Week 4 - H - Stroke - Grand Rounds lecture - OXford Classification, acute management

Question 1

Stroke is the experience of persisting (greater than 24 hours) neurological complications of cardiovascular disease What is the mnemonic to remember the signs of a stroke? If the stroke is to have caused a left hemiparesis, where would the stroke have occured? What is the difference between hemiparesis and hemiplegia?

Answer 1

FAST * Face * Arms * Speech * Time to call 999 If stroke causes a left hemiparesis, the stroke would have occurred in the right side of the brain Hemiparesis - partial paralysis Hemiplegia - total paralysis

Question 2

In people who are right handed, which hemisphere is the speech and language centre located?

Answer 2

In people who are right handed, the speech and language centre is located i the left hemisphere of the brain - therefore a left hemisphere infarct will affect these centres

Question 3

Describe some of the functions of each of the lobes? Where is Broca’s area and what does it do? Same for Wernickes area? Where is auditory and visual information processed? Where is the motor and sensory control? Also behaviour, emotions, visuospatial awareness, memory

Answer 3

Frontal lobe - motor control, behaviour and attention, speech, language, memory, emotions, Brocas area (speech production) Parietal lobe - sensory control, visuospatial awareness Temporal lobe - Wenickes area (speech comprehension), auditory information, language, memory Occipital lobe - These lobes: receive and process visual information , contain areas that help in perceive in shape and colours.

Question 4

One of the systems for the classification of stroke is the oxford stroke classification. What are the four categories of stroke here?

Answer 4

Total anterior circulation syndrome/infarct (TACI/TACS) Partial anterior circulation syndrome (PACS) Posterior circulation syndrome (POCS) Lacunar syndrome (LACS)

Question 5

Describe each of the categories of oxford classification of stroke

Answer 5

TACS - All three of: Hemiparesis - Unilateral weakness (and/or sensory deficit) of face, arm and leg - Homonymous hemianopia Higher cortical dysfunction (dysphasia, visuospatial defect) PACS - Any 2 of the three above POCS - Any one of - Isolated homonymous hemianopia, loss of consciousness, cerebellar or brainstem syndrome LACS - Any one of - pure sensory, pure motor, sensorimotor, ataxic hemiparesis

Question 6

What area of the brain would an infarct affect, to cause a homonymous haemianopia? WHich part of the optic pathway? Which lobe of the brain has the primary motor cortex? Which lobe of the brain has the primary sensory cortex??

Answer 6

Homonymous hemianopia - this would be the frontal/parietal - the lesion would be in the optic tract Primary motor cortex - this is precentral gyrus area (in front of the central sulcus) - located in the frontal lobe of the brain Primary sensory cortex - this is postcentral gyrus area (behind the central sulcus) - located in anterior region of the parietal lobe

Question 7

What is ataxic hemiparesis?

Answer 7

This is where there is partial paralysis of one side of the body with ipsilateral limb ataxia and limb incoordination - both are contralateral to the side of the lesion

Question 8

Describe the features of a brainstem or cerebellar syndrome that may be present in a posterior circulation stroke? Does locked in syndrome arise due to a lesion in the brainstem or cerebellum? What is the syndrome due to?

Answer 8

Cerebellar infarct -

• Dysdiadochinesia,
• Dysmetria (past pointing),
• Ataxia,
• Slurred speech,
• Hypotonia,
• Intention tremor,
• Nystagmus,
• Gait

Brainstem - quadriplegia, gaze distubrances, locked in syndrome Bilateral ventral pontine lesion causes locked in syndrome Ataxi hemiparesis -LACS

Question 9

Patient 38 year old healthy female 10/52 pregnant, recent hypermesis and 1 child already On folic acid, thiamine, metaclopramide, odansetron Fhx - protein C deficiency WHat is the relavance of the protein C deficiency?

Answer 9

Protein C deficiency is a disorder that increases the risk of developing abnormal blood clots; the condition can be mild or severe

Question 10

The 38 year old female awoke at 9am on Thursday 20th december with a left hemiparesis to which 999 was called Symptoms resolves on the way to the hospital but returned at 9.54 am What is a left hemiparesis? What is the diagnosis of the initial occurrence?

Answer 10

Left hemiparesis - partial paralysis of the left side of the body - face, arms, legs Diagnosis is a transient ischaemic attack as it lasted less than 24 hours

Question 11

NIHSS scores when assessed within the first 48 hours following a stroke have been shown to correlate with clinical outcomes at the 3-month and 1-year mark. National institutes of health stroke scale (NIHSS) Scores range from stroke severity for 0-42 * Describe each catgeory within the 0-42 range?

Answer 11

0 - no stroke symptoms 1-4 = minor stroke 5-15 - moderate stroke 16-20 - moderate to severe stroke 21-42 - severe stroke

Question 12

38 year old female Patient on examination had: Left arm/leg/face weak/numb Left homonymous hemianopia Left inattention Dysarthria NIHSS score of 19 BP -102/64 SEWS 0 ECG normal What type of oxford classifcation stroke is this?

Answer 12

Patient had Right sided - total anterior circulation syndrome Patient had a moderate to severe stroke on NIHSS

Question 13

Stroke team took the patient to CT at 10.39 am - within 45 mins of stoke What is the scan pointing to here for the woman?

Answer 13

There is a hyperdense middle cerebral artery in the right hemisphere here - small acute infarct but blocking a main artery

Question 14

When the patient was found to have the hyperdense area showing an acute ifnarct, what would be the treatmnet? Remember onset of symptoms was 45 mins ago The O&G team decided even though pregnant, the nomral route of action would be okay

Answer 14

Patinet was thrombolysed - witin 4.5 hours of symptoms - thrombolysis is important

Question 15

Until this year, what was the only proven treatment for acute ischaemic stroke? * How does this work? * When does it have to be given within? * What is always carried out 24 hours post-therapy? What is the recent therapy that can now be used in adjunct to thrombolysis if the thombolysis alone does not work? or if people are not suitable for thrombolysis ie people with high bleeding risks

Answer 15

iv TPA - tissue plasminogen activator (aka alteplase) -thrombolysis - converts plasminogen to plasmin which breaks down clots Has to be given within 4.5 hours of onset of symtpoms Always carry out 24 hour post-lysis CT to identify bleeds before giving antiplatelet agents Endovascualar therapy is the recent therapy that can be given now

Question 16

Tf the patient has had sympotms for greater than 4.5 hours, what should be given as treatment? If the 24-hour post thrombolysis CT is negative for haemorrhage, what should be given for treatment?

Answer 16

All people presenting with acute stroke who have had a diagnosis of primary intracerebral haemorrhage excluded by brain imaging should, as soon as possible but certainly within 24 hours, be given: aspirin 300 mg orally If the 24 hours post-thrombolysis is negative then start on antithrombotic medication - usually aspirin for 10days/2weeks before changing

Question 17

It is important to identify the causative factors for the stroke - ie whether the stroke was athero or cardio embolic What tests should be carried out to determine the cause? In patients where considering, endovascular therapy, what should be carried out prior to this?

Answer 17

ECG - looks for atrial fibrillation - cardioembolic Carotid Doppler ultrasound - looks for carotid artery stenosis - atheroembolic CT/MRI angiography determines the location of the tumour for endovascular therapy Also measure glucose to ensure this hasnt caused any focal neurology signs

Question 18

If the cause of the stroke is found to be atehroembolic, what is the long term antithrombotic treatment? (1st and 2nd line) If the cause is found to be cardioembolic, what is the treatment?

Answer 18

Atheroembolic Continue the aspirin for 14 days and then prescribe - 1st line - clopidogrel 2nd line - aspirin+dipyridamole Cardioembolic Continue the aspirin for 10-14 days and then prscribe Warfarin

Question 19

Define a transient ischaemic attack?

Answer 19

A transient ischaemic attack is the sudden onset of focal CNS phenomena due to a temporary occlusion of the cerebral circulation lasting less than 24 hours

Question 20

If a patient experiences a transient ischaemic attack, what is the scoring system used to determine whether the patient should be assessed by a specialist within 24 hours of within 7 days?

Answer 20

This is the ABCD2 scoring system

Question 21

What are the different categories of the ABCD2 scoring system and what is the maximum score? WHich scores count for 2points?

Answer 21

Max score is 7

• Age >/= 60 years = 1point
• Blood pressure >/= 140/90 = 1point
• Clinical features
  
  • * Unilateral weakness = 2 points
  • * Speech disturbance without weakness = 1point
• Duration of symptoms
  
  • * Symptoms lasting >/= 1hour = 2points
  • * Symptoms lasting 10-59 minutes =1point
• Diabetes = 1point

Question 22

What score indicates referral to be assessed by a specialist within 24 hours? When should all TIA patients be seen by a specialist however?

Answer 22

A score of >/= 4 should be assessed by a specialist within 24 hours All patients with a suspected TIA should be seen within 7 days