Week 1 Stroke and TIAs

Question 1

What are the common presentation types? (onsets and patterns)

Answer 1

Sudden vs gradual onset.
Unilateral vs bilateral limb involvement
Facial weakness could be isolated as seen in Bell’s palsy or generalised as seen in stroke and Guillain- Barre syndrome.

Question 2

Give examples of sudden vs more gradual onset of neurological symptoms

Answer 2

Sudden- stroke/vascular
Gradual: Neurodegenerative, metabolic, inflammatory

Question 3

What is the most important investigation when it comes to differentiating between limb and facial weakness types?

Answer 3

CT-rule out haemorrhages

Question 4

List out some investigations one can do for differentiation between facial and limb weaknesses

Answer 4

MRI, Angiograms, bloods (including glucose to rule out hypo) , BP, sets of obs, doppler US, Electrocardiogram to see arrhythmias, and echocardiogram to see structural abnormalities

Question 5

What is the main difference between electrocardiogram and echocardiogram?

Answer 5

Although they both monitor the heart, EKGs and echocardiograms are two different tests. An EKG looks for abnormalities in the heart’s electrical impulses using electrodes. An echocardiogram looks for irregularities in the heart’s structure using an ultrasound.

Question 6

What is the rapid assessment tool for identifying stroke?

Answer 6

FAST- facial weakness, arm/leg weakness, speech disturbances. Time is very important to scale onset and duration of episode!

Question 7

What supportive care is there for stroke patients?

Answer 7

Physiotherapy, SLT, OT, respiratory therapy/monitoring

Question 8

List common ddx for facial and limb weaknesses

Answer 8

Ischaemic stroke, haemorrhages, neuromuscular disorders, endocrine disorders, hypo episodes, multiple sclerosis, bell’s palsy

Question 9

What is Bell’s Palsy?

Answer 9

Bell’s palsy is an idiopathic syndrome characterized by unilateral, lower motor neuron facial weakness, without sparing the extraocular muscles and muscles of mastication.
It presents with mild-moderate postauricular otalgia, hyperacusis (rare), and nervus intermedius symptoms such as altered taste and dry eyes/mouth.
The mainstay of management is corticosteroids. The prognosis of Bell’s palsy is generally favourable, with the majority of patients experiencing spontaneous recovery within weeks to months.

Question 10

What is Multiple Sclerosis?

Answer 10

Multiple Sclerosis (MS) is a chronic, inflammatory, autoimmune disease of the central nervous system, characterised by the demyelination and axonal loss of neurons. Key symptoms include sensory disease, optic neuritis, internuclear ophthalmoplegia, cerebellar ataxia, and spastic paraparesis. Diagnosis largely involves the use of clinical history, MRI findings, and CSF analysis, aligning with the McDonald criteria. Management of MS involves both acute and chronic strategies, with glucocorticoids commonly used for acute attacks, and a combination of disease-modifying therapies (DMTs) and symptomatic treatments used in the long-term.

Question 11

What is Guillain-Barre syndrome?

Answer 11

Guillain-Barré Syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy characterised by a rapid, progressive, ascending symmetrical weakness, often preceded by infection. Diagnosis is largely clinical but supported by specific investigations such as lumbar puncture and nerve conduction studies. Treatment is mainly supportive, with options for disease-modifying treatments like intravenous immunoglobulins (IVIG) or plasmapheresis in severe cases.

Question 12

Which proportion of strokes is higher( ischaemic vs haemorrhagic)?

Answer 12

85% ischaemic vs 15% haemorrhagic

Question 13

How many strokes on average in the UK?

Answer 13

100,000

Question 14

A 70-year-old woman with a history of hypertension and diabetes suddenly develops weakness in her left arm and slurred speech while cooking. Her family rushes her to the emergency room within 1 hour of symptom onset.

What is the most likely type of stroke she’s experiencing?
What immediate treatment should she receive?

Answer 14

Urgent CT imaging is required to rule out a haemorrhagic stroke, but it is an Ischemic stroke.

If imaging confirms ischemia, she may be a candidate for thrombolysis (e.g., with alteplase within 4.5 hours of the symptom onset) and then aspirin 300mg daily for two weeks.

Question 15

A 68-year-old man presents with sudden weakness in his right arm and leg, but his speech and facial muscles are unaffected. A CT scan shows a small infarct in the internal capsule.

What type of stroke has he likely suffered, and what is his long-term prognosis?

Answer 15

This presentation is consistent with a lacunar infarct, a type of ischemic stroke affecting the small perforating arteries, they can cause pure motor deficits like hemiparesis.
The prognosis is generally better than large artery strokes, with a lower risk of mortality but a higher risk of recurrent strokes.

Question 16

A 60-year-old woman presents with a haemorrhagic stroke.
What is the management and prognosis for haemorrhagic stroke compared to ischemic stroke?

Answer 16

The prognosis for haemorrhagic stroke is generally worse than for ischaemic stroke, with higher mortality and risk of disability.
The management for haemorrhagic strokes is dependent on the patient and their stroke, most patients however are not suitable for surgical intervention, but any anticoagulants (e.g. warfarin) and antithrombotic medications (e.g. clopidogrel) should be stopped to minimise further bleeding

Question 17

What can reverse warfarin?

Answer 17

Vitamin K and prothrombin complex

Question 18

What are the main differences between TIA and stroke?

Answer 18

TIA neurological deficits typically resolve within 24 hours whereas stroke does not. This is because blockage resolves in TIA before significant damage to the brain occurs and without infarction. Clinical features resolve typically within 1 hour.

Question 19

Which of the following is not standard treatment after TIA?
* Carotid endarterectomy
* Thrombolysis with e.g. Alteplase
* Antihypertensives e.g. ACE inhibitors, e.g. Ramipril
* Low-dose Aspirin
* Warfarin
* Statins e.g. atorvastatin

Answer 19

Thrombolysis. Indicated within 4.5 hours of symptoms for acute ischaemic stroke where imaging has ruled out haemorrhage.

Question 20

Why are antiplatelets like clopidogrel used for MGx of TIAs?

Answer 20

To reduce risk of future strokes and TIAs by reducing clotting ability, especially because patients are at high risk of having a stroke after TIA (TIA is seen like a forewarning for stroke)

Question 21

How does the pathophysiology of TIA differ from stroke? Describe it.

Answer 21

Reduced blood flow to neurons cause reduced ATP production due to less aerobic respiration which means ion pumps, e.g. Na+/K+ pumps are left without ATP.
This causes ionic imbalances with increased intracellular calcium concentration, which activates proteases and lipases, damaging structures.
Autoregulation tries to compensate for hypoperfusion by dilating other vessels.
Transient neurological symptoms may appear without permanently affecting brain tissue, due to delay between hypoperfusion and autoregulatory mechanisms. If brain tissue dies in this time, then stroke instead.

Question 22

Which of the following imaging techniques is not performed without indication for alternative diagnosis?
* MRI
* Carotid ultrasound
* CT head

Answer 22

CT head. Although used in stroke situations, not used for transient ischaemic attacks unless an alternative diagnosis that CT head may find is suspected. Remember CT head first in suspected stroke patients but not i suspected TIA pts

Question 23

Which of the following is the most common underlying cause of TIA?
* Atherosclerosis
* Arterial dissection
* Drug misuse

Answer 23

Atherosclerosis

Question 24

Which of the following is not a typical clinical feature of TIA?
* Homonymous hemianopia
* Dysarthria
* Aphasia
* Sudden severe headache
* Palpitations
* Increased salivation
* Haemoptysis

Answer 24

Haemoptysis

Question 25

What is Haemoptysis?

Answer 25

Haemoptysis (coughing up blood or bloody sputum) has a wide range of causes. Many cases will be mild and self-resolving e.g. in the case of acute infection, but it should be considered a red flag symptom and investigations undertaken to rule out any serious underlying cause. Causes can be classified by where anatomically the bleeding is coming from e.g. the trachea or bronchi, the lung parenchyma or the lung vasculature. Important causes to consider include pulmonary emboli, tuberculosis, lung cancer and vasculitis. Massive haemoptysis is a medical emergency, the management of which differs depending on whether the patient is for resuscitation or for palliation.

Question 26

What is the incidence of first ever TIA?
* 50 per 100 000 people per year
* 20 per 100 000 people per year
* 1 per 100 000 people per year
* 500 per 100 000 people per year

Answer 26

50 per 100,000

Question 27

Which of the following is not a modifiable risk factor for TIA?
* Smoking
* Atrial fibrillation
* Sedentary lifestyle
* Ethnicity

Answer 27

Ethnicity

Question 28

10) Which of the following is a TIA mimic that should be excluded?
* Hypoglycaemia
* Macular degeneration

Answer 28

Hypoglycaemia

Question 29

What is the first-line imaging modality for investigating suspected stroke and why is it preferred?

Answer 29

Non Contrast CT is usually the first-line imaging modality for evaluating suspected stroke because it is quick and widely available

Question 30

How do NCCT images differ between ischaemic and haemorrhagic stroke pts?

Answer 30

• Findings in Stroke: In ischemic stroke, NCCT may show early signs of ischemia, such as loss of gray-white differentiation, sulcal effacement, and hypodensity in the affected area (but these signs may take hours to develop).

In hemorrhagic stroke, NCCT can quickly identify acute blood in the brain as hyperdense (bright) areas.

Question 31

What are some early signs of ischaemia that may be visible on an NCCT scan? (first few hours)

Answer 31

Within the first few hours, a number of signs are visible depending on the site of occlusion and the presence of collateral flow. Early features include:

a)loss of grey-white matter differentiation, and hypoattenuation of deep nuclei:

b)lentiform nucleus changes are seen as early as 1 hour after occlusion, visible in 75% of patients at 3 hours 6

c)cortical hypodensity with associated parenchymal swelling with resultant gyral effacement

d) cortex which has poor collateral supply (e.g. insular ribbon) is more vulnerable

Question 32

What are the goals of CT in acute settings?

Answer 32

The goals of CT in the acute setting are:

exclude intracranial haemorrhage, which would preclude thrombolysis

look for any “early” features of ischaemia

exclude other intracranial pathologies that may mimic a stroke, such as a tumour

Question 33

What is the earliest possible CT sign in ischaemic stroke films?

Answer 33

The earliest CT sign visible is the hyperdense vessel sign, representing direct visualisation of the intravascular thrombus/embolus and as such is visible immediately.

Although this can be seen in any vessel, it is most often observed in the middle cerebral artery (see hyperdense middle cerebral artery sign and middle cerebral artery dot sign) .

It may be of therapeutic and prognostic value to differentiate this hyperdense ‘regular’ thromboembolic focus from a calcified cerebral embolus. In very rare instances of fat macroembolism, a hypodense vessel sign may be seen instead

Question 34

Usually, how long for CT imaging to detect ischaemic stroke?

Answer 34

Depending on just which area of the brain is involved, they begin to be seen on CT scans after about 12-18 hours.

This means that very early ischemic strokes are not detected on CT scans. As ischemic damage continues to evolve, however, the additional changes make these areas visible on CT scans

Question 35

What DDx can NCCT rule out for ischaemic stroke?

Answer 35

NCCT can also rule out other causes of neurological symptoms like brain tumors (which may appear as mass lesions), trauma, and infections (e.g., abscesses).

Question 36

What is the role of CT Angiography (CTA) in stroke evaluation?

Answer 36

• Purpose: CTA is used to assess the blood vessels in the brain and neck. It is typically performed after NCCT.
• Findings in Stroke: CTA can detect large vessel occlusions (such as in the middle cerebral artery or basilar artery), stenosis, or dissections that may be causing ischemic stroke.
• Differential Diagnosis: It helps differentiate stroke from conditions like arterial dissection or vasculitis. It can also assess for aneurysms or arteriovenous malformations (AVMs) in hemorrhagic stroke cases.

Question 37

What is CT perfusion (CTP) used for in the context of stroke, and how does it assist in treatment decisions?

Answer 37

CTP is used to assess cerebral blood flow, cerebral blood volume, and mean transit time to evaluate the extent of ischemic tissue and the penumbra (tissue that is at risk but salvageable with treatment).
* Findings in Stroke: It helps distinguish between the infarct core (irreversibly damaged tissue) and the ischemic penumbra, which may guide treatment decisions (e.g., thrombolysis or thrombectomy).
* Differential Diagnosis: CTP can help differentiate ischemic stroke from other causes of acute neurologic symptoms by showing perfusion abnormalities, such as in seizures or migraines.

Question 38

9. What are the benefits of using MRI (specifically diffusion-weighted imaging) in the diagnosis of stroke compared to CT?

Answer 38

• Purpose: MRI, particularly diffusion-weighted imaging (DWI), is highly sensitive for detecting acute ischemic stroke within minutes of onset.

Question 39

What types of neurological conditions other than stroke can be diagnosed using MRI?

Answer 39

• Findings in Stroke:
  o Diffusion-Weighted Imaging (DWI): Shows hyperintensity (bright signal) in areas of acute ischemia.
  o T2/FLAIR Sequences: Used to identify chronic ischemic changes and differentiate between old and new infarcts.
• Differential Diagnosis: MRI is excellent for detecting demyelinating diseases (e.g., multiple sclerosis), brain tumors, infections (such as abscesses or encephalitis), and other causes of neurological deficits. It is also used to evaluate conditions like posterior reversible encephalopathy syndrome (PRES) and cerebral venous sinus thrombosis (CVST).

Question 40

What is Magnetic Resonance Angiography (MRA) used for in context of stroke and how does it differentiate between DDx and stroke?

Answer 40

Magnetic Resonance Angiography (MRA)
* Purpose: MRA is used to visualize blood vessels in the brain and neck, similar to CTA but without the need for contrast in some sequences.
* Findings in Stroke: It detects large vessel occlusions, stenosis, and vascular malformations, and can assess flow in the carotid arteries and the Circle of Willis.
* Differential Diagnosis: MRA is useful in identifying vascular pathologies such as aneurysms, arterial dissections, and vasculitis.

Question 41

What is the role of carotid Doppler ultrasound in the investigation of stroke?

Answer 41

• Purpose: Carotid Doppler is a non-invasive ultrasound technique used to assess blood flow and detect stenosis or plaque in the carotid arteries, which may lead to ischemic strokes.
• Findings in Stroke:
  o Identifies carotid artery stenosis, a common cause of thromboembolic stroke, by measuring the flow velocity and detecting turbulent flow in narrowed vessels.
• Differential Diagnosis: Carotid Doppler helps differentiate ischemic stroke caused by emboli from carotid artery disease versus other causes of ischemia (e.g., cardiac embolism or small vessel disease).

Question 42

How does carotid Doppler detect carotid artery stenosis, and why is this significant for stroke patients?

Answer 42

Carotid Doppler is a non-invasive ultrasound technique used to assess blood flow and detect stenosis or plaque in the carotid arteries, which may lead to ischemic strokes.

Carotid Doppler helps differentiate ischemic stroke caused by emboli from carotid artery disease versus other causes of ischemia (e.g., cardiac embolism or small vessel disease).

Question 43

Outline the use of transcranial doppler US in identifying and treating stroke.

Answer 43

• Purpose: TCD is a non-invasive ultrasound used to assess blood flow within the brain’s major arteries (e.g., middle cerebral artery, basilar artery).
• Findings in Stroke: It detects reduced blood flow velocity in cases of arterial stenosis or occlusion.
• Differential Diagnosis: TCD can assess for emboli in real-time, vasospasm in conditions like subarachnoid hemorrhage, or hyperemia after reperfusion therapy.

Question 44

Summarise the DDx found through the imaging forms commonly used to identify and treat stroke.

Answer 44

Summary of Differential Diagnosis Using Imaging:
* Stroke (Ischemic or Hemorrhagic): Non-contrast CT, CTA, MRI (DWI), MRA, CTP, DSA.
* TIA: Carotid Doppler, MRI (DWI may be negative or show small infarcts), MRA.
* Mimics (Seizures, Migraines, Tumors): MRI, EEG, CT.
* Cardioembolic Sources: Echocardiography, MRA/CTA for aortic arch evaluation.
* Vascular Pathologies (Dissection, Vasculitis, Aneurysm): CTA, MRA, DSA, TCD.

Question 45

What is the general presentation of a vascular or stroke suspect patient?

Answer 45

A sudden onset of neurological symptoms suggests a vascular cause (e.g., stroke). Stroke
symptoms are typically asymmetrical. Common symptoms are:
* Limb weakness
* Facial weakness
* Dysphasia (speech disturbance)
* Visual field defects
* Sensory loss
* Ataxia and vertigo (posterior circulation infarction)

Question 46

What is a migraine and how does it mimic and also differ from stroke?

Answer 46

Migraine
* Definition: Severe, recurrent headache often accompanied by nausea, vomiting, and
sensitivity to light/sound.
* Stroke-like symptoms: Visual disturbances (aura), sensory changes, speech difficulty.
* Non-stroke symptoms: Gradual onset, throbbing pain, relief after sleep, recurrent in
pattern.

Question 47

What is a tumour and how does it mimic and also differ from stroke?

Answer 47

Tumour
* Definition: Abnormal growth of tissue in the brain that can cause neurological deficits by
compressing brain structures.
* Stroke-like symptoms: Weakness, vision changes, speech difficulties, headaches.
* Non-stroke symptoms: Progressive, gradual onset, worsening over time, personality
changes

Question 48

What is an abscess and how does it mimic and also differ from stroke?

Answer 48

Abscess
* Definition: Collection of pus in the brain due to infection, causing inflammation and
pressure on brain tissue.
* Stroke-like symptoms: Focal neurological deficits (e.g., weakness, speech problems),
seizures, headache.
* Non-stroke symptoms: Fever, progressive course, altered consciousness due to infection

Question 49

What is a subarachnoid haemorrhage and how does it mimic but also differ from a stroke?

Answer 49

Subarachnoid Haemorrhage (SAH)
* Definition: Bleeding into the space surrounding the brain, often due to a ruptured
aneurysm.
* Stroke-like symptoms: Sudden severe headache (“thunderclap”), vomiting, confusion,
vision changes.
* Non-stroke symptoms: Neck stiffness (from meningism), photophobia, loss of
consciousness.

Question 50

What is a subdural haematoma and how does it mimic but also differ from a stroke?

Answer 50

Subdural Hematoma
* Definition: Collection of blood between the brain’s surface and its outer covering (dura),
typically after trauma.
* Stroke-like symptoms: Weakness, confusion, speech difficulties, vision problems.
* Non-stroke symptoms: Gradual onset, headache, history of head trauma, drowsiness.

Question 51

What is epilepsy and how does it mimic but also differ from a stroke?

Answer 51

Epilepsy
* Definition: A neurological condition causing recurrent seizures.
* Stroke-like symptoms: Sudden onset of neurological changes during seizures, confusion
post-seizure.
* Non-stroke symptoms: Convulsions, aura before seizures, repeated pattern.

Question 52

What is Todd’s Palsy and how does it mimic but also differ from a stroke?

Answer 52

Todd’s Palsy
* Definition: Temporary weakness or paralysis following a seizure.
* Stroke-like symptoms: Focal weakness (often one-sided), speech difficulties, sensory
loss.
* Non-stroke symptoms: Occurs after a seizure, transient and typically resolves within 24-
48 hours.

Question 53

What is Multiple Sclerosis and how does it mimic but also differ from a stroke?

Answer 53

Multiple Sclerosis (MS)
* Definition: An autoimmune disorder causing demyelination in the central nervous system,
leading to neurological deficits.
* Stroke-like symptoms: Weakness, vision problems, speech difficulties, sensory loss.
* Non-stroke symptoms: Symptoms come and go (relapsing-remitting course), fatigue,
gradual onset.

Question 54

What is Myasthenia Gravis and how does it mimic stroke but also differ from it?

Answer 54

Myasthenia Gravis
* Definition: An autoimmune disorder causing muscle weakness due to dysfunction at the
neuromuscular junction.
* Stroke-like symptoms: Speech difficulties, swallowing problems, weakness.
* Non-stroke symptoms: Fluctuating muscle weakness (worsens with activity, improves
with rest), eyelid drooping (ptosis).

Question 55

What is Bell’s Palsy and how does it mimic but also differ from a stroke?

Answer 55

Bell’s Palsy
* Definition: Sudden, temporary facial paralysis or weakness due to facial nerve
inflammation.
* Stroke-like symptoms: Facial weakness (often mistaken for stroke).
* Non-stroke symptoms: Only affects the face (usually one side), inability to close eye, often
resolves spontaneously.

Question 56

What is functional neurological disorder and how does it mimic but also differ from stroke?

Answer 56

Functional Neurological Disorder
* Definition: Neurological symptoms that appear due to abnormal brain function, without
structural damage.
* Stroke-like symptoms: Weakness, speech issues, sensory loss, tremors.
* Non-stroke symptoms: Symptoms may fluctuate, often triggered by psychological stress,
inconsistent examination findings.

Question 57

What is hypoglycaemia and how does it mimic but also differ from stroke?

Answer 57

Hypoglycemia
* Definition: Low blood sugar levels causing neurological deficits.
* Stroke-like symptoms: Confusion, weakness, speech difficulties, vision changes.
* Non-stroke symptoms: Sweating, shaking, palpitations, rapid onset after missed meals or
insulin use, resolves with glucose.

Question 58

What is Hypothermia and how does it mimic but also differ from stroke?

Answer 58

Hypothermia
* Definition: Dangerously low body temperature that can affect brain function.
* Stroke-like symptoms: Confusion, slurred speech, clumsiness.
* Non-stroke symptoms: Shivering, cold skin, exposure to cold environment, slow onset of
symptoms.

Question 59

What is sepsis and how does it mimic but also differ from stroke?

Answer 59

Sepsis
* Definition: Life-threatening organ dysfunction caused by a severe infection.
* Stroke-like symptoms: Confusion, weakness, speech difficulty.
* Non-stroke symptoms: Fever, rapid breathing, rapid heart rate, known infection, altered
consciousness.

Question 60

How do patients with a Hx of stroke but also develop new symptoms present?

Answer 60

. Old Strokes with New Illness
* Definition: Patients with a history of stroke who develop new symptoms due to other
medical issues.
* Stroke-like symptoms: Weakness, speech difficulties, confusion (due to prior stroke
deficits).
* Non-stroke symptoms: New symptoms due to infection, dehydration, or other illness,
fluctuation of symptoms.

Question 61

What is dementia and how does it mimic but also differ from stroke presentation?

Answer 61

Dementia
* Definition: Chronic or progressive deterioration of cognitive function, affecting memory,
thinking, and behavior.
* Stroke-like symptoms: Confusion, memory problems, language difficulties.
* Non-stroke symptoms: Gradual decline over months to years, preserved motor function
until late stages.

Question 62

What happens in the brain when a person has a stroke?

Answer 62

Brain cells die

Question 63

What are the clinical classifications of stroke?

Answer 63

Total Anterior Circulation Stroke (TACS), Partial Anterior Circulation Stroke (PACS), Lacunar Stroke (LACS), Posterior Circulation Stroke (POCS), Intracerebral haemorrhage (ICH) and subarachnoid haemorrhage.

Question 64

What are the likely symptoms of an anterior circulation stroke?

Answer 64

Contralateral symptoms including hemiparesis of limbs, facial weakness, sensory loss, dysphasia, dysarthria and homonymous hemianopia.

Question 65

What is the clinical significance of the C.O.W in the presentation of stroke pts?

Answer 65

If there is blood vessel damage or blockage in one area, collateral blood flow can be provided and help protect against ischaemia.

Question 66

Why do anterior circulation strokes present the way they do?

Answer 66

Anterior circulation strokes affect areas of the brain supplied by the middle or anterior cerebral arteries. These arteries supply the parts of the brain that control motor, sensory, speech, vision etc. Hence when these parts of brain tissue die, they present with symptoms like those above.

Question 67

What functions does the frontal lobe carry out?

Answer 67

Motor functions (voluntary movement), personality, emotions and plays a role in speech and sense of smell.

Question 68

What are the functions of the parietal lobe?

Answer 68

Sensory functions (processes input from senses) and spatial awareness

Question 69

What are the functions of the occipital lobe?

Answer 69

Vision including distance, depth, colour, recognition and memory formation.

Question 70

What are the functions of the temporal lobe?

Answer 70

Hearing, memory and understanding language

Question 71

How do clinical features of stroke link to functions of lobes of the brain?

Answer 71

Symptoms of stroke vary depending on which lobes are affected.

Question 72

How is hypertension linked to stroke?

Answer 72

Hypertension can cause cerebral artery remodelling. This makes the lumen of the arteries smaller and artery walls thicker. Leading to increased risk of stroke.
Hypertension causes atherosclerosis which increases risk of blood clot formation, which can lead to stroke.
High blood pressure increases risk of bleeding in the brain (haemorrhagic stroke).

Question 73

A 23-year-old man comes into A&E from a car accident, with a brief loss of consciousness but improved temporarily, but is deteriorating again. He has a headache, his pupil is dilated, his breathing has become deep and irregular, and he is confused

1) What is the term given to the set of symptoms he is facing, given the nature of his likely diagnosis?

2) What type of haemorrhage is this likely to be?

3) What artery is likely to be damaged?

Answer 73

1) A Lucid Interval

2) This man has had a head trauma, and the loss of consciousness, improvement and then deterioration is called the lucid interval which is characteristic of extradural haemorrhages. He also has signs of brainstem compression which is caused by pressure on the brain from the blood leading to herniation.

3) The middle meningeal artery is the most likely to be damaged by serious head trauma, especially at the Pterion which is the spot where the frontal, parietal, temporal and sphenoid bones join together.

Question 74

A 65-year-old woman with history of type 2 diabetes comes into A&E with sudden onset numbness and unilateral weakness in her right leg. When questioned, she described a sudden loss of vision in right eye and felt as though a ‘curtain came down’. These symptoms lasted for about 2 hours.

4) Which artery has been affected?

5) What is the phenomenon called where the “curtain came down over her eyes”?

6) What is she likely to have suffered?

Answer 74

4) 90% of TIAs occur in the anterior cerebral circulation, and this woman had leg weakness, and a temporary reduction in the retinal ophthalmic / ciliary blood flow (amaurosis fugax) – this all points to the ACA territory. Stroke symptoms would last for more than 24hrs, so this is not a stroke

5) Amaurosis fugax/transient monocular blindness

6) A TIA as symptoms and neurological deficit subsides and goes away in under 24hrs.

Question 75

A 60-year-old male patient comes into A&E with acute onset unilateral facial drooping. He takes amlodipine for hypertension and has recently had a viral infection.

7) Within 24 hours, the facial drooping has resolved, and the patient has no other symptoms. What is your diagnosis?

Answer 75

6) A TIA as symptoms and neurological deficit subsides and goes away in under 24hrs.

Question 76

8) What are the features of a TIA in the carotid artery or C.O.W territory?
9) What are the features of a TIA in the vertebra basilar region?

Answer 76

Question 77

What are the clinical features seen in anterior cerebral artery occlusion/infarct in stroke?

Answer 77

10) Remember that clinical presentation depends on size and the location of the infarct. Broadly speaking, anterior cerebral artery presents with:

Leg weakness (more likely than arm weakness) with or without sensory loss in the legs
Gait apraxia and/or truncal ataxia
Incontinence
Drowsiness (frontal lobe affected)
lower extremity > upper

Question 78

11) What are the clinical features of a middle cerebral artery stroke?

Answer 78

11) MCA/middle cerebral artery stroke – Most common stroke presentation.

CONTRALATERAL
Weakness (and/or sensory deficit) of the face, arm and leg
Homonymous hemianopia (visual field loss in the same halves of each eye)
Higher cerebral dysfunction – Dysphasia, Aphasia, Visuospatial deficit
Upper extremity>lower

Question 79

12) What are the clinical features seen in a posterior cerebral artery stroke?

Answer 79

12) Posterior cerebral artery syndrome is a condition whereby the blood supply from the posterior cerebral artery (PCA) is restricted, leading to a reduction of the function of the portions of the brain supplied by that vessel: the occipital lobe, the inferomedial temporal lobe, a large portion of the thalamus, and the upper brainstem and midbrain.

You would experience all of some of the following because of occipital lobe dysfunction.

• Isolated homonymous hemianopia or cortical blindness
• Prop agnosia – Inability to recognize faces
• Visual agnosia – Cannot interpret visual info

Question 80

13) What are the clinical features of a brainstem infarct?

Answer 80

13) Brainstem infarcts – Vertebrobasilar artery:
Quadriplegia/ quadriparesis
Dysarthria & speech impairment
Vertigo, nausea, vomiting
Drowsiness
Locked in syndrome

Question 81

14) What are the clinical features of an extradural haemorrhage?
15) What are the clinical features of a subdural haemorrhage?

Answer 81

14) Typical background:
Head injury
Brief LOC (loss of consciousness or drowsiness)
Lucid interval – haematoma is still small, can last hours to a few days
Followed by rapid decline, severe headache, vomiting, confusion, seizures, raised ICP

15) Fluctuating consciousness
Drowsiness
Headache
Confusion
Behavioral change
Signs of ICP – vomiting, nausea, seizure, raised BP
Coma – many present with this

Essentially, if you get a question regarding extradural haemorrhages try and see if there is any mention of trauma or accident as extradural is more than likely the result of collision and then bleed whereas subdural have a more physiological pathophysiology ( blood clot mobilizing and blood pooling from bridging veins into subdural space)

Question 82

16) What is the scale used to predict if a patient has had a stroke in the emergency department, as recommended by the Royal College of Physicians?

Answer 82

16) The FAST screening tool (Face/Arms/Speech/Time) is widely known by the general public following a publicity campaign. It has a positive predictive value of 78%. In the emergency department, doctors use the ROSIER scale.

Question 83

17) Which of the following best describes the effect of an ischaemic stroke in the anterior, middle and posterior cerebral arteries?

a) a) ACA: impaired judgment, upper limbs affected, paraesthesia MCA: hemiparesis of lower ipsilateral face, peripheral vision loss, PCA: dysphagia, ataxia, nystagmus.
b) b) ACA: contralateral lower limb weakness MCA: hemiparesis of lower contralateral face, speech impairment, contralateral weakness, PCA: acute vision loss, memory loss
c) c) ACA: confusion, limb weakness, hemiparesis, MCA: impaired judgment, nausea, language dysfunction, PCA: Gait apraxia, bitemporal hemianopia, deafness
d) d) ACA: hemiparesis of lower contralateral face, speech impairment, contralateral weakness, MCA: acute vision loss, confusion, memory loss, PCA: contralateral lower limb weakness, urinary incontinence

Answer 83

17) B:
The ACA supplies the medial portions of the frontal lobes and superior medial parietal lobes, which are involved in lower limb supply and - therefore occlusion to this artery will cause contralateral lower limb weakness.

The MCA supplies areas of the frontal, temporal and parietal lobes including the areas responsible for facial, throat, and hand/arm innervation (both sensory and motor), hence occlusion causes speech impairment, contralateral weakness and hemiparesis of the lower contralateral face (this is forehead sparing due to the bilateral innervation of the frontalis muscle, indicating the UMN lesion caused by stroke).
Just remember that usually in strokes it is the lower half affected! If upper half some sort of cranial pathology likely!

The PCA supplies the occipital lobe, which is involved in visual processing, hence PCA stroke can present with acute vision loss. Memory impairment occurs due to hippocampal infarction (as the hippocampus is supplied by the PCA).