Stroke (ischaemic & haemorrhagic)

Question 1

Define stroke

general & clinically

Answer 1

Rapid permanent neurological deficit from cerebrovascular insult

Clinically = focal or global impairment of CNS function developing rapidly & lasting >24hrs

Question 2

Aetiology of ischaemic stroke (5 & proportion)

Answer 2

80%

Thrombosis
Emboli
Hypotension
Vasculitis
Cocaine

Question 3

Aetiology of haemorrhagic stroke

7 & proportion

Answer 3

10%

Hypertension 
Charcot-Bouchard micro aneurysm rupture 
Amyloid angiopathy
Arteriovenous malformation
Trauma
Tumours
Vasculitis

Question 4

Epidemiology of stroke

incidence & age

Answer 4

Common (2/1000)

Patients age 70+

Question 5

Presenting symptoms of stroke

6 & 2 questions

Answer 5

• SUDDEN ONSET
• weakness
• sensory, visual or cognitive impairment
• impaired coordination
• impaired consciousness
• head or neck pain
• enquire about time of onset
• enquire about history of AF, MI, valvular heart disease, carotid artery stenosis, recent neck trauma or pain

Question 6

Signs of stroke on physical examination

general & lacunar x3

Answer 6

Examine for underlying cause (e.g. atrial fibrillation)

Affecting:

Internal capsule or pons
- pure sensory or motor deficit (or both)

Thalamus

• loss of consciousness
• hemisensory deficit

Basal ganglia

• hemichorea
• hemiballismus
• Parkinsonism

Question 7

Subdivision of stroke (2)

Answer 7

Location
(anterior vs posterior circulation)

Pathological process
(infarction vs haemorrhage)

Question 8

Investigations for stroke

7

Answer 8

Bloods
ECG
Echocardiogram
Carotid doppler US
CT head 
MRI brain
CT cerebral angiogram

Question 9

Management in hyperacute stroke

3

Answer 9

If <4.5 hrs from onset
Exclude haemorrhage with CT head
Then thrombolysis may be considered

Question 10

Management in acute ischaemic stroke

2+3

Answer 10

Aspirin + clopidogrel
Heparin
Formal swallow assessment
GCS monitoring
Thromboprophylaxis

Question 11

Secondary prevention of stroke

3

Answer 11

Aspirin & dipyridamole
Warfarin anticoagulation (AF)
Control risk factors

Question 12

Surgical treatment of stroke

Answer 12

Carotid endarterectomy

Question 13

Complications of stroke

6

Answer 13

Cerebral oedema
Immobility
Infections
DVT
Cardiovascular events
Death

Question 14

Prognosis with stroke

Answer 14

Prognosis for haemorrhagic WORSE than ischaemic
10% mortality in 1st month
10% recurrence in 1 year
50% that survive will be dependent on others

Question 15

Signs of stroke on physical examination

anterior circulation x2

Answer 15

Anterior cerebral

• lower limb weakness
• confusion

Middle cerebral

• facial weakness
• hemiparesis
• hemisensory loss
• apraxia
• hemineglect
• receptive or expressive dysphasia
• quadrantopia

Question 16

Signs of stroke on physical examination

posterior circulation x6

Answer 16

Posterior cerebral
- hemianopia

Anterior inferior cerebellar

• vertigo
• ipsilateral ataxia
• ipsilateral deafness
• ipsilateral facial weakness

Posterior inferior cerebellar

• vertigo
• ipsilateral ataxia
• ipsilateral Horner’s syndrome
• ipsilateral hemisensory loss
• dysarthria
• contralateral spinothalamic sensory loss

Basilar artery

• cranial nerve pathology
• impaired consciousness

Multiple lacunar infarcts

• vascular dementia
• urinary incontinence
• gait apraxia
• shuffling gait
• normal/excessive arm swing

Intracerebral

• headache
• meningism
• focal neurological signs
• nausea/vomiting
• signs of ICP
• seizures