Stroke

Question 1

What are the two different types of stroke?

Answer 1

Haemorrhagic and ischaemic

Question 2

What are the causes of ischaemic stroke?

Answer 2

Atherosclerotic disease causes cerebral thrombosis to form (plaque)
Atherosclerotic clot breaks off from coronary arteries and travels to brain (cardioembolic)

Question 3

How would an ischaemic stroke be diagnosed from a CT scan?

Answer 3

Demarcated hypodense zone

Question 4

What are the causes of haemorrhagic stroke?

Answer 4

Bleeding onto brain from vessel rupture or weakening

Question 5

How is an ischaemic stroke prevented?

Answer 5

Lifestyle changes

Statin treatment

Question 6

How is a haemorrhagic stroke prevented?

Answer 6

Controlled BP
Lifestyle changes
Exercise

Question 7

What are the symptoms of strokes?

Answer 7

Facial dropping or paralysis
Difficulty moving limbs
Slurred speech

Question 8

What could be non-stroke causes of the symptoms?

Answer 8

Seizures
Drug toxicity
Brain tumours
Migraines
Spinal cord lesions

Question 9

What are the stroke risk factors?

Answer 9

Older age
Male
Family history
Afro-Caribbean ethnicity
Hypertension
Hyperlipidaemia
Diabetes
Atrial fibrillation
Smoking

Question 10

Which regions result in disability if damaged and are they reversible?

Answer 10

Umbra (inner region) - Irreversible

Penumbra (outer region) - Potential for recovery

Question 11

What is Anakinra and what is its use?

Answer 11

Interleukin 1-beta antagonist
IL1-beta stimulates release of tumour necrosis factor and IL-6
Inflammation from these exacerbates brain damage so Anakinra prevents further inflammation

Question 12

What is a potential novel stroke treatment?

Answer 12

Injection of stem cells into brain to replace damaged cells

Question 13

What is thrombolysis?

Answer 13

Dissolve clot in brain but only if patient has presented within 4.5 hours of symptom onset
Alteplase used
Only for ischaemic stroke

Question 14

What is the acute treatment for ischaemic stroke?

Answer 14

High dose antiplatelet ASAP (if thrombolysed, wait 24 hours)
300mg aspirin
Continue for 14 days

Question 15

What is the acute treatment for haemorrhagic stroke?

Answer 15

If bleed ongoing, neurosurgical intervention
Cease any drugs that may contribute to bleed
Vit K or prothrombin complex concentrate if INR >1.4

Question 16

What are the acute secondary prevention measures if cardiovascular risk?

Answer 16

Lipid lowering

Give 20-80mg atorvastatin ASAP

Question 17

How should BP be controlled following a stroke?

Answer 17

If thrombolysing, ensure BP is below 185/110mmHg
If systolic BP is >150mmHg within 6hrs of symptom onset treat with antihypertensives (for haemorrhagic stroke) - IV infusion of short-acting drug (nicardipine or GTN)

Question 18

What is the long-term treatment plan for ischaemic stroke?

Answer 18

Antiplatelet or anticoagulant depending on atherosclerotic or cardioembolic
AP - Clopidogrel 1st line, aspirin and MR dipyridamole if not tolerated
AC - Novel anticoagulant or warfarin

Question 19

What are the long-term cholesterol lowering treatments for stroke?

Answer 19

Simvastatin 40mg or if total cholesterol <4mmol/L atorvastatin
Only for haemorrhagic stroke patients if hyperlipidaemia or CV risk

Question 20

What is the BP aim for patients following a stroke?

Answer 20

130mmHg systolic BP

Question 21

What are the complications of strokes? How are they managed?

Answer 21

Swallowing problems - NG/PEG tube, thickened fluids, puree diet, review medication
Depression - Screen all patients, SSRI 1st line
Dry Mouth/Dribbling - Artificial saliva, good mouth hygiene/oral glycopyrronium, atropine eye drops in mouth, hyoscine patch
Seizures - Prophylactic antiepileptics if needed, valproate and levetiracetam
Spasticity - Skeletal muscle relaxants (baclofen, tizanidine)