Stroke

Question 1

what are the two types of stroke

Answer 1

ischaemic

haemorrhage

Question 2

what type of stroke is more common

Answer 2

ischaemic (85%)

Question 3

what are the two mechanisms of ischaemic stroke

Answer 3

1. thrombotic - thrombosis from large vessels e.g. carotid
2. embolic - emboli from heart e.g. in AF

Question 4

definition of a stroke

Answer 4

rapid onset neurological deficit resulting from altered blood supply to brain lasting >24 hours

Question 5

what is a TIA

Answer 5

transient ischaemic attack due to temporary occlusion of circulation - signs and symptoms last less than 24 hours

Question 6

what investigation should every patient with TIA get

Answer 6

carotid doppler - thrombosis from carotids most common cause

Question 7

immediate management of patient who presents with TIA

Answer 7

300mg aspirin

Question 8

management of patient who has had suspected TIA in last - 7 days - over 7 days ago

Answer 8

if within 7 days – urgent (within 24 hours) assessment if over 7 days – assessment within 7 days

Question 9

secondary prevention TIA

Answer 9

1st line = clopidogrel

2nd line = aspirin + dipyridamole if patients cannot tolerate clopidogrel

Question 10

symptoms of stroke/TIA

Answer 10

motor weakness

speech problems

swallowing difficulty

visual field defects

balance problems

Question 11

blood supply to medial + lateral brain

Answer 11

Question 12

draw circle of willis

Answer 12

Question 13

what vessels are occluded in total anterior circulation stroke

Answer 13

anterior + middle cerebral arteries

Question 14

criteria for total anterior circulation stroke

Answer 14

1. unilateral weakness +/- sensory loss of arm, leg, face
2. homonymous hemianopia
3. higher cognitive dysfunction e.g dysphasia

Question 15

if there is left sided weakness + sensory loss in a TACS stroke, where is the infarct?

Answer 15

RIGHT side of brain

• contralateral to the lesion

Question 16

what artery is affected in stroke with predominant leg symptoms?

Answer 16

Anterior cerebral

Question 17

what artery is affected in stroke with predominant arm/face symptoms?

Answer 17

middle cerebral artery

Question 18

Criteria for partial anterior circulation stroke? (PACS)

Answer 18

2 out of 3 criteria for TACS

1. Unilateral weakness +/- sensory loss of arm/leg/face
2. homonymous hemianopia
3. Higher cortical dysfunction

Question 19

describe visual field defect in homonymous hemianopia

Answer 19

person only sees half the visual field of each eye

• in left homonymous hemianopia, person cannot see left side of visual field in each eye due to lesion in right occipital lobe/optic tract

Question 20

what vessels are occluded in posterior circulation stroke? (POCS)

Answer 20

vertebrobasilar arteries

Question 21

criteria for posterior circulation stroke

Answer 21

any 1 of:

1. cerebellar symptoms
2. isolated homonymous hemianopia
3. loss of consciousness

Question 22

what artery is affected in lateral medullary syndrome

Answer 22

posterior inferior cerebellar artery

Question 23

signs of lateral medullary syndrome

Answer 23

ipsilateral horners

contralateral loss of pain/temperature sensations

Question 24

what is a lacunar stroke?

Answer 24

infarcts around basal ganglia, thalamus and internal capsule

presentations include:

1. unilateral weakness +/- sensory loss of leg,arm,face
2. pure sensory loss
3. ataxic hemiparesis

Question 25

what is locked in syndrome? what artery is most commonly affected?

Answer 25

patient is aware + cognitively intact but completely paralysed apart from eye muscles basilar artery

Question 26

features of haemorrhagic stroke

Answer 26

loss of consciousness (50%) headache nausea + vomitting seizures (25%)

Question 27

what imaging is used to differentiate between ischaemic + haemorrhagic stroke

Answer 27

CT - If negative, rules out haemorrhagic stroke and allows treatment for ischaemic stroke to be started - may initially be normal in ischaemia -- MRI better for infarction

Question 28

management of ischaemic stroke presenting within 4.5 hours

Answer 28

thrombolysis with IV alteplase

Question 29

management of ischaemic stroke presenting \> 4.5 hours duration of symptoms

Answer 29

300mg aspirin

Question 30

secondary prevention drugs post ischaemic stroke

Answer 30

aspirin for 14 days then 75 mg clopidogrel after that (aspirin 75mg + dipyridimole 200mg 2nd line) statin

Question 31

secondary prevention ischaemic stroke in AF patient

Answer 31

anticoagulants 2 weeks post stroke - warfarin or rivaroxaban

Question 32

what is done 24 hours after administration of thrombolysis

Answer 32

CT to check for haemorrhage (increased risk)

Question 33

first line radiological investigation for suspected stroke

Answer 33

CT

Question 34

what scoring system is used for suspected stroke

Answer 34

ROSIER score

Question 35

what is webers syndrome

Answer 35

ipsilateral cranial nerve 3 palsy (eye is down + out) contralateral weakness

Question 36

lacunar infarcts are strongly associated with what condition

Answer 36

hypertension

Question 37

What can mimic TIA symptoms and needs to be ruled out

Answer 37

hypoglycaemia

Question 38

if a patient is on warfarin / anticoagulant / has a bleeding disorder and is suspected of having a TIA, what do they need urgenty?

Answer 38

CT head to exclude a bleed

Question 39

when is a carotid endarterectomy considered in a patient?

Answer 39

patient who has had a TIA with carotid artery stenosis \>70%

Question 40

what are some common stroke mimics

Answer 40

post ictal states complicated migraine hypoglyaemia / hyponatraemia bells palsy sepsis

Question 41

criteria for thrombectomy in ischaemic stroke

Answer 41

- within 6 hours of symptom onset if confirmed occlusion of proximal anterior circulation - between 6-24 hours if confirmed occlusion of proximal anterior circulation PLUS potential to salvage brain tissue, as shown on CT