stroke medicine

Question 1

what is a transient ischaemic attack?

Answer 1

Transient ischaemic attacks are focal neurological deficits due to blockage of blood supply to a part of the brain (focal brain dysfunction) lasting less than 24 hours (but in practice most TIAs last much less than that).

Question 2

what is the ABCD2 score?

Answer 2

a risk assessment tool designed to improve the prediction of short-term risk of a stroke after a transient ischemic attack (TIA). It is not a diagnostic tool.

Question 3

how is the ABCD2 score calculated?

Answer 3

calculated by summing up the points for five different factors including

• age
• blood pressure
• clinical features
• duration of symptoms
• diabetes.

Question 4

what ABCD2 score suggests a patient is high risk, and how should they be managed?

Answer 4

ABCD2>=4 indicates a higher risk.

If they are high risk they are prioritised to be seen in the TIA clinic or by a stroke physician as soon as possible.

People who have had a suspected TIA should have aspirin (300 mg daily) started immediately

Question 5

what investigations can be done for TIA?

Answer 5

blood tests, carotid Doppler and a brain scan (CT or MRI).

Further investigations depend on the suspected pathophysiology.

Question 6

what does TIA treatment involve?

Answer 6

The treatment would include

• lifestyle modifications
• treatment of hypercholesterolemia and hypertension
• surgical intervention for carotid artery disease if appropriate and
• antiplatelets.

Question 7

what is a crescendo TIA and what does it suggest?

Answer 7

People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke

Question 8

what is a stroke?

Answer 8

Stroke can be defined as a sudden onset of a focal neurological deficit lasting more than 24 hours or with imaging evidence of brain damage due to either infarction (emboli, in situ thrombosis or low blood flow) or haemorrhage.

classified as infarct or haemorrhage based on brain imaging

Question 9

what are some causes of hemorrhagic strokes?

Answer 9

primary: hypertension, cerebral amyloid angiopathy;
secondary: trauma, anticoagulation-associated, underlying structural abnormality

Question 10

how is the vascular territory involved in a stroke identified?

Answer 10

linically using Bamford

Classification, and subsequently with brain imaging

Question 11

what is the emergency treatment of a stroke?

Answer 11

thrombolysis for cerebral infarct/acute ischaemic stroke syndromes

anticoagulation reversal &/or selective neurosurgical intervention for intracranial bleeds

Question 12

what are the types of strokes?

Answer 12

Total anterior circulation stroke (TACS)

Partial anterior circulation stroke (PACS)

Lacunar stroke (LAC)

Posterior Circulation stroke (POCS)

Question 13

what is the Bamford classification?

Answer 13

used to describe the symptoms associated with different types of strokes

Question 14

what rapid assessment tools are used for a patient presenting with suspected stroke?

Answer 14

FAST: Face (facial drooping) Arm (arm weakness), Speech( speech slurred) and Time ( time to call 999). This was developed to raise public awareness to recognise signs of a stroke and call for help early.

ROSIER: the rosier scale has been developed to help medical staff distinguish between a stroke and a stroke mimic. This is commonly used in the accident and emergency department. A copy of this can be found in your appendix.

Question 15

what is the NIHSS scale?

Answer 15

NIH stroke scale (NIHSS) can be used as a clinical stroke assessment tool to evaluate and document neurological status in acute stroke patients.

The stroke scale can serve as a measure of stroke severity. It has 15 items which scores on levels of consciousness, language, neglect, visual-field loss, extra ocular movement, motor strength, ataxia, dysarthria and sensory loss.

Question 16

how is an ischaemic stroke treated?

Answer 16

thrombolysis with alteplase up to 4.5 post onset of stroke is beneficial

need to meet certain criteria before can be given though

Question 17

how is a haemorrhage stroke treated?

Answer 17

All people presenting with acute stroke who have had a diagnosis of primary intracerebral haemorrhage excluded by brain imaging should be given:

1) aspirin 300 mg orally if they are not dysphagic or
2) aspirin 300 mg rectally or by enteral tube if they are dysphagic.

continue until 2 weeks after onset of stroke, then initiate long term anti thrombotic treatment

Question 18

how does a stroke and TIA affect driving ability?

Answer 18

Following a stroke or TIA you are not permitted to drive for one month. After this time you may do so as long as there are no permanent neurological sequale. If you have recurrent TIA’s you cannot drive for 3 months and you must be assessed by a doctor prior to resumption of driving.

Question 19

how should patients with stable neurological symptoms from their stroke or TIA who have carotid stenosis of 70–99%be managed?

Answer 19

1) Be assessed and referred for carotid endarterectomy within 1 week of onset of stroke or TIA symptoms
2) Undergo surgery within a maximum of 2 weeks of onset of stroke or TIA symptoms
3) In both cases fitness for surgery should be assessed and there may be a small risk of stroke during surgery.

Question 20

what treatment can be considered in patient with severe MCA infarction, who are at risk of malignant MCA syndrome?

Answer 20

decompressive hemicraniectomy if any deterioration in their clinical condition occurs presenting in a decrease in conscious level.

They should be referred within 24 hours of onset of symptoms and treated within a maximum of 48 hours. They must be under the age of 60, with a CT infarct of at least 50% MCA territory and an NIHSS score of above 15

Question 21

what are some stroke mimics?

Answer 21

including seizures, space occupying lesions, hemiplegic migraine, multiple sclerosis and sepsis in those with pre-existing neurological weakness.

History and examination is important to differentiate between these

Question 22

what is the CHADS VASC 2 score?

Answer 22

important in determining if someone is suitable for anticoagulation if they are in atrial fibrillation and are at risk of stroke.

This is useful when considered with a HASBLED score. Anticoagulation now is divided into warfarin vs DOAC (Direct Oral Anti Coagulant) e.g. Apixaban, Dabigatran, Rivoraxaban, Edoxaban .

Question 23

what factors are there in a CHADS VASC score?

Answer 23

Congestive heart failure
Hypertension
Age >/= 75
DM
Stroke/TIA/TE

Vascular disease
Aged 65-74
Sex category (Female)

CHADS VASC is an acronym

Question 24

what factors are there in a HAS BLED score?

Answer 24

Hypertension
Abnormal renal/liver function
Stroke

Bleeding tendency/predisposition
Labile INR
Age>65

Drugs or alcohol

Question 25

how can enteral feeding be done in stroke patients and what is the indication?

Answer 25

NG and PEG

indication is poor swallowing following large stroke

without, patients would aspirate

Question 26

what are the risks of enteral feed?

Answer 26

aspiration

patients may not be able to tolerate oral feeding again

Question 27

when is the decision to progress from an NG to a stroke made?

Answer 27

NGs are often inserted post stroke when swallowing is affected and the decision to proceed with PEG feeding is often a complex decision making process involving the family and wider MDT.