Stroke

Question 1

Most common cause of long term disability in UK
20% of hospital beds
£5bn per year

Answer 1

Stroke

Question 2

Definition of a stroke

Answer 2

Neurological deficit of sudden onset lasting over 24hrs if vascular origin

Question 3

Symptoms of stroke

Answer 3

Loss of
Power
Sensation
Speech 
Vision
Coordination

Question 4

Dysarthria Vs dysphasia

verbal problems

Answer 4

Dysarthria is muscles

Dysphasia is processing in brain

Question 5

2 causes of stroke

Answer 5

Blockage of blood vessel to brain (ischaemic stroke) - dark 85%

Haemhorragic stroke from ruptured blood vessel in brain - white 15%

Question 6

2 arteries to brain

Answer 6

Internal carotid and vertebral

Question 6

2 arteries to brain

Answer 6

External carotid and vertebral

Question 7

What blood vessels supply anterior brain

Answer 7

Internal carotid, into middle cerebral and anterior cerebral

Question 8

What blood vessels supply posterior brain

Answer 8

Vertebral artery into cerebellar, basilar and posterior cerebral

Question 9

The homunculus

Answer 9

Supplies foot and leg centrally then hip trunk arm and and face

A small stroke in the pons or internal capsule of these nerves will result in major deficit

Question 10

Causes of ischemic stroke

Answer 10

Large artery atherosclerosis 35%
Cardioembolic eg AF 25%
Small artery occlusion eg lacunar stroke 25%
Undetermined 10-15%
Rare eg arterial dissection of venous sinus thrombosis <5%

Question 11

Causes of haemorrhagic stroke

Answer 11

Primary intracerebral hemorrhage 70%

Secondary eg subarachnoid or artiovenous 30%

Question 12

Where does carotid stenosis usually happen

Answer 12

Internal and external bifurcation

Question 12

Where does carotid stenosis usually happen

Answer 12

Internal and external bifurcation

Question 13

Cardioembolic stroke

Answer 13

AF causes clot formation in atrium then this goes to brain

Question 14

Lacunar stroke

Answer 14

Affects a small part of brain in medial and lateral lenticulostriate arteries off of middle cerebral artery

May be unnoticed

Question 15

Carotid dissection

Answer 15

Can happen with lots of exercise

Question 16

What can you tell from symptoms and signs

Answer 16

What side of brain
Brainstem or not
If cortex is involved
If lesion is in deep white matter (lacunar)
What blood vessel

Question 17

Why bother with localisation of embolus/haemorrhage

Answer 17

Confirm stroke
Better image selection
Indication of cause
Prognosis

Question 18

Unilateral (one eye) field loss

Answer 18

One optic nerve compression

Question 19

Bitemporal hemianopia (tunnel vision)

Answer 19

Chiasmal (cross over of optic nerves) by pituitary tumor

Question 20

Homonymous hemianopia (can’t see one side from both eyes)

Answer 20

Left cerebrovascular event

Question 21

Stroke subtypes

Answer 21

TACS
PACS
LACS
POCS

Question 22

TACS

Answer 22

20% of strokes

Weakness and sensory deficit
Homonymous hemianopia
Higher cerebral dysfunction (can’t talk or is clumsy)

Usually due to occlusion if proximal middle cerebral artery or internal carotid artery

60% m@1y and 6% r@1y

Question 23

PACS

Answer 23

35% of strokes 2 or 3 of TACS criteria or restricted motor/sensory deficit eg one limb face and hand or just higher cerebral dysfunction More restricted cortical infarcts eg occlusion if branches of middle cerebral artery 16% m@1y and 17% r@1y

Question 24

LAC

Answer 24

Most common is pure weakness in one side in whole of 2 of face/arm/leg Pure sensory in same distribution Sensorimotor is combination 11% m@1y and 9% r@1y

Question 25

POCS

Answer 25

25% Affects brainstem, cerebellar or occipital lobes Variable, complex presentation eg ``` Bilateral motor/sensory deficit Disordered conjugate eye movements Homonymous hemianopia Disordered breathing Tinnitus vertigo ``` 19% 1 year mortality and 20% recurrence

Question 26

Why do patients do better in stroke wards

Answer 26

``` Mobile asap Concentration on simple things Swallowing problems common in half Earth therapy Concentration of expertise ```

Question 27

How many neurons are lost each minute a large vessel occlusion isn't treated

Answer 27

1.9 million

Question 28

Time after which TPA (tissue plasminogen activator) isnt beneficial

Answer 28

330mins (4.5 hours)

Question 29

Clot busting drug found beneficial up to 4.5 hours by MHRA

Answer 29

Alteplase

Question 30

% of patients alive and independent T 90days

Answer 30

With just IVT >40% | With IVT and early thrombectomy 62%

Question 31

Assessment of stroke patients in A&E

Answer 31

If no neuro problems and AF or resolved AC problems, discuss with stroke bleep holders Neuro problems>4.5hrs contact stroke team <4.5hrs urgent CT then stroke bleep

Question 32

Contraindications to thrombolysis

Answer 32

Age (<80years usually) | Recent bleeding, high BP etc

Question 33

SIGN guidelines

Answer 33

Mortality with MCA (middle cerebral artery) stroke is up to 80% In under 60s hemicraniectomy reduced mortality from 80% to 27%

Question 33

SIGN guidelines

Answer 33

Mortality with MCA (middle cerebral artery) stroke is up to 80% In under 60s hemicraniectomy reduced mortality from 80% to 27%

Question 34

When to do hemicraniectomy

Answer 34

Up to 60y with MCA ischemic stroke with massive cerebral oedema, within 48 hours of onset

Question 35

What % of patients does aspirin in 0-48 hours benefit

Answer 35

65% of ischemic stroke, 12 prevented deaths per 100 treated

Question 36

Benefits of giving stroke unit

Answer 36

90% of patients benefit, 5 deaths per 100 prevented

Question 37

Benefits of thrombolysis

Answer 37

10% of strokes, 1 death prevented per 100

Question 38

Benefits of hemicraniectomy

Answer 38

0.5% of strokes, 22 deaths prevented per 100

Question 39

Risk for early recurrent stroke in the first 2 weeks

Answer 39

14% in Tia and stroke 1/3 of Tia patients will have an acute stroke at some point

Question 40

treatment of tia and secondary prevention drugs used

Answer 40

Decreases risk of recurrent stroke Clopidogrel 75mg or aspirin 75mg with MR 200mg Statins Blood pressure drugs

Question 41

When to do carotid endarterectomy

Answer 41

Anterior circulation occluded Tia or stroke with good recovery 70% occlusion