Stroke

Question 1

Principal risk factors of stroke

Answer 1

Older age

Smoking

Diabetes

High cholesterol

Hypertension

Atrial fibrillation

Afro-caribbean ethnicity

Question 2

Ischaemic stroke

Answer 2

Brain infarct caused by occlusion of the blood vessel.

Bamford classifications:

• Total anterior circulation infarct
• Partial anterior circulation infarct
• Posterior circulation infarct
• Lacunar circulation infarct

Question 3

Rare stroke risk factors (disease, drugs)

Answer 3

Thrombocytopenia, polycythaemia, hyper viscosity states

• Protein C def
• Factor V Leiden

Vasculitis

Cocaine

Question 4

Total anterior circulation stroke

• Cause
• Features

Answer 4

Type of ischaemic stroke. Presents with all these features:

Causes:

• ICA occlusion
• Proximal MCA occlusion
• Emboli from heart/ aortic arch/ ICA

Features:

• Contralateral Weakness or Sensory loss (contralateral)
• Homonymous hemianopia
• Higher cortical dysfunction (dysphasia, neglect, visuospatial difficulty)

Question 5

Partial anterior circulation stroke

• Cause
• Features

Answer 5

Presents with 2 features of the total anterior circulation stroke:

Causes:

• ACA occlusion
• MCA occlusion

Features:

• Contralateral Weakness or Sensory loss (contralateral)
• Homonymous hemianopia
• Higher cortical dysfunction (dysphasia, neglect, visuospatial difficulty)

Question 6

Posterior circulation stroke

• Cause
• Features

Answer 6

Ischaemic stroke affecting the vertebrobasilar system:

Causes:

• Vertebral, basilar or PCA occlusion
• Heart, aortic arch or vertebrobasilar emboli

Has one feature:

• Contralateral weakness/ sensory deficit AND cranial nerve palsy
• Cerebellar dysfunction (vertigo, ataxia, nystagmus)
• Isolated homonymous hemianopia
• Bilateral sensory/ motor deficit
• Conjugate eye movement disorder

Question 7

Lacunar stroke

• Causes
• Features

Answer 7

Type of ischaemic stroke

Causes:

• Microatheroma of small perforating arteries
• Hypertensive small vessel disease

Features (one):

• Pure sensory deficit
• Pure motor deficit
• Sensori-motor deficit
• Ataxic hemiparesis

Question 8

HPC for stroke

Answer 8

Onset of symptoms
- If 4.5 hours= thrombolysis

Duration of symptoms
- >24 hours indicates stroke

Symptoms experienced

• Headache= more suggestive of a bleed
• Visual deficit
• Weakness
• Sensory loss

Previous head injury
- Bleed?

Loss of consciousness?

• Tongue biting + incontinence= rule out seizure
• Rule of syncope

Speech disturbance

Rule out MI
- Chest pain, palpitations

Nausea/ vomitting

Question 9

PMH for stroke

Answer 9

AF

Diabetes

Ischaemic heart disease

Hypercoagulable/ Bleeding state: polycythemia, thrombocytopenia, haemophilia

Previous stroke/ TIA

SCD

Question 10

FMH for stroke

Answer 10

MI

Hypercoagulable states

Haemophillic disease states

Question 11

DH for stroke

Answer 11

Antiplatelet/ anti-coagulation

• Clopidogrel
• Epixiban, rivaroxaban, Apixaban
• Aspirin

Question 12

Examination

- CN

Answer 12

Visual field defects
Visual neglect

Swallowing
Facial droop/ weakness

Double vision
Nystagmus

Question 13

Examination

- Neuro

Answer 13

General:

• Consciousness
• Appearance: wasting, fasciulations

Mental state/ cognition

• Limbs
• Tone
• Power
• Co-ordination
• Reflexes
• Sensation: vibration, joint position, light touch, two-point discrimination, pain, temperature

Speech

• Expressive: increasingly rare repetition
• Receptive: 1/2/3 stage commands

Gait

Question 14

Power rating

Answer 14

0- No movement

1- flicker of movement

2- Movement, eliminated by gravity

3- Movement against gravity

4- Movement against gravity and resistance

5- Normal movement

Question 15

Tone rating

Answer 15

Normal

Hypotonicity

Hypertonicity

• Claspknife spasticity
• Lead pipe rigidity (across all muscle groups around joint)
• Cogwheel rigidity (extrapyramidal)

Question 16

Acute stroke treatment

Answer 16

Within 4.5 hours
- Thrombolysis (alteplase)

With

• Aspirin 24 hrs later
• possible endovascular intervention (stent retriever)

Further treatment

• Acute stroke unit care
• Swallowing assessment
• Early mobilisation,hysio
• VTE prophylaxis

Question 17

Absolute contraindications to thrombolysis

Answer 17

Intracranial haemorrhage on CT

Indications of a subarachnoid bleed

History of stroke, neurosurgery or head trauma in the last 3 months.

History of intracranial haemorrhage

Active internal bleeding

Uncontrolled hypertension (>185 SBP or >110 DBP

Known intracranial AV malformations, neoplasm or aneurysm

Endocarditis

Bleeding diathesis: low platelet, heparin within 48 hours with elevated aPTT, oral anticoags with INR>1.7, use of DOACs

Hypoglycaemia

Question 18

Subrarachnoid bleeds

• Stats
• Causes

Answer 18

Accounts for 5% strokes

Causes:

• Berry aneurysm (most cases)
• AV malformation
• Bleeding disorder
• Tumour
• Acute bacterial menin

Question 19

Stroke investigations

- Bloods

Answer 19

• FBC: anaemia, infection, polycythaemia, platelets
• U+Es: electrolyte imbalance, dehydration
• LFT: evidence of disease?
• CK: muscle breakdown evidence if laid down for long
• Glucose: rule out hypoglycaemia, identify diabetes risk
• CRP: infection, inflammation
• Culture: if sepsis suspected
• ESR: elevated in vasculitis/ sepsis

Question 20

Stroke investigations

Answer 20

Bloods: glucose, fbc, U+Es
CT/ MRI head
ECG

Echo

• Murmur or endocarditis
• AF