Stroke session teaching

Question 1

History aspects of which suggests stroke cause

Answer 1

• Sudden onset
• Maximal at onset
• Focal neurology - specific
• Negative symptoms

In TIA they will make complete recovery

Question 2

Ischaemic vs haemorrhagic stroke

Answer 2

• Can present the same until CT - more likely to vomit as blood irritates brain
• Ischaemic - normal CT initially, then black on CT after time passes (12 hrs or more usually)
• Haemorrhagic - white on CT

Question 3

early CT changes for ischaemic stroke

Answer 3

• Hyperdense artery sign (MCA travels within sylvian fissure, thrombus)
• Sulcal effacement - brain oedema
• Loss of grey-white matter differentiation - swollen brain, cytotoxic oedema - often causes loss of caudate nucleus and internal capsule

Question 4

Other causes of hyperdense sign

Answer 4

• Hypercoagulable state - eg clotting disorder, renal failure
• Calcification

Question 5

Vasogenic oedema

Answer 5

NOT for stroke oedema - this is caused by tumour instead

Question 6

CT for stroke symptoms older than 10 days?

Answer 6

• Haemorrhage will go from white to black on CT as time progresses
• If delayed presentation - need to do MR to differentiate cause

Question 7

Non-focal neurological symptoms of stroke - THESE CAN HAVE OTHER CAUSES

Answer 7

• Light-headedness/faint
• Blackouts
• Incontinence
• Confusion

Any of following if isolated:
* Vertigo
* Tinnitus
* Dysphagia
* Slurred speech
* Double vision
* Loss balance

Question 8

Clinical description of stroke

Answer 8

• Geographical
• Vascular region
• NIHSS

Question 9

POCS

Answer 9

• Ipsilateral CN palsy + contralateral motorsensory loss OR
• Bilateral motorsensory loss OR
• Cerebellar signs OR
• Pure homonymous hemianopia OR
• Cortical blindness (infarcts both lobes)

Question 10

TACS vs PACS

Answer 10

• Motor/sensory loss of at least 2 of face/arm/eg + dysphasia (if dominant) or neglect (if not) and HH
• PACS is 2 of 3 TACS
• OR cortical dysfunction alone

Question 11

NIHSS

Answer 11

• 13 item scoring system
• Structured neuro exam
• Takes 5 mins
• Indicates score severity
• Can predict outcome - if below 12 good or excellent

Question 12

ASPECTS scoring

Answer 12

• Validated score looking at anterior circulation
• Divides into 10 areas
• 10 = normal score - all areas look fine
• Ischaemic change = lose point per area
• Can help make decisions about what treatments to give - thrombolyse sometimes down to 5 or sometimes less

Question 13

Need to do before thrombolysis

Answer 13

• Weigh patient
• IV access and x 2 stroke bloods (but don’t wait for results)
• CT head
• NIHSS
• Assess exclusion criteria
• Consultant make decision

Question 14

Contraindications to thrombolysis

Answer 14

• Previous intracranial haemorrhage
• Seizure at onset of stroke
• Intracranial neoplasm
• Suspected subarachnoid haemorrhage
• Stroke or traumatic brain injury in preceding 3 months
• Lumbar puncture in preceding 7 days
• Gastrointestinal haemorrhage in preceding 3 weeks
• Active bleeding
• Oesophageal varices
• Uncontrolled hypertension - >200/120mmHg

Question 15

When to anticoagulant post ischaemic stroke for AF?

Answer 15

early as 3 days after stroke
Change of practice recently

Question 16

What to worry about re thrombolysis

Answer 16

• BP control - if systolic <185/110 contraindicate
• Neurological deterioration - re-scan
• IC and EC haemorrhage
• Angiooedema - more common if on ACEi (bradykinin related), half tongue, contralateral to hemisphere of stroke

Question 17

Typical location of hypertensive strokes

Answer 17

Haemorrhagic deep within the brain - basal ganglia

Question 18

When neurosurgery is considered?

Answer 18

• Cerebellar haemorrhage >3cm and deteriorating - decompressive craniectomy to prevent press on brainstem
• Obstructive hydrocephalus - blood in ventricles and block CSF (dilation of lateral ventricle horns)
• ICH and structural lesion
• Young patient with moderate or lobar haemorrhages who are deteriorating

Question 19

Managing haemorrhagic stroke

Answer 19

• Lower BP to below 140 systolic within 1 hr - IV labetalol (if present within 6 hours)
• Reverse warfarin
• DOACs - talk to haematology - tranexamic acid and prothrombin concentrate

Question 20

When to treat high BP in ischaemic stroke?

Answer 20

• Hypertensive encephalopathy
• Hypertensive nephropathy
• Hypertensive cardiac failure or MI
• Aortic dissection
• Pre-eclampsia

Question 21

What is malignant MCA syndrome?

Answer 21

• Consequence of large vessel occlusion of MCA
• –> oedema of MCA territory = loss sulci, hypodensity, midline shift, lost lateral ventricles
• –> cushings triad
• Often in younger people - brains naturally larger
• Monitor GCS and reimage
• Need decompressive hemicraniectomy
• DOES NOT SAVE FROM STROKE EFFECTS but does prevent death - need to have conversation with family and pt prior

Question 22

Cerebral venous sinus thrombosis

Answer 22

• Rare cause of acute stroke (if cortical veins - transverse and sigmoid involved)
• Present with headache, seizures and focal neurological deficit
• More likely in prothrombotic tendency, infection, dehydration and malignancy
• Treat with anticoagulant for 3 months

Question 23

Venous infarct

Answer 23

• Blocks drainage vessels of brain
• Leads to back pressure
• = swelling, oedema
• Can then cause ischaemia
• MORE SWOLLEN and can contain haemorrhage
• Appearance is tumour like on CT

Question 24

Management of venous sinus thrombosis of brain

Answer 24

• Anticoagulant - just like DVT
• EVEN if haemorrhage within brain
• LMWH then transition to DOACs

Question 25

ABCD2 score

Answer 25

IGNORE - used to estimate risk of stroke following TIA
Triage TIA referrals daily - see within 24hrs
If symptom onset was 1 week before, allow longer time to be able to see

Question 26

Secondary prevention of stroke

Answer 26

• Clopidogrel 75mg
• Aspirin 300mg OD for 2 weeks first, then switch clopidogrel after
• Aspirin only if clopi not tolerated