Stroke presentation, investigations and therapy

Question 1

Stroke symptoms (11)

Answer 1

Loss of power

Loss of sensation

Loss of speech

Loss of vision

Loss of coordination

Headache

vomiting

neck stiffness

Photophobia - sensitive to bright light

Fit

Incontinence

Question 2

WHO definition of stroke

Answer 2

a stroke is a neurological deficit (loss of function) that comes on suddenly. It lasts more than 24 hours and is of vascular origin

Question 3

if symptoms last less than 24 hours what would the diagnosis likely be?

Answer 3

transient ischaemic attack

Question 4

what things might you find upon taking a neurological history/examination of a patient who has had a stroke? (5) ie signs

Answer 4

Motor (clumsy or weak limb)

Sensory (loss of feeling)

Speech: Dysarthria - unclear /Dysphasia - can’t generate words
Neglect / visuospatial problems

Vision: loss in one eye, or hemianopia - blindness over half the field of vision.
Gaze palsy

Ataxia/ vertigo / incoordination / nystagmus - involuntary eye movement

Question 5

what is a stroke?

Answer 5

Damage to part of the brain due to blockage of a blood vessel by thrombus or embolus or for about 10% of patients it can be due to haemorrhage from rupture of a blood vessel

Question 6

Causes of stroke (4)

Answer 6

Blockage of a vessel with thrombus or clot

Disease of vessel wall

Disturbance of normal properties of blood

Rupture of vessel wall
(haemorrhage)

85% infarction
15% haemorrhage

Question 7

Describe what happens in an ischaemic stroke

Answer 7

clot stops blood supply to an area of the brain

Question 8

Describe what happens in a haemorrhagic stroke

Answer 8

haemorrhage/blood leaks into brain tissue

Question 9

what is the most common cause of cardioembolic stroke?

Answer 9

atrial fibrillation

Question 10

3 main causes of ischaemic stroke

Answer 10

Large artery atherosclerosis
Cardioembolic
Small artery occlusion

Question 11

what can you tell about a stroke from a patient’s symptoms? (5)

Answer 11

what side of the brain is affected

whether the lesion is in the brainstem (a brainstem stroke)

whether the cortex is involved (a cortical stroke)

or if the lesion is in the deep white matter (a lacunar stroke)

what blood vessel is involved

Question 12

Modifiable and non-modifiable risk factors for stroke (8)

Answer 12

Modifiable
High blood pressure
Atrial fibrillation
Smoking
Diabetes mellitus 

Non-modifiable
Age
Race
Family history
History of TIA or stroke

Question 13

What investigations are done to diagnose a stroke? (6)

Answer 13

Blood tests: Full blood count (platelets, red cells), lipids.
ECG

Imaging:-
CT scan
MRI scan
Carotid doppler - image of arteries using ultrasound

Sometimes an echocardiogram can be helpful to look for clots in the heart

Question 14

why is a CT a good imaging technique to detect stroke

Answer 14

Quick

shows up blood

Question 15

why is an MRI a good imaging technique to detect stroke or why might CT be preferred?

Answer 15

shows up ischaemic stroke better than CT does

it takes longer though and can be quite claustrophobic

Question 16

the longer a stroke is left untreated what happens?

Answer 16

the more neurons that are lost and more damage is caused

Question 17

what thrombolytic treatment is used for

a patient admitted with a stroke within 4.5 hours of definite onset of symptoms?

Answer 17

if suitable then intravenous rt-PA - Tissue plasminogen activator is a protein involved in the breakdown of blood clots

Question 18

what should not be used to treat patients in the acute phase of stroke?

Answer 18

Streptokinase - thrombolytic agent

Question 19

what priorities are in place for patients having a stroke? (5)

Answer 19

ambulance priority (blue light) in 
appropriate cases

rapid triage on arrival at hospital

immediate access to specialist stroke services

rapid brain imaging

rapid specialist assessment

Question 20

define aphasia

Answer 20

speech impairment

Question 21

what is NIHSS

Answer 21

NIH Stroke Scale for quantifying stroke severity

Question 22

What is the middle cerebral artery infarction mortality rate

Answer 22

up to 80%

Question 23

what should be offered within 48 hour stroke onset to an individual under age of 60 who has suffered from MCA territory ischaemic stroke complicated by massive cerebral oedema?

Answer 23

surgical decrompession by hemicraniectomy

Question 24

list the treatment options for acute stroke

Answer 24

stroke unit - focus on things like swallowing, positioning etc early therapy

thrombolysis - only if haemorrhagic cause is ruled out
aspirin - prevents platelet aggregation
hemicraniectomy considered

Question 25

what presents in 50% of stroke patients?

Answer 25

swallow problems

Question 26

what is a TIA?

Answer 26

Aetiology no different from definite stroke.
A TIA is a “warning stroke” or “mini-stroke“ with stroke-like
symptoms persisting less than 24 hours, that clears without residual disability.

Prompt evaluation is needed

About 1/3 of those who have a TIA will have an acute stroke some time in the future.

Question 27

express study

Answer 27

Risks & benefits of urgent assessment & treatment of TIA & minor stroke in a TIA clinic

Phase 1: 0-30 months
daily appointment clinic
Rx advice faxed to GP

Phase 2 : 30-60 months

• emergency access clinic
• treatment started in clinic

Question 28

what is a carotid endarterectomy?

Answer 28

surgical procedure to remove a build-up of fatty deposits (plaque), which cause narrowing of a carotid artery

Question 29

more general secondary prevention options

Answer 29

Arrange follow up in primary care

review health, social care needs

speak about lifestyle changes ie not drinking or smoking

Question 30

what types of drugs are used in seocndary prevention (preventing another stroke)

Answer 30

Anti-hypertensive drugs - beta blockers, ACE inhibitors
Anticoagulant drugs - warfarin or heparin
Lipid modification drug treatment - statins
Antiplatelet therapy - aspirin or clopidogrel

Question 31

Vitamin K link to stroke

Answer 31

Vitamin K is essential for blood clotting. However, when Vitamin K levels are too high, people can form excessive blood clots quickly, which can cause stroke,

Question 32

How does Atrial Fibrillation cause stroke?

Answer 32

AFib puts patients at an increased risk for stroke because blood may not be properly pumped out of the heart, which may cause it to pool and form a clot. This clot can then travel to the brain and block the flow of blood to part of the brain which can result in a stroke.

Question 33

Stroke management/therapy

Answer 33

Acute
protect airway - prevent hypoxia / aspiration
Urgent CT/MRI/ECG - esp if considering thrombolysis
Antiplatelet agent - Aspirin if haemorrhagic cause ruled out
Thrombolysis - alteplase - only if haemorrhagic cause ruled out - always do a CT after thrombolysis to check for bleeding
transfer to stroke unit

prevention
primary (before any stroke) - control risk factors, lifelong anticoagulation in AF

secondary (preventing repeat) - Lower BP and cholesterol and control other risk factors
antiplatelet agents - aspirin and clopidogrel
anticoacgulate - warfarin 2 weeks later

Question 34

2 main treatment drugs given for acute stroke

Answer 34

atelplase - thrombolysis

aspirin - if allergic, give another antiplatelet