Stroke + TIA

Question 1

S+S brainstem stroke

Answer 1

Quadriplegia

Locked in

Question 2

S+S lacunar stroke + what is it

Answer 2

Occurs secondary to small vessel disease (atherosclerosis), involves subcortical stroke: Pure motor Pure sensory Ataxic hemiparesis

Usually associated with HTN

Small infarcts around basal ganglia, internal capsule, thalamus + pons

Question 3

S+S total + partial anterior circulation infarct

Answer 3

All 3 = TACS, 2 = PACS:

Unilateral weakness and/ or sensory disturbance of face, arm + leg

Homonymous hemianopia

High cerebral dysfunction eg dysphasia, visuospatial disorder

Question 4

Posterior circulation syndrome S+S

Answer 4

1 present to be POCS:

Cranial nerve palsy + contralateral deficit

Bilateral motor/ sensory deficit

Conjugate eye movement disorder (horizontal gaze palsy)

Cerebellar dysfunction: ataxia, vertigo, nystagmus Isolated

homonymous hemianopia

Question 5

Investigation + management of stroke (acute)

Answer 5

CT head within 4 hours to exclude haemorrhage

If no evidence of haemorrhage, given alteplase within 4.5 hrs. If over 4.5 hrs, 300mg aspirin (rectal if NBM)

Repeat CT head at 24 - 48 hrs

Bloods, BM, MRI (24 - 48 hrs later), carotid Duplex USS (for ischaemic strokes)

Keep BP (IV infusion of GTN or labetaolol), BM + O2 controlled

Sip test - spoon of water, then cup, then add thickener - if not, NBM + NG tube

Question 6

S+S carotid TIA

Answer 6

Unilateral motor/ speech difficulty

Loss of vision

Question 7

S+S vertebrobasilar TIA

Answer 7

Bilateral visual defects

Vomiting

Vertigo

Dysphagia

ataxia

Question 8

Investigations and treatment of TIA (long term)

Answer 8

ECG, echo, carotid USS, CT within a week

Aspirin 300mg then clopidogrel + statin

HTN management

Question 9

Types of ischaemic stroke

Answer 9

Embolism Thrombosis - blood clot forming locally Systemic hypoperfusion due to hypotension Cerebral venous sinus thrombosis

Question 10

Types of haemorrhagic stroke

Answer 10

Intracerebral haemorrhage, intraventricular, SAH

Extradural - egg shaped

Subdural - slithers around the side like a snake

Question 11

What is the Bamford classification?

Answer 11

Classification for ischaemic strokes Also called Oxford system TACS, PACS, POCS, LACS

Question 12

What is the ABCD2 score?

Answer 12

Assess risk of stroke in 90 days after TIA Age >60 BP >140/90 Clinical features of TIA (unilateral weakness = 2, speech disturbance = 1) Duration >60 mins = 2, 10-59 mins = 1 Diabetes

Score >4 = give aspirin 300mg + specialist assessment within 24 hrs

Question 13

Management of stroke (long term)

Answer 13

Aspirin for first 14 days (300mg) + then switch to clopidogrel 75mg lifelong

Statin

HTN management (ACD rule)

Carotid endarteterecomy

warfarin/ NOAC if AF, + digoxin/ B blocker if needed

Question 14

What to do with a high INR?

Answer 14

>5/6 + any bleed = vit K (oral phytomenodione) >8 = vit K

Question 15

Monitoring of warfarin

Answer 15

Yearly FBC

Stable INR = checks every 12 weeks

Question 16

What affects warfarin dose?

Answer 16

Alcohol Leafy green veg - cause low INR

Abx, steroids (make INR go up)

Question 17

Monitoring with NOACS

Answer 17

FBC, LFTs, coag check + INR baseline FBC + LFTs yearly

Question 18

RF for ischaemic stroke

Answer 18

Carotid stenosis , AF, valve disease, atherosclerosis

CVD RF (smoking, HTN, DM, alcohol (ETOH))

COCP

Polycythaemia vera (production of more Hb + RBC)

Question 19

Comparison of ischaemic vs haemorrhagic stroke on CT scan

Answer 19

Haemorrhagic - white blood

Ischaemic = delayed response in brain

Question 20

Causes of extra + subdural haemorrhages + likely patients + presentation?

Answer 20

Extradural = usually in young patients, due to head strike. Have lucid interval but then lose consciousness over few hours. Damage to middle meningeal artery or vein

Subdural = due to falls, no obvious cause - commonly in elderly + drunks - venous bleeding so presents slowly. Can be acute, subacute (3-7 days) or chronic (2-3 weeks)

Question 21

What is the circle of willis?

Answer 21

Connecting arteries in brain

Question 22

What are the cerebellar signs?

Answer 22

DANISH P

Dysdiadokinesis

Ataxia

Nystagmus

Intention tremor

Slurred speech

Homonymous hemianopia

Past pointing

Question 23

SAH presentation + RF

Answer 23

Sudden onset thunderclap headache, typically pulsates towards occiput

Can vomit or LOC

RF: berry aneurysms

Star shape on CT

Question 24

What is a carotid endarterectomy?

Answer 24

Removing debris if carotid artery is stenosed (50-70% lumen occluded)

Question 25

What is alteplase, what are the CI?

Answer 25

t-PA

CI: <18, >80, onset of symptoms >4 hrs, seizures, neuro signs resolved, fully dependant on carers

Question 26

Management of haemorrhagic stroke

Answer 26

Neurosurgery - clipping + coiling

Vasospasm is common complication so give nimodepine

Control HTN with infusions