Viva - Ischaemic Stroke

Question 1

Screening tools for stroke

Answer 1

FAST, face arms speech and time

Question 2

Stroke territory features

Answer 2

Anterior cerebral artery —> contra lateral leg, behaviour change

MCA - Weakness of contralateral face and arm, speech, hemianopia, sensory deficit

Posterior - Visual field defect, sensory defect

Verterbrobasillar - dizziness, ataxia, balance, voice and swallowing, low GCS

Cerebral vein and sinuses - Headache, vomiting, decreased GCS

Question 3

Classification of stroke is called…?

Answer 3

The Bamford Classification

Question 4

Classification catergories

Answer 4

Total Anterior Circulation (TACS)
Partial Anterior Circulation PACS
Lacunae Syndrome LACS
Posterior Syndrome POCS

Question 5

Features of TACS

Answer 5

All 3 of:

Unilateral motor, sensory or both affecting AT LEAST two of face, arm or leg

Higher cerebral dysfunction, (speech and swallowing)

Homonomous hemianopia

Question 6

What is the likely territory of a TACS

Answer 6

MCA

Question 7

Features of PACS

Answer 7

Two out of the three features of PACS

Unilateral motor/sensory affecting two of face, arm, leg

Higher function loss

Homonomous hemianopia

Question 8

Territory of PACS

Answer 8

Occlusion of MCA or branch of ACA

Question 9

Features of lacunae syndrome

Answer 9

Pure motor/sensory defect of two of face, arm, leg

Sensory motor deficit not meeting PACS/TACS criteria

Ataxic hemiparesis

Dysarthria, clumsy hand

Question 10

Territory of LACS

Answer 10

Occluded small deep penetrating artery subcortical

Question 11

Features of POCS

Answer 11

Isolated homonomous hemianopia or Cortical blindness

Cranial nerves palsy, brain stem or cerebellar

LOC

Question 12

Territory of POCS

Answer 12

Brain stem, cerebellum, occipital lobe

Question 13

What imaging for a stroke

Answer 13

Initial Non Contrast CT excludes haemorrhage

MRI will demonstrate infarct better but is not readily available.

Later - Carotid Doppler, MRI, TTE
If right to left shunt consider TOE, bubble contrast

Question 14

NICE guidelines for urgent imaging of head in 1 hours

Answer 14

Thrombolysis or anti coag is indicated

Known to be taking anti coag

Known bleeding tendancy

GCS<13

Progressive/fluctuating symptoms

Papilloedema, neck stiffness, fever

Severe headache at onset

Question 15

Management of Stroke, Key Bullet points

Answer 15

1) Investigate
2) Maintain physiology
3) Consider thrombolysis
4) Aspirin
5) Decompressive craniectomy
6) Therapeutic hypothermia
7) IR approaches
8) General supportive measures

Question 16

Describe the investigations you would do

Answer 16

Imaging as discussed
Bloods - FBC, U&E, CRP, ESR, TFT, lipids
ECG
TTE/TOE +/- bubble

Question 17

How do you maintain normal physiology

Answer 17

Glucose 4-10
BP - Do not routinely lower BP ass likely to maintain CPP
BUT - if a hypertensive emergency —end organ (encephalopathy, nephropathy etc) Tolerate a BP of 220/120

BUT - if thrombolysing, BP should be under 185/110

Cautiously with short acting agents with obs for deterioration

Oxygenation

Temperature

Question 18

Criteria for thrombolysis

Answer 18

Alteplase rTPA should be given within 4.5 hours of the onset of symptoms (IST-3 Trial)

Dose is weight dependent

Question 19

Contraindications to thrombolysis

Answer 19

Acute or previous intracranial haemorrhage

Severe uncontrolled hypertension >185 or dia >110

Head trauma or stroke in last 3/12

Thrombocytopenia or coagulapathy

Oral anticoagulant or heparin in the last 48 hours

Surgery in 14 days

GI/GU bleeds

Hypo or hyperglycaemia

Seizure with stroke

CNS structural issue

Recent MI

Question 20

Dose of aspirin

Answer 20

Exclude haemorrhage, give 300mg, po or NG

Consider PPI

Question 21

When to do decompressive craniectomy

Answer 21

High risk of MCA syndrome

> 50% MCA territory stroke on CT
82ml volume infarct at 6 hours MRI, 145ml at 14 hours

Consider when:
Under 60
Deficits in keeping with MCA infarct
NIHSS score of > 15
CT showing more than 50% territory

Question 22

Describe the trials to do with decompressive craniectomy

Answer 22

DESTINY
DECIMAL
HAMLET trials

Craniectomy if under 60 and within 48 hours of infarct

Mortality from 71 to 21%

But GOS scores low —> survivors left with disability, usually severe

Question 23

Talk about therapeutic hypothermia

Answer 23

No effect in reducing risk of poor outcome or death (Cochrane)

Question 24

Role of IR

Answer 24

Clot retrieved and recanelisation +/- intra-arterial rTPA who present 6-8 hours after symptoms

Use in subset of patients with carotid or MCA who do badly with it rTPA

Question 25

What are the general measures

Answer 25

VTE
Physio and mobility
Nutrition - SALT
Pressure area care

Question 26

When would you admit to Itu

Answer 26

Seizures
Deteriorating neuro status/airway compromised
Mass effect due to large SOL
Resp failure
To help with intervention

Question 27

Risk of pneumonia

Answer 27

Old age
Aphasia, dysarthria
Post stroke disability
Cognitive impairment
Abnormal water swallow test

Question 28

When does focal cerebral ischaemia result in coma

Answer 28

Brain stem stroke - basilar artery occlusion

Malignant MCA syndrome, cerebral oedema leading to tentorial hernia Timon

Venous thombosis - ICH, oedema, seizures

Question 29

How do you assess the swallow

Answer 29

Bedside swallow test before eating and drinking

If coughing or wet voice after water, withhold oral intake
SALT input

Bedside tests - two step swallowing provocation test and repetitive saliva swallow test