Week 3-stroke

Question 1

What is a transient ischaemic attack?

Answer 1

A transient ischaemic attack is a stroke lasting less than 24 hours.
“Brief episode of neurological dysfunction caused by focal brain or retinal ischaemia with symptoms lasting typically less than 1 hour without evidence of acute infarction”

Question 2

Does a TIA need treatment?

Answer 2

Yes needs immediate treatment to prevent a full blown stroke.

Question 3

What investigations would be done by the rapid access neuromuscular clinicians after a suspected TIA?

Answer 3

History
Cardiac imaging
ECG
Blood tests.

Question 4

Which forms of drug reduce the risk of stroke?

Answer 4

Statins and antiplatelet drugs

Question 5

What is a TIA referred to before the 24 hours is up?

Answer 5

TIA is a retrospective diagnosis so until the 24 hour mark has passed it is known as an acute cerebrovascular syndrome.

Question 6

What causes cell death in hemorrhagic stroke?

Answer 6

Not only does hypoxia lead to cell death but the bleeding itself activates an inflammatory cascade leading to cellular damage and death.

Question 7

What common medical conditions can mimic stroke?

Answer 7

Seizures (can give unilateral weakness)
Presyncope (dizziness and lightheadedness don’t normally coincide with stroke. Vertigo can however be seen in posterior strokes)
Sepsis
Acute confusion (delirium)
Transient global amnesia (period where people can’t remember what happened).

Question 8

What does ROSIER score stand for?

Answer 8

Recognition of stroke in the emergency room.

Question 9

Positive points on the ROSIER score?

Answer 9

Asymmetrical face weakness, asymmetrical arm weakness, asymmetrical leg weakness, speech disturbance, visual field defect.

Question 10

Negative points on the ROSIER score

Answer 10

Loss of consciousness or syncope, seizures.

Question 11

When is the ROSIER score indicative of a stroke?

Answer 11

When the score is more than 0. If less than zero, unlikely.

Question 12

What sort of imaging will you initially do on presentation of a patient with suspected stroke?

Answer 12

CT scan initially. Very sensitive for blood acutely and readily accessible.

Question 13

What colour does blood show up on a CT scan?

Answer 13

White.

Question 14

When would you use an MRI over a CT scan in stroke patients?

Answer 14

CT scan loses sensitivity for blood after about 1 week. Then you should use MRI.

Question 15

What would an infarcted area look like on a CT scan?

Answer 15

Darker area.

Question 16

What symptoms would you expect with a total anterior circulation stroke?

Answer 16

Hemiplegia (paralysis of one side of the body) contralateral to the lesion usually with ipsilateral sensory loss.
Hemianopia contralateral to the lesion
New disturbance of higher cerebral dysfunction (e.g. dysphagia)

Question 17

What symptoms would you expect with a partial anterior circulation stroke?

Answer 17

any of:
Motor/sensory deficit with hemianopia
Motor/sensory deficit with new higher cerebral dysfunction
New higher cerebral dysfunction with hemianopia
New higher cerebral dysfunction alone
A pure motor/sensory deficit less extensive than would be seen in lacunar stroke.

Question 18

What symptoms would you expect with a posterior circulation stroke?

Answer 18

Any of- ipsilateral cranial nerve palsy with contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Disorder of conjugate eye movement
Cerebellar dysfunction without ipsilateral long tract sign
Isolated hemianopia or cortical blindness

Question 19

What is a lacunar infarct?

Answer 19

Infarcts in the small perforating vessels supplying the deep structures of the brain.

Question 20

Which imaging method is best for a posterior circulation stroke?

Answer 20

Generally MRI because CT doesn’t deal well with all the bony structures.

Question 21

What sorts of functions does the left side of the brain control?

Answer 21

In most people this is the dominant side. From here you get speech, number skills, written language and reasoning.

Question 22

What sorts of functions does the right side of the brain control?

Answer 22

Creativity, music, spatial orientation and artistic awareness.

Question 23

What is the most common cause of stroke?

Answer 23

Atheroemboli (50%)

cardioembolic are just 20%

Question 24

What is the most common cause of cardioembolic stroke?

What else can cause it?

Answer 24

Atrial fibrillation.

Ventricular thrombus, prosthetic valves, rheumatic fever

Question 25

Why can patent foramen ovale cause cardioembolic stroke?

Answer 25

There is a connection between the two atria meaning clots that form in the venous system can get into the arterial system. These can then travel up and cause a stroke.

Question 26

What are the primary causes of hemorrhagic stroke?

Answer 26

Hypertension

Amyloid angiopathy

Question 27

Where do hypertensive hemorrhagic strokes occur in contrast to amyloid antipathy hemorrhagic stroke?

Answer 27

Hypertensive tend to be deeper in the brain whereas amyloid ones are more on the peripheries.

Question 28

What is the aim of thrombolysis treatment?

Answer 28

To break up the clot.

Question 29

When should thrombolysis be done by?

Answer 29

4.5 hours after symptom onset.

Question 30

Benefit increases the quicker you thrombolyse a patient. True or false?

Answer 30

True- time=brain tissue. The quicker you are, the less brain tissue is deprived of oxygen and therefore the more brain tissue saved.

Question 31

What would you do to differentiate between hemorrhagic and infarct stroke?

Answer 31

CT head- to make sure you don’t thrombolyse a patient with a hemorrhagic stroke.

Question 32

In the acute setting, the CT scan of a infarct stroke will show?

Answer 32

Often it will be normal. This is good because the tissue hasn’t been too damaged and inflammation and oedema haven’t set in.

Question 33

After the initial management of a stroke patient, what other investigations would you like to have done?

Answer 33

Blood pressure
Cholesterol
Carotid scan (to look for a clot)
ECG- look for AF. Possibly 24 hour monitoring.

Question 34

What does the ABCD2 stand for?

Answer 34

A-ge- greater than 60 (1 pt)
B- Blood pressure > 140/90 (+1)
C- Clinical features- unilateral weakness (+2), speech disturbance w/out weakness (1)
D-duration of symptoms- ( <10 mins-0, 10-59 mins- 1, >60-2)
D-diabetes (1 pt)

Question 35

What medications would you prescribe once the patient has been confirmed to have a stroke?

Answer 35

Antiplatelet therapy. In the acute setting use aspirin.
Then afterwards 1st line is clopidogrel, 2nd line is aspirin.
Statins- lower cholesterol

Question 36

What two scores assess bleeding risk? What is the purpose of each of them?

Answer 36

CHA2DVASc score- assesses the risk of infarct within 1 year. If the person scores 0- don’t give anticoagulation. If greater than 0- give anticoagulation.
HASBLED score- works out the risk of bleeding when on anticoagulation.

Question 37

A total anterior circulation infarct usually affects which arteries in the brain?

Answer 37

Usually affects the MCA and ACA. This means you will have symptoms affecting both these areas- higher cortical dysfunction (dysphagia, dysphasia), hemianopia, contralateral motor and/or sensory deficit (hemiplegia)

Question 38

A partial anterior circulation infarct usually affects which arteries in the brain?

Answer 38

Usually a branch of the MCA or ACA.

Results in two out of the three TACI symptoms. Higher cortical dysfunction, hemianopia, hemiplegia.

Question 39

A lacunar infarct usually affects which arteries in the brain?

Answer 39

Usually affects the deep penetrating vessels that supply the deep cerebral white matter, basal ganglia or pons. Results in symptoms- any one of the following

• pure motor or pure sensory
• sensorimotor ataxic
• hemiparesis, clumsy
• hand dysarthria
• higher cortical dysfunction

Question 40

A posterior circulation infarct affects which arteries in the brain?

Answer 40

The ones supplying the brainstem, occipital lobes and cerebellum. (PCA supplies occipital lobe)
Results in symptoms of brainstem signs, ataxia, isolated homonymous hemianopia.