Stroke

Question 1

Define TIA (transient ischaemic attack)

Answer 1

Brief episode of neurological dysfunction

Symptoms last typically <1 hour and definitely <24 hours

Question 2

Describe the 3 different types of ischaemic stroke

Answer 2

Atheroembolic infarcts (clots from the carotids)

Cardioembolic infarct (clot from the heart)

Small vessel disease (arteriosclerosis elsewhere causes emboli)

Question 3

What are some of the causes of haemorrhagic strokes?

Answer 3

Amyloid angiopathy

AVM

Aneurysm

Tumours

Question 4

What are the 4 main stroke syndromes?

Answer 4

Total anterior circulation syndrome (TACS)

Partial anterior circulation syndrome (PACS)

Posterior circulation syndrome (POCS)

Lacunar syndrome (LACS)

Question 5

What are the functions of the RIGHT side of the brain which may be affected by a stroke?

Answer 5

Creativity
Spatial orientation
Control of the left side of the body

Question 6

What are the functions of the LEFT side of the brain which may be affected by a stroke?

Answer 6

Language
Number skills
Reasoning
Control of the right side of the body

Question 7

Which side of the brain is usually the dominant hemisphere?

Answer 7

LEFT

Question 8

How many strokes are due to atrial fibrillation?

Answer 8

1 in 6

due to stasis of blood leading to clot formation

Question 9

Why does a patent foramen oval increase the risk of strokes?

Answer 9

Blood crosses from the RA to the LA of the heart through the patent foramen ovale.

Therefore clots from DVTs reach the heart and instead of going to the lungs to cause a PE, they go to the brain to cause a stroke.

Question 10

What investigations should be done for a suspected stroke?

Answer 10

CT (very good at identifying haemorrhage acutely)

MRI (better than CT for identifying infarcts and haemorrhage if a week has passed)

Bloods

Carotid scan, ECHO, ECG angiogram

Question 11

How should an ischaemic stroke be managed acutely?

Answer 11

Thrombolysis (tissue plasminogen activator IV TPA)
+ aspirin 24 hours later
If <4.5 hours from onset

Aspirin only if >4.5 hours from onset

Question 12

What secondary prevention should be done post stroke?

Answer 12

Anticoagulants (cardioembolic infarcts and AF)

Antiplatelts (infarcts)

Statins

Antihypertensives

Lifestyle advice

Question 13

What are some of the risk factors for stroke?

Answer 13

Hypertension

Diabetes

Smoking/ diet/ obesity

Carotid disease

Question 14

Posterior circulation syndrome storkes involve which vessels?

Answer 14

Vertebral artery or basilar artery and their branches

Question 15

Lacunar syndrome stokes involve vessels in which parts of the brain?

Answer 15

Deep parts of the brain; basal ganglia, thalamus, white matter and brainstem

Question 16

How would a total anterior circulation stroke (TACS) present?

Answer 16

Hemiplegia and/ or hemisensory loss (2+ of face/arm/leg)

Homonoymous hemianopia

Higher cortical dysfunction

Question 17

How would a partial anterior circulation stroke (PACS) present?

Answer 17

2/3 of the criteria for TACS

Question 18

How would lacunar syndrome present?

Answer 18

Pure motor or sensory storke

Motor + sensory deficits

Ataxia

Question 19

How would a posterior circulation stoke (POCS) present?

Answer 19

BILATERAL motor and/or sensory deficit

Cranial nerve dysfunction

Isolated homonymous hemianopia

Cortical blindness

Question 20

How should a haemorrhagic stroke be managed acutely?

Answer 20

Antihypertensives

Surgery; craniotomy or aspiration

Question 21

Neglect syndrome is most likely to be due to a stroke on which side of the brain?

Answer 21

Right side of the brain

Question 22

What is the hyper dense middle cerebral aftery sign an indicator for?

Answer 22

Thrombolysis

Question 23

What is meant by higher cortical dysfunction? Which strokes does this occur with? Which sides of the brain are affected with which symptoms?

Answer 23

Higher cortical function refers to language problems or neglect depending on the side of the brain affected

It occurs with TACS/ PACS

Language problems (LEFT) neglect (RIGHT)

Question 24

What are the causes of cardioembolic strokes?

Answer 24

Arrhythmias

Valvular heart disease

Prosthetic valves

Post MI

Congenital defects

Question 25

Which drug is given after aspirin for ischaemic strokes for lifelong prevention?

Answer 25

Aspirin is given for 2 weeks and then…

Clopidogrel lifelong

OR warfarin if the stroke was caused by a cardioembolic infarct

Question 26

Polycystic kidney disease increases the risk of which type of stroke?

Answer 26

Subarachnoid haemorrhage

due to the presence of berry aneurysm

Question 27

Ataxic hemiparesis occurs with which stroke syndrome?

Answer 27

Lacunary syndrome

Question 28

What is amarousis fugax?

Answer 28

Type of TIA involving the retinal artery

• rapid painless loss of vision in one eye

Question 29

Why are ‘watershed’ areas of the brain more sensitive to hypoxia?

Answer 29

They are at the periphery of vascular territories and so are less well supplied and most distant from the heart

Question 30

Which sex immediately gains a score of 1 on the CHA2DS2VASx scoring system?

Answer 30

Female sex

Question 31

What treatment is given for cardioembolic strokes?

Answer 31

Same as for other ischaemic strokes - but after the 2 weeks of aspirin, warfarin is given rather than clopidogrel for life long prevention

Question 32

What is the rosier scoring system used for?

Answer 32

To assess the likelihood of stroke being the cause for current symptoms

Question 33

Which artery is the most likely to be affected in thromboembolic disease?

Answer 33

Middle cerebellar artery

This is due to its alignment from the internal carotid artery

Question 34

Which stroke syndrome is the only one which would cause BILATERAL sensory/ motor loss?

Answer 34

POCS

The rest all cause UNILATERAL sensory or motor loss

Question 35

Which imaging test must also be done other than CT if a haemorrhagic stroke is suspected?

Answer 35

Cerebral angiography