Stroke & TIA

Question 1

What are the types of stroke?

Answer 1

Ischaemic 85%

Haemorrhagic 15%

Question 2

What are the causes of a stroke?

Answer 2

Small vessel occlusion
Cardiac emboli: Endocarditis, MI, carotid dissection
Atherothromboembolism: Carotids
CNS bleed: AV malformation, HTN, trauma, aneurysm rupture, anticoagulation

Question 3

How does a stroke present?

Answer 3

Dysphagia
C/L weakness/paralysis + sensory loss
I/L facial palsy (forehead sparing)
Homonymous hemianopia

Question 4

What signs are specific to an ischaemic stroke?

Answer 4

50% flaccid initially
C/L sensory loss + hemiplegia, dysphagia, hemianopia
Basilar artery = Locked in syndrome
Lacunar = Ataxic hemiparesis & dysarthria, cognition INTACT

Question 5

What signs are specific to a haemorrhage stroke?

Answer 5

Severe headache
N&V
↓GCS, ↓BP
Pontine haemorrhage = Locked in syndrome, Quadriplegia, B/L miosis (still reactive)

Question 6

What Sx can help you deduce specifically where a quadranopia is?

Answer 6

Inferior quadranopia = Posterior stroke

Superior quadranopia = Temporal stroke

Question 7

How is a stroke investigated?

Answer 7

Urgent CT/MRI (if no ‘immediate CT’ Sx then CT in <24hours)
Hyperdense MCA sign on CT: Appears in 90mins of ischaemia
Signs of cause: ECG, Pulse (AF)
Bloods: FBC, U&E, Coag, Glucose, Na+, Ca2+, Cholesterol

Question 8

How is a stroke managed acutely?

Answer 8

Nil by mouth
ISCHAEMIC=
1) Aspirin 300mg: ASAP after haemorrhage excluded
1) Alternative- Clopidogrel
2) THROMBOLYSIS IN 4.5HOURS OF Sx: Alteplase 10% dose as bolus then rest over 60mins
WITHHOLD ASPIRIN FOR 24hours post-ALTEPLASE
Adjunct) Mechanical thromectomy
Decompressive hemicraniotomy = MCA infarct
Glucose: Maintain 5-15

HAEMORRHAGIC = Neurosurgery

Question 9

If someone has greater deficit in their arms/face than their legs, where is the stroke?

Answer 9

Middle cerebral artery

Question 10

If someone has greater deficit in their legs than their arms/face, where is the stroke?

Answer 10

Anterior cerebral artery

Question 11

In terms of Sx how is a lacunar stroke in the thalamus & internal capsule described?

Answer 11

Internal capsule = Pure motor Sx

Thalamus = Pure sensory Sx

Question 12

What scoring system can be used in A&E to recognise risk of someone having a stroke?

Answer 12

-NIHSS: Score severity
-ROSIER:
>1: Stroke likely
-score: Consider alt diagnosis
-LOC = -1
-Convulsive episode = -1
-Face weakness = 1
-Arm weakness = 1
-Leg weakness = 1
-Speech disturbance = 1
- Visual field defect = 1

Question 13

What conditions can mimic a stroke?

Answer 13

Migraine
Hypoglycaemia
Seizure
Brain tumour/ space-occupying lesion
Sepsis
Syncope
CN7 palsy
Toxic metabolic states

Question 14

What are the indications for immediate head CT in a stroke?

Answer 14

• Tx by thrombolysis or early anticoagulation
• On an anticoagulant
• known bleeding tendency;
• GCS <13
• Unexplained progressive or fluctuating Sx
• Papilloedema, neck stiffness or fever
• Severe headache at onset of stroke Sx

Question 15

What are the indications for thrombolysis?

Answer 15

Sx consistent w/stroke
Clear time of onset
Presents in <4.5hours
No CI

Question 16

What are the contraindications to thrombolysis?

Answer 16

• Imaging: Haemorrhage, extensive small vessel disease, >1/3 MCA infarct
• > 4.5hours since onset
• Anticoagulated (NOAC except Dabigatran)
• Seizure post-stroke
• Stroke/Head injury in <3m
• Major surgery in <3m
• Platelets <100
• sBP consistently >185

Question 17

How is a TIA different from a stroke?

Answer 17

Sx lasting <24hours

Question 18

How is a haemorrhagic stroke treated acutely?

Answer 18

ALERT neurosurgery
Nimodipine
?Airway protection
Decompensating = Surgery

Question 19

What is the the long-term management after a stroke?

Answer 19

Clopidogrel 75mg
Warfarin: AF
Statin: Cholesterol >3.5
HTN: Amlodipine/Labetalol

Question 20

What follow-ups need to be done post-stroke?

Answer 20

SALT Assessment
Carotid artery doppler <1week:
ESSENTIAL if ant circulation stroke
>50% occluded = vascular surgeons 
DVLA: CANNOT drive for 1month if residual loss inform DVLA who will arrange their own assessment

Question 21

How do the results of carotid doppler correlate to treatment?

Answer 21

Asymptomatic + <70% = Aspirin/Clopidogrel
Asymptomatic + >70% = Aspirin/Clopidogrel +/- Carotid endarterectomy
I/L symptomatic >50% = Carotid endarterectomy

Question 22

What stockings should be warn for VTE prophylaxis post-stroke?

Answer 22

Pneumatic stockings

Question 23

What are the Sx of a cerebellar stroke?

Answer 23

POCS (POst Circulation Syndrome)

DANISH Sx

Question 24

What territories does a TACS stroke affect?

Answer 24

Total Anterior Circulation
Middle/Anterior cerebral artery
ALL of:
U/L weakness 
Homonymous Hemianopia
Higher cortical dysfunction (Dysphasia, visuospatial)

Question 25

What territories does a PACS stroke affect?

Answer 25

Partial Anterior Circulation Syndrome
Middle/Anterior cerebral artery
2 of:
U/L weakness 
Homonymous Hemianopia
Higher cortical dysfunction (Dysphasia, visuospatial)

Question 26

How is a TIA managed?

Answer 26

Aspirin 300mg STAT then OD for 2weeks
Reduce after to 75mg OD
Neuro: In <7d = 24hour referral, if >7d= 1w referral

Question 27

What Score can be used to screen someone with a TIA for a potential stroke?

Answer 27

ABCD2
A: >60yo
B: BP >140/90
C: U/L weakness arm/face (2) OR Speech disturbance (1)
D: DM
D: Sx <10mins (0) OR 10-59 (1) OR >60 (2)

SCORE:
>6 = Admission
>4 or Crescendo = Neuro in 24hours
<4 = Neuro in 1 week

Question 28

What type of aphasia does a lesion in Broca’s or Wernicke’s area lead to?

Answer 28

Broca’s = Expressive: Lesion at inferior frontal gyrus
Speech non-fluent/halting/ laboured, comprehension = normal
Wernicke’s = Receptive: Lesion at superior temporal gyrus
Sentences make no sense but fluent, comprehension = impaired

Question 29

When should a CT be repeated in stroke?

Answer 29

24hours after thrombolysis (check for haemorrhagic transformation)

Question 30

What are the DVLA rules for TIA?

Answer 30

CANNOT drive for 1month