Weakness

Question 1

What are key aspects in a stroke history?

Answer 1

• Exact onset (may effect thrombolysis)
• Progression of symptoms
• Risk factors

Question 2

What is the Initial management of a stroke?

Answer 2

• CT within one hour
• Thrombolysis if haemorrhagic stroke excluded and within 4.5 hours of onset if no contraindications
• If cannot thrombolyse then start aspirin 300mg for 2 weeks or clopidogrel 300mg PO STAT then 75mg OD

Question 3

What are the further managements of stroke once they are on the ward?

Answer 3

• Speech and language assessment
• Nutritional optimisation
• Early mobilisation
• Treat infections and protect pressure areas
• Long terms drugs
• MDT rehab
• Consider carotid endarterectomy

Question 4

What is the management of a suspected TIA?

Answer 4

Aspirin 300mg PO for 2 weeks or Clopidogrel 300mg PO STAT then 75mg OD
If AF then start anticoagulation
Specialist review within 24 hours
If carotid stenosis then >50% then carotid endarterectomy
Long term drugs

Question 5

What long term drugs should patients be on following a stroke?

Answer 5

Antihypertensives
Clopidogrel 75mg OD or anticoagulation if AF
Statins - but wait 48 hours after stroke

Question 6

What is the driving advice that should be given to patients following a stroke?

Answer 6

Should not drive for 4 weeks, need to tell DVLA if still having symptoms after 4 weeks

Question 7

What is a pyramidal distribution of weakness and what does this suggest?

Answer 7

Pyramidal weakness is the extensors in the upper limbs and the flexors in the lower limbs

Question 8

What are the differentials for a unilateral UMN weakness (pyramidal weakness)?

Answer 8

Work down from the brain to the cord:

• Intracranial - Stroke or SOL - hemisensory loss
• Brainstem - Stroke or SOL - may be crossed signs
• Spinal cord - MS, Infarct/haemorrhage, SOL, disc prolapse, trauma

Question 9

What are the differentials for a bitlateral UMN (pyramidal weakness)?

Answer 9

3 M’s
MS
Motor neurone disease - normal sensation
Myelopathy - cord compression (due to cervical myelopathy, SOL, disc prolapse, paraspinal infection), truma, transverse myelitis

Question 10

What are the causes of unilateral LMN weakness?

Answer 10

Work from nerve root to peripheral nerve:
-Radiculopathy - Disc prolapse, OA with osteophytes
-Plexopathy - Brachial - trauma e.g. dislocated shoulder, congenital (erb’s palsy), thoracic outlep syndrome, neoplastic inflitration/compression
-Peripheral nerve palsy - Median - carpal tunnel, distal radius fracture, penetrating forearm injury
Ulnar - compression at the elbow/ cubital tunnel syndrome, fractures
Radial - Trauma/compression at axilla (crutches, stabbing), humeral shaft fracture, elbow dislocation
Axillary - Shoulder dislocation, surgical neck of femur fracture
Common peroneal - plaster cast compression/trauma

Question 11

What are the causes of bilateral LMN weakness and abnormal sensation?

Answer 11

ABCDE

• Alcohol
• B12 deficiency
• Charcot Marie Tooth, Carcinomas
• Diabetes, drugs (TB drugs, cisplatin, amiodarone)
• Every Vasculitis (SLE, RA, Polyarteritis nodosa) and some infections e.g. herpes, syphilis

Question 12

What are the causes of bilateral LMN weakness with normal sensation?

Answer 12

Chronic inflammatory demyelinating polyneuopathy
Myotonic dystrophy
Progressive muscular atrophy

Question 13

What conditions cause an acute flacid paralysis bilaterally?

Answer 13

Guillain-Barre syndrome
Cauda equina syndrome
Transverse myelitis

Question 14

What conditions cause proximal weakness?

Answer 14

DENIM

• Dystrophies - DMD
• Endocrinological - Cushing’s syndrome, hyper/hypothyroid
• Neuromuscular - myasthenia gravis (fatigable), Lambert-Eaton myasthenic syndrome
• Inflammatory - dermato/polymyositis
• Metabolic/congenital/mitochondrial myopathies

Question 15

What are the elements of the oxford stroke classification?

Answer 15

Unilateral hemiparesis
Homonymous hemianopia
Higher cognitive dysfunction e.g. dysphasia

Question 16

What vessels are involved and what symptoms would present with a total anterior circulation infarct?

Answer 16

Involves the middle and anterior cerebral arteries
Will present with all 3:
-Unilateral hemiparesis
-Homonymous hemianopia
-Higher cognitive dysfunction e.g. dysphasia

Question 17

What vessels are involved and what symptoms would present with a partial anterior circulation infarct?

Answer 17

Involves smaller arteries of the anterior circulation e.g. upper and lower divisions of the middle cerebral artery divisions
Presents with 2 of:
-Unilateral hemiparesis
-Homonymous hemianopia
-Higher cognitive dysfunction e.g. dysphasia

Question 18

What vessels are involved and what symptoms would a lacunar stroke cause?

Answer 18

involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis

Question 19

What vessels are involved and how do posterior circulation infarcts present?

Answer 19

involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia