Stroke

Question 1

What is stroke?

Answer 1

The experience of persisting neurological complications of cardiovascular disease - it is NOT a diagnosis

Question 2

What are the 3 broad categories of stroke?

Answer 2

Haemorrhage, infarct and subarachnoid haemorrhage

Question 3

What scoring system is used to diagnose stroke and what score would make a stroke the likely cause?

Answer 3

Rosier score, score of >0 makes stroke likely, score =0 makes stroke unlikely but not impossible

Question 4

What are the features associated with total anterior circulation syndrome (TACS)?

Answer 4

• Hemiplegia involving at least 2 of; face, arm and leg +/- hemisensory loss
• Homonymous hemianopia
• Cortical signs - dysphasia, neglect
• Most severe type of stroke with only about 5% of patients independently living at 1 year

Question 5

What are the features associated with partial anterior circulation syndrome (PACS)?

Answer 5

2 out of 3 features present in a TACS (hemiplegia, homonymous hemianopia and cortical signs) or; Isolated cortical dysfunction such as dysphasia or pure motor/sensory signs less severe than in lacunar syndromes e.g. monoparesis

Question 6

What is lacunar syndrome?

Answer 6

Lacunar infarcts are small infarcts in the deeper parts of the brain (basal ganglia, thalamus, white matter) and in the brainstem

Question 7

What causes lacunar syndrome and what are the features?

Answer 7

• They are caused by occlusion of a single deep penetrating artery
• Affect any 2 of face, arm and leg
• Best prognosis of all the strokes

Question 8

What are the features associated with posterior circulation syndrome (POCS)?

Answer 8

• Cranial nerve palsies
• Bilateral motor and/or sensory deficits
• Conjugate eye movement disorders
• Isolated homonymous hemianopia
• Cortical blindness
• Cerebellar deficits without ipsilateral motor/sensory signs

Question 9

What is usually affected in a cortical event in the dominant (left) hemisphere?

Answer 9

Language - major implications for rehabilitation

Question 10

What happens as a result of cortical events in the non-dominant (right) hemisphere?

Answer 10

Spatial awareness is affected - neglect

Question 11

What are the causes of ischaemic cerebrovascular disease in order of commonness?

Answer 11

Atherothromboembolism (50%), intracranial small vessel disease (25%), cardiac source of embolism (20%), rare causes (5%)

Question 12

How is small vessel disease classified?

Answer 12

6 types:

• Type 1 - arteriosclerotic (age/risk factor related)
• Type 2 - sporadic and hereditary cerebral amyloid angiopathy (CAA)
• Type 3 - genetic small vessel disease distinct from CAA Type 4 - inflammatory and immunologically mediated e.g. Churg-Strauss syndrome and Wegener’s granulomatosis
• Type 5 - venous collagenosis
• Type 6 - other small vessel disease

Question 13

Does atrial fibrillation increase or decrease the risk of stroke?

Answer 13

Increase - 5 fold! Around 1 in 6 strokes are due to AF

Question 14

How is haemorrahagic stroke classified?

Answer 14

Primary intracerebral and secondary intracerebral haemorrhage

Question 15

What are causes of primary intracerebral haemorrhage?

Answer 15

Hypertension and amyloid angiopathy

Question 16

What are causes of secondary intracerebral haemorrhage?

Answer 16

Arteriovenous malformation, aneurysm, tumour

Question 17

How is stroke acutely managed?

Answer 17

Thrombolysis (e.g. alteplase)/thromectomy, imaging, swallow assessment, nutrition and hydration, antiplatelets, stroke unit care, DVT prophylaxis

Question 18

How can stroke be prevented (secondarily)?

Answer 18

Medication, lifestyle, carotid surgery

Question 19

What factors are taken into account when deciding whether to thrombolyse a patient or not?

Answer 19

Age, time since onset, previous intracerebral haemorrhage or infarct, atrophic changes, blood pressure, diabetes, potential benefit to be gained by thrombolysis

Question 20

What does the FAST acronym for recognising symptoms of stroke stand for?

Answer 20

Facial weakness, Arm weakness, Speech problems, Test all 3 symptoms

Question 21

In the hyperacute setting of a stroke what may a brain CT scan show?

Answer 21

May be essentially normal :( but may show hyperdense middle cerebral artery for example

Question 22

What used to be the ONLY proven treatment for acute ischaemic stroke?

Answer 22

IV tPA (tissue plasminogen activator) - limited to <4.5 hours from onset of symptoms, large and proximal clots less likely to re-canalise

Question 23

What is the difference between a cardioembolic and an atheroembolic stroke?

Answer 23

Cardioembolic - fibrin dependent ‘red thrombus’ Atheroembolic - platelet dependent ‘white thrombus’

Question 24

How is a stroke investigated?

Answer 24

Full lipid profile, blood pressure, carotid scan, ECG, consider 72 hour ECG and echo cardiogram

Question 25

What is the ABC of medical stroke prevention?

Answer 25

• Antithrombotic therapy (antiplatelets, anticoagulants)
• Blood pressure
• Cholesterol
• Diabetes + Don’t smoke

Question 26

What score is used to assess risk of stroke?

Answer 26

CHA₂DS₂VASc score

• Congestive heart failure
• Hypertension
• Age>75 (2 points)
• Diabetes mellitus
• Stroke/TIA/thrombo-embolism (2 points)
• Vascular disease
• Age 65-74
• Sex category i.e. female

Maximum score is 9 points

Question 27

What drug based therapy has been proven to reduce the risk of stroke by up to 28%?

Answer 27

Perindopril based therapy

Question 28

How much of a risk reduction is associated with carotid endarterectomy?

Answer 28

Absolute risk reduction = 15.9%, depends on suitability of patient and expertise of surgical centre