Stroke

Question 1

Stroke definition

Answer 1

Rapid onset of neurological deficit

Lasting >24 hours

Result of vascular lesion and associated with infarction of central nervous system

Question 2

Stroke in evolution

Answer 2

When symptoms and signs are getting worse

Question 3

Minor stroke

Answer 3

One in which the patient recovers without a significant neurological deficit, usually within 1 week

Question 4

Transient ischaemic attack

Answer 4

Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without acute infarction

Tendency to recur and may herald thromboembolotic stroke

Question 5

Site of thrombosis

Answer 5

Atheromatous plaque in carotid, vertebral or cerebral arteries

Question 6

Site of emboli

Answer 6

Arise from atheromatous plaques in carotid/ vertebrobasilar arteries or from cardiac mural thrombi or from left atrium in atrial fibrillation

Question 7

Risk factors for thromboembolic stroke

Answer 7

Hypertension

Diabetes mellitus

Cigarette smoking

Hyperlipidaeima

Oral contraceptive

Excessive alcohol consumption

Polycythaemia

Atrial fibrillaiton

Migraine

Vasculitis

Cocaine

Question 8

Antithrombotic treatment

Answer 8

Aspirin 300mg should be given immediately and continued long term 75mg

Clopidogrel given to patients that can’t tolerate aspirin

Long term anticoagulation with warfarin for patients with af, some valvular lesions or dilated cardiomyopathy

Question 9

Cerebral hemisphere infarcts

Answer 9

Following occlusion of the branch of the middle cerebral artery

Sings contralateral to the lesion:

• hemiplegia
• hemisensory
• UMN facial weakness
• hemianopia

Initially hypotonic hemiplegia with decreased reflexes, within days develops to spastic hemiplegia with increased reflexes and extensor plantar response

Question 10

Lacunar infarcts

Answer 10

Small infarcts that produce localised deficits

e.g. pure motor or pure sensory stroke

Question 11

Brainstem infarction

Answer 11

Causes complex patterns of dysfunction depending on the sites involved

• lateral medullary syndrome
• coma
• locked in syndrome
• pseudobulbar palsy

Question 12

Lateral medullary syndrome

Answer 12

Most common of the brainstem vascular syndromes

Caused by occlusion of the posterior inferior cerebellar artery

Presents with sudden vomiting and vertigo, ipsilateral Horner’s syndrome, facial numbness, cerebellar signs and palatal paralysis

On the opposite side of the lesion there is loss of pain and temperature sensation

Question 13

Coma

Answer 13

Result of involvement of the reticular activating systen

Question 14

Locked in syndrome

Answer 14

All voluntary muscles are paralysed except for those that control eye movement

Caused by upper brainstem infarction

Question 15

Pseudobulbar palsy

Answer 15

Caused by lower brainstem infarction

Bilateral UMN lesions causing weakness of the same muscle groups

Dysarthria, dysphagia and nasal regurgitation but the tongue is small and spastic and there is no fasiculations

Question 16

Vascular dementia

Answer 16

Syndrome caused by multiple small cortical infarcts

Resulting in generalised intellectual loss

Stepwise progression with each infarct

Final picture is of dementia, pseudobulbar palsy and a shuffling gait resembling Parkinson’s disease

Question 17

Investigations for acute stroke

Answer 17

Brain CT to see site of lesion, distinguish between ischaemic/ haemorrhagic, identify conditions mimicking stroke

MRI if underlying pathology uncertain, diagnosis is in doubt or imaging is delayed for more than 10 days after stroke

Blood tests: glucose, FBC (identify polycythaemia), ESR (raised in few causes of vasculitis), creatinine and electrolytes, cholesterol and INR if taking warfarin

ECG: look for AF or MI

Question 18

Risk factors for intercerebral haemorrhage

Answer 18

Hypertension

Excess alcohol consumption

Increasing age

Smoking

• lead to secondary vascular changes such as small vessel disease and arterial aneurysms

Question 19

Presentation of intercerebral haemorrhage

Answer 19

Sudden loss of consciousness and stroke

Often accompanied by severe headache

Question 20

Subarachnoid haemorrhage

Answer 20

Spontaneous arterial bleeding into the subarachnoid space

• berry aneurysms (aquired lesions)
• congenital ateriovenous malformations

Question 21

TACI

Answer 21

All of:

• dense hemiparesis
• homonymous visual field loss
• dysphagia (if dominant hemisphere, normally left hemisphere)
• neglect
• other disturbance of cerebral function e.g. parietal lobe signs

Question 22

PACI

Answer 22

Any two of:

• dense hemiparesis (flaccid)
• homonymous visual field loss
• dysphagia (if dominant hemisphere, normally left hemisphere)
• neglect
• other disturbance of cerebral function e.g. parietal lobe signs
• OR isolated disturbance of higher cerebral function alone
• OR pure motor/ sensory deficit less extensive than for LACI

Question 23

LACI

Answer 23

Any one of:

• pure motor hemiparesis (pure motor signs alone)
• pure sensory hemiparesis (pure sensory signs)
• sensori motor hemiparesis (mixed motor/ sensory signs)
• ataxic hemiparesis
• isolated movement disorder

Question 24

POCI

Answer 24

Any of:

• unequivocal signs of brainstem dysfunction
• isolated hemianopia
• cerebellar signs