Strokes: TIAs, Ischemic, Haemorrhagic

Question 1

Stroke

• main types and subtypes
• risk factors for each one

Answer 1

Ischemic - MOST COMMON
-TIA - U24hrs + transient focal neuro dysfunction
-stroke - 24hrs+
Thrombotic or embolic
CV risk factors + AF

Hemorrhagic
-SAH
-intracerebral 
Age
HTN
AVM
AC use

Question 2

Typical focal loss presentation of ischemic stroke

Presentation of hemorrhagic stroke

Answer 2

Motor weakness
Balance problems
Speech problems
Visual field problems - homohemi
Dysphagia

In addition

• decreased consciousness
• headache
• N+V
• seizures

Question 3

Presentation of cerebral hemisphere infarcts

• ACA
• MCA
• PCA
• PCA supplying midbrain

Answer 3

ACA
-contralateral leg weakness/tingling dominant

MCA

• contralateral arm weakness/tingling dominant
• contralateral homohemi
• aphasia

PCA

• contralateral homohemi with macular sparing
• visual agnosia
• cranial nerves

PCA supplying midbrain (Webers)

• ipsilateral CN3 palsy
• contralateral weakness of upper/lower extremities

Question 4

Presentation of

• brainstem infarcts
• retinal/opthalmic infarcts

Answer 4

Quadriplegia
Locked in syndrome

Amaurosis fugax - painless curtain coming down in eye

Question 5

Presentation of cerebellar infarcts

• ant inferior cerebellar
• post inferior cerebellar

Answer 5

Ant inferior cerebellar - lat pontine

• ipsilateral facial paralysis, deafness
• vertigo, vomiting

Post inferior cerebellar - lat medullary

• ipsilateral facial pain, temp loss
• vertigo, vomiting
• contralateral limb/torso pain, temp loss
• ataxia, nystagmus

Question 6

Key investigations

Answer 6

CT - is it ischemic or hemorrhagic?

MRI

Question 7

Management of

• ischemic stroke
• TIA
• hemorrhagic stroke

Answer 7

Ischemic confirmed => 300mg aspirin ASAP
If within 4.5hrs of onset => thrombolysis (alteplase)
If within 6hrs of onset => thrombectomy

TIA
300mg aspirin ASAP
If within 1 wk => urgent assesment within 1 day
If 1wk+ => urgent assessment within 1wk
If many TIAs/cardioembolic source/severe carotid stenosis => admit and observe

Hemorrhagic
CT confirmation => neurosurgery referral
-stop AC
-lower HTN

Question 8

2ndary prevention

Answer 8

Clopidogrel

Risk factor modification

• statins 80mg
• HTN, DM
• diet, exercise
• smoking, alcohol

Carotid artery disease => endarterectomy, stenting
AF => DOAC