are affected - both Meyer and Baum’s loops or one or the other would give homonymous quadrantopia.

Question 13

What is the INR, and what is the target range for most patients? If a patient’s INR is above target range, what is an appro course of action?

Answer 13

INR is used to measure warfarin effects on the extrinsic pathway of clotting.
The target range for INR in anticoagulant use (e.g. warfarin) is 2 to 3. If it is above this, the clotting time is too slow and too much warfarin has been given.
Stop warfarin and if necessary short term anticoag can be given e.g. enoxaparin until it is safe to restart warfarin.