Stroke

Question 1

Stroke definition?

Answer 1

Acute onset of focal neurological symptoms and signs due to disruption of blood supply

Question 2

Stroke effects?

Answer 2

People don’t often die from initial stroke but can come out of it severely disabled

Question 3

How many types of stroke? and what are they called?

Answer 3

Ischaemic

Haemorrhagic

Question 4

Reason for haemorrhagic stroke?

Answer 4

Raised BP
Weakened blood vessel wall due to structural abnormalities
-aneurism
-Atriovenous malformation
Inflammation of vessel walls (vasculitis)

Question 5

Reason for ischaemic stroke?

Answer 5

Thrombotic- clot blocking artery at site of occlusion

Embolic- Clot blocking artery has traveled to artery, it occludes from somewhere more proximal in arteries or heart

Hypoperfusion- Due to reduced blood flow due to stenosed artery rather than occlusion of artery

Question 6

Non-modifiable risk factors for stroke?

Answer 6

Age
Family History 
Gender 
Race- south Asians 
Previous stroke

Question 7

Potentially modifiable risk factors for stroke?

Answer 7

Hypertension 
Smoking 
Hyperlipidaemia 
Smoking 
Prior history of TIA 
Atrial fibrillation 
Diabetes 
Congestive heart Failure 
Alcohol excess 
Obesity 
Physical Inactivity 
Poor socioeconomic status

Question 8

Smoking________ risk of ischaemic stroke

Answer 8

Doubles

Question 9

What type of stroke are statins recommended for?

Answer 9

Ischaemic

Question 10

Rarer causes of stroke?

Answer 10

Homocysteinemia
Vasculitis,
Antiphospholipid antibody syndrome
Protein S, C, Antithrombin III deficiency
Paradoxical embolism(venous clot to arterial side) through patent foramen ovale
Pulmonary AV shunts(these are openings large enough between arterial and venous circulations)
Genetic- Factor V Leiden mutation, common prothrombin mutation, MELAS, CADASIL,Fabry’s disease
Cardioembolic- mural thrombi, infective endocarditis, myxoma
Cervical artery dissection

Question 11

Behavioral modification of stroke prevention?

Answer 11

Diet
Exercise
Smoking cessation
Weight control

Question 12

Approach to managing stroke?

Answer 12

Present- fixing the problem? thrombolysis or thrombectomy in ischaemic stroke

Stopping further strokes in future - identify and treat cause

Helping patient adjust to disability- rehab

Question 13

Questions to ask when managing a stroke?

Answer 13

Is it a stroke?
What kind?
Cause?
Appropriate secondary prevention?

Question 14

What conditions does a stroke mimic?

Answer 14

Hypoglycaemia
Seizure - part of brain may not function temporarily after
Migraine
Metabolic- hyperglycaemia or Hyponatremia
Brain tumors- space occupying lesions
Functional hemiparesis

Question 15

Only way of differentiating between different types of stroke?

Answer 15

Brain Imaging

Question 16

Types of brain imaging for stroke?

Answer 16

CT brain +- angiography
MRI with DWI +-angiography
MRI with SWI (looks for old bleeds)

Question 17

Arheroebolism?

Answer 17

embolism from a thrombus forming on a atherosclerotic plaque- platelet rich clots

  infarcts in same side as 
  affected carotid artery

Question 18

Cardioembolism?

Answer 18

Embolism from a clot formed in the heart(usually left atrium)
- clotting factor rich clots
infarcts in more than one arterial territory, bilateral

Question 19

Tests to see for atheroembolism?

Answer 19

Carotid scanning

CT/MRI angiography of aortic arch

Question 20

Tests to see for carioembolism?

Answer 20

Echocardiogram
ECG
24 hour 5 day ECG monitor tests
AF

Question 21

Investigating cause of bleeding in haemorrhagic stroke?

Answer 21

Hypertensive- deep in brain usually
If young, not hypertension and superficial haemorrhage- aneurism
Multiple haemorrhages- vasculitis, moya moya disease

Question 22

Reversing disability in ischaemic stroke?

Answer 22

Thrombolysis - up to 4.5 hours from onset of symptoms

Thrombectomy- Up to 6 hours from symptom onset

Question 23

How thrombolysis works?

Answer 23

Clot forms
tPA injected intravenously
Blood clot dissolves
Restored blood flow

Question 24

When are thrombectomies indicated?

Answer 24

Large arterial proximal occlusions

Question 25

Process of thrombectomy?

Answer 25

Blood clots restricts blood to affected area of brain

Stent retriever is navigated to side of blocked blood vessel. Retriever is advanced through clot and expands and integrates into it

Retriever and clot are retracted into catheter and removed

Question 26

Surgical management of stroke?

Answer 26

• Haematoma evacuation
• Relief of raised intracranial presure : obstructive hydrocephalus, large total MCA infarctions
• Carotid endarterectomy

Question 27

Explain TIAs?

Answer 27

Patients who present like a stroke but within a few minutes are better
Temporary neurological symptoms due to occlusion of artery stopping blood flow - because arteries are capable of dissolving clots
Risk of TIA after stroke

Question 28

TIA definition?

Answer 28

focal neurological symptoms that resolve within 24 hrs

Question 29

Investigations used to find causes of thrombosis or embolism in ischaemic stroke?

Answer 29

Blood tests- glucose, lipids, thrombophillia

Assess for hypertension

Question 30

What does medical management to prevent next stroke depend on?

Answer 30

What caused it

Question 31

If a stroke was atheroembolic or due to thrombus prevent another one by?

Answer 31

Antiplatelets (aspirin) 
Statins to treat high lipids 
Diabetes management 
Hypertension management 
Lifestyle advice

Question 32

If a stroke is due to atrial fibrillation prevent further stroke by?

Answer 32

Anticoagulate ASAP

• Warfarin (Vit K antagonists)
• Direct acting oral coagulants
• Rivaroxaban, Dabigatran, apixaban, edoxaban

-Antihypertensives- more important in stroke than in CHD or PAD