Stroke

Question 1

What is the definition of a stroke?

Answer 1

Focal neurological deficit of sudden onset with symptoms lasting over 24 hours.

Question 2

Approximately what percentage of strokes are ischaemic and what percentage are haemorrhagic?

Answer 2

Ischaemic ~ 85%

Haemorrhagic ~ 15%

Question 3

A patient describing a sudden onset, severe, ‘thunderclap’ headache would suggest what cerebral event has occurred?

Answer 3

A subarachnoid haemorrhage

Question 4

What is amarausis fugax and what type of stroke does it tend to be seen in?

Answer 4

Painless, temporary loss of vision in one or both eyes.

Seen in Anterior circulation/carotid artery strokes.

Question 5

In what circumstances does aphasia tend to occur?

Answer 5

If the dominant hemisphere (usually left) is affected and it’s a middle cerebral artery stroke.
Frontal lobe affected –> expressive dysphasia (Broca’s)
Temporal lobe affected –> receptive dysphasia (Wernicke’s)

Question 6

What are the key investigations to order in suspected stroke?

Answer 6

CT head immediately - but normal CT doesn’t exclude ischaemic stroke (can take up to 24 hours to appear on CT)
Blood glucose - exclude hypoglcyaemia which can mimic stroke
ECG - check for arrhythmia
Bloods - FBC, ESR, glucose, hyperlipidaemia, INR if on warfarin, TFTs
Echocardiogram - check for emboli for heart

Question 7

What scoring tool can be used to determine the likelihood of stroke?

Answer 7

Recognition Of Stroke In the Emergency Room (ROSIER score).
Loss of consciousness= -1
Seizure activity= -1
New acute onset of asymmetrical facial weakness/asymmetrical arm weakness/asymmetrical leg weakness/speech disturbance/visual field defect = all worth 1 point.
Stroke unlikely if score is 0 or less
Score >0 = stroke likely so treat immediately.

Question 8

Why should treatment not be started immediately to control hypertension in stroke patients?

Answer 8

Important to maintain cerebral perfusion and the patient needs the HTN to do this. BP should be lowered gradually.

Question 9

How should an ischaemic stroke be managed if it has been less than 4.5 hours since the onset of symptoms?

Answer 9

Thrombolysis using Alteplase.
Then 24 hours later, give aspirin 300mg (PR if dysphagic) then continue aspirin 75mg.
Supportive care (stroke rehab, early mobilisation)
Swallowing assessment
VTE prophylaxis with a heparin can be considered for ongoing management.

Question 10

How should an ischaemic stroke be managed if it has been more than 4.5 hours since the onset of symptoms or there’s a contraindication to thrombolysis?

Answer 10

Aspirin 300mg
Supportive care (stroke rehab, early mobilisation)
Swallowing assessment
VTE prophylaxis with a heparin can be considered for ongoing management.

Question 11

How should haemorrhagic stroke be managed?

Answer 11

Urgent neurosurgical evaluation and input.
Consider reversal of anticoagualtion if appropriate i.e. for patients on warfarin, give i.v. vitamin K and prothrombin complex concentrate

Question 12

What drugs may be considered for the long term management/secondary prevention of stroke?

Answer 12

Antiplatelet therapy (aspirin/clopidgrel)
Lipid modification (statins)
BP control (ACE-i/CCB/diuretics)
Anticoagulation (warfarin/DOACs)