Stroke & TIA

Question 1

What is the difference between a stroke & TIA?

Answer 1

Sudden onset/ rapidly-developing focal or global neuro disturbance

Stroke: lasts >24 hours or leads to death
TIA: lasts <24 hours

Question 2

What are the two types of haemorrhagic stroke?

hint: where is the bleed?

Answer 2

Intracerebral: within the brain
Subarachnoid: between brain & arachnoid

Question 3

What % of strokes are ischaemic & haemorrhagic?

Answer 3

85% ischaemic

15% haemorrhagic

Question 4

What are the two main causes of ischaemic stroke?

Answer 4

Occlusion from a thrombus (complication of atherosclerosis)

Embolus of blood clot (complication of AF)

Question 5

What are some rarer causes of harmorrhagic stroke?

one in young people/ neck trauma & one associated with prothrombotic tendency

Answer 5

Carotid artery dissection (younger people/ neck trauma)

Cerebral venous thromobosis (in those with a prothrombotic tendency )

Question 6

Give some mobility problems associated with stroke

HAFS

Answer 6

Hemiparesis/ hemiplegia

Ataxia

Falls

Spasticity (muscles continually contracted)

Question 7

What are the two types of dysphasia? & areas of the brain associated with them?

Answer 7

Receptive (wernicke’s)

Expressive (broca’s)

Broca’s area is anterior to wernickes

Question 8

What are some cognitive problems associated with stroke?

Answer 8

Dyspraxia
Impaired concentration
Hemispatial neglect

Question 9

How may a posterior circulation stroke present?

Answer 9

Symptoms of acute vestibular syndrome:

Acute persistent continuous vertigo with nystagms, N&V & new gait unsteadiness

Question 10

When can antiplatelet treatment be started?

Answer 10

Only once haemorrhagic stroke has been ruled out by a brain scan

Question 11

How should you manage someone before stroke is confirmed?

Answer 11

ABC approach

Give oxygen if sats are <95%

Maintain blood glucose of 4-11

Question 12

How do you manage a confirmed ischaemic stroke?

Answer 12

Oral aspirin

Thrombolysis with alteplase

Question 13

What is alteplase & how does it work?

Answer 13

Fibrinolytic: activates plasminogen to degrade fibrin & break up thrombus

Question 14

How is alteplase delivered?

Answer 14

IV injection

Question 15

What is the target time for thrombolysis with alteplase?

Answer 15

Within 4.5 hours of stroke onset

Question 16

What dose of aspirin should be given?

Answer 16

150-300mg

Question 17

How long post-stroke should aspirin be continued?

Answer 17

For 2 weeks, before long-term anti-thrombotic treatment is commenced

Question 18

What can be given if patient is allergic to aspirin?

Answer 18

Clopidogrel

Question 19

What is the indication for thrombectomy

Answer 19

Confirmed occlusion in the proximal anterior circulation

Question 20

What is the immediate management of haemorrhagic stroke?

Answer 20

If on an anticoagulant, consider administering a reversal agent
e.g. Vitamin K (takes 4 hours to work)
Or OCTUPLEX (works in 30 minutes)

Question 21

What are the ABCDE for secondary prevention of stroke?

Answer 21

A - antiplatelet (clopidogrel)
B - blood pressure control
C - cholesterol control (statin)
D - diet
E - exercise

Question 22

What common side effects can people get from statins?

Answer 22

Headache

GI upset

Question 23

Do ischaemic stroked always show up on CT?

Answer 23

No, <50% don’t show up

Question 24

Cushing’s triad is a late sign of raised ICP. What is cushing’s triad?

Answer 24

HTN
Bradycardia
Altered respiratory rate (cheyne stokes)

Question 25

What further test should be carried out if ?SAH but CT head does not show blood? What would you be looking for?

Answer 25

Lumbar puncture (12 hours post-onset) Looking for xanthochromia (used to differentiate in vivo haemorrhage from traumatic LP)

Question 26

Why is lumbar puncture contraindicated in raised ICP?

Answer 26

Risk of coning

Question 27

What is the most common visual defect in stroke?

Answer 27

Homonymous hemianopia

Question 28

Which artery is most commonly affected in stroke? | Why is this?

Answer 28

MCA | Least resistance, big vessel, continuation of the internal carotid

Question 29

What are the 4 classifications of stroke in the Bamford classification?

Answer 29

TACS - total anterior circulation stroke PACS - posterior anterior circulation syndrome POCS - posterior circulation syndrome LACS - Lacunar syndrome

Question 30

What are the 3 features of TACS?

Answer 30

unilateral weakness Homonymous hemianopia Higher cerebral dysfunction

Question 31

How is PACS classified?

Answer 31

2 of the features of TACS (homonymous hemianopia/ unilateral weakness/ higher cerebral dysfunction

Question 32

How is POCS classified?

Answer 32

One of: Cerebellar or brainstem syndromes Loss of consciousness Isolated hemianopia

Question 33

What are the later signs of stroke on examination?

Answer 33

UMN signs: hypertonia, hyper-refleia, flexed arm & extended leg, clonus

Question 34

What is the ROSIER score?

Answer 34

Recognition of stroke in the emergency room score Score >0: investigate for stroke There are also negative scores

Question 35

What scale can be used to grade stroke severity?

Answer 35

NIHSS (national institute of health stroke scale)

Question 36

What are the 3 ways to treat an acute ischaemic stroke?

Answer 36

Aspirin Thrombolysis Thrombectomy

Question 37

When would aspirin be indicated over thrombolysis?

Answer 37

If INR is too high/ more than 4.5 hours post-CVA

Question 38

How is alteplase delivered?

Answer 38

IV | 10% given as a bolus, then the rest IV over 1 hour

Question 39

What does systolic BP need to be under for thrombolysis?

Answer 39

Systolic BP <185

Question 40

Give 3 complications of thrombolysis

Answer 40

Bleeding (haemorrhagic transformation) Anaphylaxis Hypotension

Question 41

When is thrombectomy indicated?

Answer 41

Proximal anterior circulation clot

Question 42

How soon should thrombectomy be done?

Answer 42

Within 6 hours of stroke onset

Question 43

How soon after the stroke should patients be switched to clopidogrel?

Answer 43

after 2 weeks

Question 44

What should you consider as a cause in younger patients? (e.g. 18 y/o with a DVT)

Answer 44

VSD (ventricular septal defect)

Question 45

Following TIA, who should be seen by a specialist?

Answer 45

Everyone

Question 46

What is the management of TIA?

Answer 46

Aspirin 300mg | Refer for assessment in 24 hours in TIA clinic

Question 47

What is used for secondary prevention of TIA?

Answer 47

Clopidogrel, 75mg once daily

Question 48

How can you differentiate between an UMN lesion and Bell's palsy (LMN)?

Answer 48

Forehead sparing in UMN lesion | In Bell's palsy the whole half of the face is affected