Stroke and TIA

Question 1

What is a stroke? What distinguishes it from a TIA?

Answer 1

Acute onset of neurological deficit lasting for >24h that is vascular in origin

If the symptoms <24h then it is a TIA

Question 2

What are the two main blood supplies to the brain?

Answer 2

Internal carotids (supply the anterior and middle cerebral arteries)
Basilar arteries (supply the posterior cerebral arteries)

Question 3

What are the two types of stroke?

Answer 3

Ischaemic (80%) and haemorrhagic

Question 4

What are some symptoms of anterior circulation strokes?

Answer 4

Speech disturbances 
Unilateral limb weakness 
Facial droop 
Numbness and loss of sensation 
Cognitive impairment

Question 5

What area of the brain is more affected by posterior circulation strokes and therefore what are some common symptoms?

Answer 5

The CEREBELLUM (DANISH)
Nausea, dizziness, vertigo, lack of coordination, memory loss, limb weakness, ataxia, sensory deficits bilaterally

Question 6

What are some common causes of stroke?

Answer 6

Infarctive pathway (atherosclerosis, plaque, thrombosis)
- MOST COMMON 
Carotid artery dissection 
SAH 
Thromboembolism from AF 
SAH

Question 7

What investigations should be done in patients with potential strokes?

Answer 7

CT head ASAP (at least within 24h)
FBC, ESR, CRP, U&E, Ca, Glucose, Cholesterol, INR
ECG
Carotid dopplers 
Angiography

Question 8

How should you initially assess a patient with stroke?

Answer 8

Exclude hypoglycaemia
CT head within 24h
Assess for high risk factors
Thrombolyse if indicated (<4h from symptom onset)
Assess swallow before giving oral foods and fluids

Question 9

What are some high risk factors on presentation for a patient with ?stroke?

Answer 9

Known bleeding tendency or on anti-coags
Reduced consciousness 
Unexplained progressive or fluctuating symptoms 
Papilloedema neck stiffness or fever 
Severe headache at onset 
Indication for thrombolysis

Question 10

What are the indications for thrombolysis in ?stroke patient?

Answer 10

Urgent CT or MRI is mandatory to exclude haemorrhage
IV alteplase provided it is within 4hrs of clearly defined symptom onset
BP must be <185/110mmHg prior to thrombolysis
EXCLUSION IF: (prev hx of stroke, MI or head trauma within 3/12, LP or arterial puncture at non compressible site within 7 days, major operation in previous 14 days, GI or GU haemorrhage within previous 21 days, any previous hx of IC bleed, active haemorrhage or acute trauma, rapidly improving symptoms, seizures at onset, hx suggestive of SAH, pregnant or breastfeeding)

Question 11

How should stroke be managed?

Answer 11

Thrombolyse
Alternatively can consider a carotid endarterectomy (if thrombus is found to be carotid)
300mg aspirin
Control hydration, blood pressure, O2 and glucose

Question 12

How will CT heads appear for patients with ischaemic and haemorrhagic strokes?

Answer 12

Ischaemic - large darkened patch

Haemorrhagic - large bright, white patch with possible midline shift and compression/disappearance of ventricles.

Question 13

What classification system is used to classify strokes?

Answer 13

Oxford Classification system

Question 14

What criteria classify a Total anterior circulation infarct and a Partial one?

Answer 14

TACI:

• Unilateral hemiparesis or hemisensory loss of face arms and legs
• Homonymous hemianopia
• Higher cognitive dysfunction (expressive or receptive dysphasia, visual or sensory inattention, neglect)

PACI is 2/3 of these

Question 15

What classifying criteria are there for a lacunar infarct?

Answer 15

Pure motor hemiparesis 
Poor hemi sensory loss
Sensorymotor stroke 
Hemi ataxia 
Dysarthria