Stroke

Question 1

Stroke definition

Answer 1

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

Question 2

Two types of stroke

Answer 2

Haemorrhagic and ischaemic

Question 3

What is the most common type of stroke?

Answer 3

Ischaemic

Question 4

Most common cause of haemorrhagic stroke

Answer 4

Hypertension

Question 5

What is haemorrhagic stroke?

Answer 5

Stroke due to a burst blood vessel

Question 6

What things can cause a weakened blood vessel wall eventually leading to stroke?

Answer 6

Structural abnormalities (aneurysm, arteriovenous malformation), vasculitis

Question 7

What is ischaemic stroke?

Answer 7

Stroke caused by an occlusion in a blood vessel leading to the brain not receiving enough oxygenated blood

Question 8

Thrombotic ischaemic stroke

Answer 8

Clot blocking an artery at the site of occlusion

Question 9

Embolic ischaemic stroke

Answer 9

Clot blocking artery has travelled to the artery it occludes from somewhere more proximal in the arteries of the heart

Question 10

Hypoperfusion ischaemic stroke

Answer 10

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

Question 11

Non-modifiable risk factors for stroke

Answer 11

Age, family history, gender, race, previous stroke

Question 12

Potentially modifiable risk factors for stroke

Answer 12

Hypertension, hyperlipidaemia, smoking, previous history of TIA, atrial fibrillation, diabetes, congestive heart failure, alcohol excess, obesity, physical inactivity, poor socioeconomic status

Question 13

Rarer causes of stroke

Answer 13

Homocysteinemia, vasculitis, antiphospholipid antibody syndrome, protein S, C, antithrombin III deficiency, paradoxical embolism, cardioembolic, cervical artery dissection

Question 14

Diet modification for the prevention of stroke

Answer 14

Mediterranean diet, decrease sodium intake, decrease intake of simple sugars, daily calorie intake

Question 15

Behavioural modification efforts for the prevention of stroke

Answer 15

Diet modification, exercise, weight control, smoking cessation

Question 16

6 essential questions when investigating as stroke

Answer 16

Is this a stroke?
What kind of stroke is this?
What caused the stroke?
Have I tried my best to answer question 3?
Is the patient on the appropriate secondary prevention following investigations?
Have I answered any questions the patient has?

Question 17

Stroke mimics examples

Answer 17

Hypoglycaemia, seizure-postictal states, migraine, hyperglycaemia, hyponatraemia, brain tumours

Question 18

What is the only way to differentiate between ischaemic and haemorrhagic stroke

Answer 18

Brain imaging

Question 19

Investigations for ischaemic stroke

Answer 19

Blood tests - glucose, lipids, thrombophilia screen (younger patients), assess for hypertension, any other suggestions that the patient has blood vessel disease

Question 20

Atheroembolism

Answer 20

Embolism from a thrombus forming on an atherosclerotic plaque – platelet rich clots. It infarcts in the same side as the affected carotid artery

Question 21

Cardioembolism

Answer 21

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

Question 22

Investigations when an atheroembolism is suspected

Answer 22

CT/MRI angiography of aortic arch, carotid scanning

Question 23

Investigations when a cardioembolism is suspected

Answer 23

ECG (AF, old ischaemic changes), echocardiogram, 5-day ECG to look for paroxysmal AF

Question 24

Treatments for ischaemic stroke and when they can be given

Answer 24

Thrombolysis (IV injection of t-PA) - up to 4.5 hours from onset of symptoms
Thrombectomy (catheter injected to pull clot out) - up to 6 hours after onset of symptoms

Question 25

Medical management to prevent next stroke if the first stroke was atheroembolic or due to thrombus

Answer 25

• Antiplatelets (aspirin 75mg and dipyridamole MR 200mg twice daily/clopidogrel 75mg daily)
• Statins to treat high lipids
• Diabetes management
• Hypertension management
• Lifestyle advice

Question 26

Medical management to prevent next stroke if first stroke was due to atrial fibrillation

Answer 26

Warfarin, direct oral anticoagulants

Question 27

Surgical management of stroke

Answer 27

Haematoma evacuation (although not really done anymore), obstructive hydrocephalus to relieve intracranial pressure, carotid endarterectomy

Question 28

Transient ischaemic attack

Answer 28

Temporary neurological symptoms due to occlusion of artery stopping flow of blood. It is temporary because the arteries are capable of dissolving small clots

Question 29

How long do symptoms of transient ischaemic attacks last?

Answer 29

Usually resolve within 24 hours

Question 30

Risk of stroke after TIA within the first month and the next 5 years

Answer 30

First month = 11-15% risk of stroke

Next 5 years = 24-29% risk of stroke