Stroke

Question 1

Anterior cerebral artery stroke symptoms:

Answer 1

• contralateral hemiparesis and sensory loss

- lower extremity>upper

Question 2

Middle cerebral artery stroke symptoms:

Answer 2

• contralateral hemiparesis and sensory loss
• upper>lower
• contralateral homonymous hemianopia
• aphasia

Question 3

Posterior cerebral artery stroke symptoms:

Answer 3

• contralateral homonymous hemianopia with macular sparing

- visual agnosia

Question 4

Weber’s syndrome:

Answer 4

• branches of posterior cerebral after that supply the midbrain
• ipsilateral CNIII palsy
• contralateral weakness of upper and lower extremity

Question 5

Posterior inferior cerebellar artery stroke:

Answer 5

• lateral medullary syndrome
• Wallenberg syndrome
• ipsilateral facial pain and temp loss
• contralateral: limb/torso pain and temperature loss
• ataxia, nystagmus

Question 6

Anterior inferior cerebellar artery stroke:

Answer 6

• lateral pontine syndrome
• symptoms similar to Wallenberg’s
• ipsilateral: facial paralysis and deafness

Question 7

Retinal/ophthalmic artery stroke:

Answer 7

amaurosis fugax

Question 8

Basilar artery stroke:

Answer 8

locked in syndrome

Question 9

What is a lacunar strore:

Answer 9

• either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
• strong association with HTN
• common sites include the basal ganglia, thalamus and internal capsule

Question 10

Ischaemic strokes:

Answer 10

• 85%
• thrombotic strokes
• embolic strokes: fat, air or bacteria, atrial fibrillation important cause
• RF: age, HTN, smoking, hyperlipidaemia, diabetes mellitus

Question 11

Haemorrhagic strokes:

Answer 11

• 15%
• intracerebral haemorrhage
• subarachnoid haemorrhage
• RF: age, HTN, arteriovenous malformation, anticoagulant therapy

Question 12

Assessment and investigation of strokes:

Answer 12

• FAST (78% predictive value)
• ROSIER >1 = stroke likely
• non contrast CT

Question 13

Fluid management post-stroke:

Answer 13

• hypovolaemia can worsen ischaemic penumbra and increase risk of complications
• oral hydration preferable if safely able to swllow
• IV hydration otherwise - isotonic saline without dextrose

Question 14

Glycaemic control post-stroke:

Answer 14

• post-stroke, hyperglycaemia increases mortality

- keep level between 4-11mmol/L

Question 15

Blood pressure management post-stroke:

Answer 15

• anti-hypertensives only post ischaemic stroke if hypertensive emergency or: hypertensive encephalopathy, hypertensive nephropathy, hypertensive cardiac failure/MI, aortic dissection, pre-eclampsia/eclampsia
• lowering BP can compromise collateral blood flow to affected region
• lower BP by 15% in first 24 hours
• labetalol, nicardipine and clevidipine
• if candidates for thrombolytic therapy: bP reduced to 185/55mmHg or lower

Question 16

Disability scale used for stroke management:

Answer 16

Barthel Index

Question 17

Criteria assessed as part of Oxford Stroke classification:

Answer 17

1. unilateral hemiparesis and/or hemisensory loss of face, arm and leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphagia

Question 18

Total anterior circulation infarcts:

Answer 18

• middle and anterior cerebral arteries

- all 3 criteria present

Question 19

Partial anterior circulation infarcts:

Answer 19

• smaller arteries of anterior circulation e..g upper or lower division of middle cerebral artery
• 2 of the above criteria are present

Question 20

Lacunar infarcts:

Answer 20

• involves perforating arteries around internal capsule, thalamus and basal ganglia
• present with one of:
  1. unilateral weakness of face and arm, arm and leg or all three
  2. pure sensory stroke
  3. ataxic hemiparesis

Question 21

Posterior circulation infarcts:

Answer 21

• involves vertebrobasilar arteries
• present with 1 of following:
  1. cerebellar or brainstem syndromes
  2. loss of consciousness
  3. isolated homonymous hemianopia

Question 22

Lateral medullar syndrome:

Answer 22

• aka Wallenberg’s syndrome
• ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
• contralateral: limb sensory loss

Question 23

Weber’s syndrome:

Answer 23

• ipsilateral III palsy

- contralateral weakness

Question 24

Definition of TIA:

Answer 24

transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischaemia without acute infarction

Question 25

Immediate management of TIA:

Answer 25

aspirin 300mg immediately unless:

• bleeding disorder or taking anticoagulant (immediate admission for imaging to exclude haemorrhage)
• already taking low dose aspirin
• aspirin contraindicated

if more than 1 TIA: admission or observation discussion with stroke specialist

if within last 7 days: urgent assessment within 24 hours by stroke specialist

if more than a week: refer for specialist assessment ASAP within 7 days

Question 26

Further management of TIA:

Answer 26

antithrombotic therapy:

• clopidogrel first line
• aspirin and dipyridamole

carotid artery endarterectomy:

• if stroke or TIA in carotid territory and not severely disabled
• if carotid stenosis >70%

Question 27

Imaging of choice for TIA:

Answer 27

MRI brain with diffusion weighted imaging (best at detecting ischaemic change)

Question 28

When is carotid artery endarterectomy considered in a TIA patient?

Answer 28

carotid artery stenosis >70%

Question 29

What is the first line investigation for suspected stroke?

Answer 29

Non contrast CT