strokes and scoring systems

Question 1

A 60-year-old man presents to the Emergency Department with what he believes to be an acute stroke that has been occurring for the past 80 minutes. Which of the following is the most appropriate scoring scale to aid in triage in the Emergency Department?

Answer 1

ROSIER scoring sytem for acute stroke in acute setting

Question 2

what is FAST

Answer 2

This scoring system is not the single best answer because FAST is designed as a scoring system to help screen for stroke amongst the general population

Question 3

what scoring system for risk of stroke in patients with Atrial Fibrillation

Answer 3

CHA2DS2-VASc

A score of 0 indicates low risk and anticoagulation may not be considered. A score of 1 indicates low-moderate risk and anticoagulation should be considered. A score of greater than 2 indicated high risk and anticoagulation should be started when weighed against bleeding risk.

Question 4

what scoring system is used for recognising the probability of a stroke after a transient ischaemic attack(TIA

Answer 4

ABCD2

Question 5

what is the glasgow-blatchford score

Answer 5

This is a scoring system to assess if a patient can undergo an endoscopy as an outpatient following an upper GI bleed.

Question 6

what is CURB-65

Answer 6

This is a scoring system to assess management options for a patient presenting with a community acquired pneumonia.

=

Question 7

This is a scoring system for assessing the bleeding risk for a patient on anti-coagulation

Answer 7

HASBLED

Question 8

haemorrhagic stroke management

Answer 8

reversal of any anticoagulation (using beriplex/octaplex +/- vitamin K) and aggressive BP control.

The systolic BP should be kept <140mmHg within an hour of admission and ideally kept above 120mmHg. This can be done with Glyceryl Trinitrate (GTN) or labetalol.

Question 9

string of beads on MRI carotid

Answer 9

fibromuscular dysplasia

Fibromuscular dysplasia (FMD), formerly called fibromuscular fibroplasia, is a group of non-atherosclerotic, non-inflammatory arterial diseases that most commonly involve the renal and carotid arteries.

Management of cases with reno-vascular hypertension includes antihypertensive therapy, percutaneous angioplasty of severe stenoses, and reconstructive surgery in cases with complex FMD that extends to segmental arteries.

Question 10

A 65 year old male patient is brought to the emergency department after his wife noticed he had sudden difficulty speaking and an inability to raise his right arm. He has a past medical history of hypertension. He is a non-smoker but admits to drinking 5 units of alcohol per day.

CT head is performed on arrival to the emergency department and reveals hyper-attenuation in the left middle cerebral artery vascular territory.

Which of the following pathophysiological processes is responsible for the most likely diagnosis?

Answer 10

Cerebral amyloid angiopathy

This is the correct answer. The clinical findings and CT results are consistent with haemorrhagic stroke. Cerebral amyloid angiopathy is a form of vessel disease in which amyloid builds up in the wall of blood vessels. It is a risk factor for haemorrhagic stroke and dementia, and is thought to be associated with hypertension

Question 11

Decompressive hemicraniectomy

when should it be considered

Answer 11

A decompressive hemicraniectomy should be considered in patients who are less than 60 years old, have severe stroke symptoms, reduced consciousness, and CT-defined infarct of at least 50% of the middle cerebral artery territory. This may not improve their disability caused by the stroke, but increases their survival rate following stroke.

Question 12

what is acute vestibular syndrome

Answer 12

This is a term that encompasses vestibular neuronitis and labyrinthitis. Both of these present with vertigo that can last for days (remember, Ménière’s Disease: Hours. BPPV: Minutes). Both vestibular neuronitis and labyrinthitis are thought to be caused by viral infections of the inner ear.

Question 13

suspected stroke what happens first

Answer 13

non-contrast-CT head to rule out intracranila haemorrhage

hyperdense lesion - bright - indicative of blood

This is the correct answer. The first step in managing a stroke is ordering an urgent CT head scan, in order to differentiate between an ischaemic stroke and a haemorrhagic stroke. This is important because the treatment differs greatly between these two causes of stroke, with the latter involving neurosurgical input, and the former including a loading dose of Aspirin and consideration for thrombolysis. Treating a haemorrhagic stroke with aspirin can worsen the bleed; and involving neurosurgery in an ischaemic stroke is inappropriate. Thus, accurate diagnosis is the first essential step in managing these patients

Question 14

contraindications to thrombolysis

Answer 14

e.g. recent head trauma, GI or intracranial haemorrhage, recent surgery, acceptable BP, platelet count, and INR ( CI if over 1.7 ).

Question 15

two TIA in week how do you refer

Answer 15

aspirin 300mg and review in TIA clinic within 24hr

Question 16

features on unsafe swallow and management

Answer 16

Features of unsafe swallow include any of the following symptoms upon drinking water in an upright position: drooling, dysphonia or a ‘wet’ voice, >2 seconds to initiate swallow, coughing during or within 1 minute of swallowing. If this occurs, the most important action is to ensure that the patient is completely nil by mouth including to fluids (nil by mouth with IV fluids), plus the SALT team should be urgently called to assess the patient’s swallow (this is the specialist team that is expert in swallowing)

Question 17

evidence of carotid artery stenosis on imaging with a history of a stroke or transient ischaemic attack ipsilaterally (ie. in line with the stenosed vessel).

Answer 17

NICE recommends carotid endartectomy for patients with

Question 18

A temporary loss of consciousness occurring in an elderly person after a fall with fluctuating or gradual decline of mentation is classic of

Answer 18

subdural

This presents with a “Thunderclap” headache that comes on suddenly. Patients may experience signs of meningism, drowsiness, coma, seizures. CT brain scan performed within 24 hours of the bleed may demonstrate bleeding in the subarachnoid space - subarachnoid

Question 19

This would present with a lucid interval followed by rapid decline (reduced mentation, seizures, coma). CT brain scan would demonstrate a biconcave disk/lens shaped bleed

Answer 19

extradural

Question 20

This would present with raccoon eyes sign or “Battle sign”. Additionally, cerebrospinal fluid may be seen leaking out of the nose or the ears

Answer 20

base of the skull fracture

Question 21

imaging for carotid artery stenosis

Answer 21

duplex US

Question 22

This is the correct answer. The patient presents with a contralateral hemiparesis, contralateral homonymous hemianopia, and evidence of higher cortical dysfunction (neglect)

Answer 22

total ant cerebral infarct - anterior and middle cerebral

Question 23

what is a lacunar stroke

Answer 23

A lacunar infarct (LACI) is defined by: a pure motor stroke, pure sensory stroke, sensorimotor stroke, or ataxic hemiparesis. There should be NO: visual field defect, higher cerebral dysfunction, or brainstem dysfunction. A LACI affects small deep perforating arteries, typically supplying internal capsule or thalamus.

Question 24

POCI is what

Answer 24

Cerebellar dysfunction, OR
Conjugate eye movement disorder, OR
Bilateral motor/sensory deficit, OR
Ipsilateral cranial nerve palsy with contralateral motor/sensory deficit, OR
Cortical blindness/isolated hemianopia.

Question 25

basiliar artery occlusion linked to

Answer 25

locked in syndrome (quadriparesis with preserved consciousness and ocular movements), loss of consciousness, or sudden death.

Question 26

what is wallenberg syndrome - CN of medulla -PICA -

Answer 26

(lateral medullary syndrome) causes ipsilateral Horner’s syndrome, ipsilateral loss of pain and temperature sensation on the face, and contralateral loss of pain and temperature sensation over the contralateral body.

Question 27

what is webers sydnrome

Answer 27

eber’s syndrome/medial midbrain syndrome (paramedian branches of the upper basilar and proximal posterior cerebral arteries): causes an ipsilateral oculomotor nerve palsy and contralateral hemiparesis.