Stroke/TIA

Question 1

What are the dizzy plus syndromes in relation to arterial events?

Answer 1

Superior cerebellar artery occlusion = dizzy. Anterior inferior cerebellar artery = dizzy and deaf. Posterior inferior cerebellar artery = dizzy, dysphagic and dysphonic

Question 2

What are the signs of a vertebrobasilar circulation occlusion/stroke?

Answer 2

hemianopia, cortical blindness, diplopia, vertigo, nystagmus, ataxia, dysarthria, dyphasia, hemi or quadraplegia, unlateral or bilateral sensory symptoms, hiccups, coma. DANISH - dysdiadokinesis, dysmetria, ataxia (towards side of lesion), nystagmus, intention tremor, slurred speech, hypotonia

Question 3

What are the signs/symptoms of lateral medullary syndrome? Occlusion of what arteries may cause lateral medullary syndrome?

Answer 3

vertigo, vomiting, dysphagia, ipsilateral ataxia, soft palate paralysis, ipsilateral horner’s syndrome and cross-pattern sensory loss - analgesia to pinprick on ipsilateral face and contralateral trunk and limbs. Occlusion of vertebral artery or posterior inferior cerebellar artery

Question 4

What are the modifiable risk factors for stroke?

Answer 4

Hypertension, smoking, DM, heart disease (valvular, ischaemic, AF), peripheral vascular disease, past TIA, raised PCV, carotid bruit, the Pill, raised lipids, high alcohol use, raised clotting, increased homocysteine, syphilis

Question 5

What are the signs of stroke?

Answer 5

sudden onset, with potential progression over hours
focal signs of infarct area
suggests bleeding - meningism, severe headache and coma within hours
suggests ischaemia - carotid bruit, AF, past TIA, IHD

Question 6

What are the signs of a cerebral infarct?

Answer 6

contralateral hemiplegia - initially flaccid then becomes spastic
Contralateral sensory loss
dysphasia
homonymous hemianopia
visuo-spatial deficit

Question 7

What are some of the signs of a brainstem infarct?

Answer 7

Quadraplegia
disturbances to gait
disturbances to vision
locked-in syndrome

Question 8

Where are lacunar infarcts found anatomically? What are the signs of a lacunar infarct?

Answer 8

basal ganglia, internal capsule, thalamus and pons.
Produces 5 syndromes - ataxic hemiparesis, pure motor, pure sensory, sensorimotor and dysarthria/clumsy hand.
Cognition/consciousness intact except thalamic strokes

Question 9

What are some of the differentials to a diagnosis of stroke?

Answer 9

Head injury, hyper/hypoglycaemia, subdural haemorrhage, intracranial tumours, hemiplegic migraine, Epilepsy (Todd’s palsy), CNS lymphoma, pneumocephalus (air entry), Wernicke’s encephalopathy, Drug overdose, Hepatic encephalopathy, Mitochondrial cytopathies, herpes encephalitis, HIV, HTLV-1, Toxoplasmosis, Abscesses, (extras - mycotic aneurysm, Coccidioides immitis, Acanthamoedba/naegleria)

Question 10

What should the management be within 1 hour of presentation to hospital?

Answer 10

ABCD:
Protect the airway
pulse, BP and ECG - look for AF, maintain high blood pressures
Blood glucose - aim for 4-11 mmol/L
Urgent CT/MRI - CT to rule out haemorrhage if thrombolysis possible, and in cerebellar stroke (cerebellar haematoma requires urgent evacuation)
Thrombolysis - if symptoms <4.5 hours ago
NBM until swallowing assessment done, hydrate with IVF but beware cerebral oedema risk
Antiplatelet agents - once haemorrhagic stroke excluded, give Aspirin 300mg
Refer to stroke unit urgently

Question 11

What are the most common causes for a stroke?

Answer 11

Small vessel occlusion
cerebral microangiopathy
thrombosis in situ
cardiac emboli - AF, endocarditis, MI
atherothromboembolism - eg from carotids
CNS bleeds - HTN, trauma, aneurysm rupture, anticoagulation, thrombolysis

Question 12

What demographic of patient should the less common causes of stroke be considered? What are some of the other causes?

Answer 12

Younger patients

Sudden BP drop >40mmHg (watershed stroke)
carotid artery dissection
vasculitis
subarachnoid haemorrhage
venous sinus thrombosis
antiphospholipid syndrome
thrombophilia
Fabry's disease
CADASIL/CARASIL

Question 13

What is the primary prevention’s used for stroke?

Answer 13

look for and control: HTN, DM, hyperlipidaemia and cardiac disease. Smoking cessation

Increase exercise - increased HDL’s and increased glucose tolerance

Lifelong anticoagulation if rheumatic or prosthetic heart valve

Question 14

What is the secondary prevention’s used for stroke?

Answer 14

controlling risk factors as for primary prevention

Antiplatelet agents - clopidogrel monotherapy

Anticoagulation - start warfarin if indicated (non-valvular AF or ischaemic stroke, prosthetic valves, acute MI) 2 weeks after the stroke (if clinically and radiologically small then 7-10 days)

Question 15

What is the CHA2DS2-Vasc score?

Answer 15

Represents the risk of stroke in the next year in a patient with a diagnosis of AF

C - congestive heart failure
H - hypertension
A2 - age >75 = 2
D - diabetes mellitus
S2 - stroke/tia/thrombo-embolism = 2
V - vascular disease
A - age 65-74
Sc - sex category female

Question 16

What is the HASBLED score?

Answer 16

assesses 1 year risk of major bleeding in patients taking anticoagulants with AF

H - hypertension
A - abnormal liver function
A - abnormal renal function
S - stroke
B - bleeding
L - labile INRs
E - elderly >65yrs
D - drugs
A - alcohol

Question 17

What are some of the complications of a stroke?

Answer 17

aspiration pneumonia
pressure sores
contractures
depression
stress in spouse

Question 18

What is the definition of a TIA?

Answer 18

sudden onset of focal CNS phenomena due to temporary occlusion of part of the cerebral circulation with symptoms resolving within 24 hours of onset.

Question 19

What are the signs of a TIA?

Answer 19

attacks can be single or many. They should mimic strokes of the same arterial territory.

Global event (dizziness, syncope) are not typical of TIAs

Multiple highly stereotyped attacks suggests critical intracranial stenosis

Can present as amaurosis fugas= (one eye’s vision progressively lost like a curtain descending)

Question 20

What are the common causes of TIA?

Answer 20

atherothromboembolism from the carotid if most common
Cardioembolism - mural thrombus post-MI or in AF, valve disease or prosthetic valve
Hyperviscosity - polycythaemia, sickle-cell anaemia, leukostasis (very high WCC), myeloma
Vasculitis is a rare cause - cranial arteritis, PAN, SLE, syphilis

Question 21

What is the differential diagnosis to a TIA?

Answer 21

hypoglycaemia
migraine aura - symptoms spread and intensify over minutes, often with visual scintillations
focal epilepsy - symptoms spread over seconds and often include twitching and jerking
hyperventilation
retinal b leeds
Rare mimics: malignant hypertension, MS (paroxysmal dysarthia), intracranial tumours, peripheral neuropathy, phaeochromocytoma, somatization

Question 22

What is the treatment for TIA?

Answer 22

control CV risk factors: HTN (cautiously lowe BP, aim for <140/85), hyperlipidaemia, DM, smoking cessation
Antiplatelet drugs: clopidogrel 75mg/d
warfarin indications: cardiac emboli
carotid endarterectomy: if >70% stenosis

Question 23

What are the rules regarding driving after a TIA?

Answer 23

avoid for 1 month and inform the DVLA only if multiple attacks in a short period or residual deficit

Question 24

What is the score used to determine the risk of stroke following a TIA?

Answer 24

ABCD2 which predicts the short-term risk of a stroke after TIA (up to 90 days, but optimised for 2 days post TIA)
A: age >60
B: BP>140/90
C: clinical features - unilateral weakness = 2, speech disturbance w/o weakness = 1
D: duration of symptoms - >1h = 2, 10-59mins = 1
D: diabetes