Week 5 - A 68 year old woman with a left hemiplegia following a conscious collapse

Question 1

What is the most likely cause? What other possibilities should you consider?

Answer 1

Question 2

What are the important features of the examination and anciliary history?

Answer 2

Question 3

What are 2 screening tools used in the ED for stroke?

Answer 3

Question 4

List 10 Contraindications for thrombolysis?

Answer 4

Question 5

What investigations would you order?
- 2 most important? Others?
- platelet count needed for tPA?
- Which 2 cardiac causes are you looking for?

Answer 5

Question 6

What do the CT and CTA show? It is now 2 hours and 50 minutes post stroke onset. How would you proceed?

Answer 6

Question 7

What in-hospital care should this patient receive and what further
investigations should be performed?

Answer 7

Question 8

What are some possible complications which may arise in the
subacute stage of stroke?

Answer 8

Question 9

What chronic treatment should this patient receive?

Answer 9

Question 10

Define stroke?

Answer 10

A stroke is an acute neurologic condition resulting from a disruption in cerebral perfusion, either due to ischemia (ischemic strokes) or hemorrhage (hemorrhagic strokes).

Question 11

Epidemiology of Stroke?

Answer 11

Stroke is the second most common cause of death and disability worldwide. While stroke is more common with increasing age, 20% of strokes occur in patients aged less than 60. Ischaemic stroke is the commonest form of stroke. Other causes include intracerebral haemorrhage and subarachnoid haemorrhage.

Question 12

What is a Lacunar Stroke?

Answer 12

A subcortical stroke that is primarily associated with hypertension and diabetes mellitus. Lipohyalinotic thickening of vessel walls results in the occlusion of small, penetrating arteries that supply the subcortical regions of the brain (internal capsule, pons, thalamus, putamen, and caudate). Typically presents as specific lacunar syndromes that are characterized by the absence of cortical signs (e.g., aphasia, hemianopsia, agnosia, apraxia).

Question 13

List 6 types of Lacunar Stroke?

Answer 13

Question 14

Answer 14

Question 15

What is the most common type of lacunar stroke? How does it present clinically?

Answer 15

Infarction of the posterior limb of the internal capsule is the most common type of lacunar stroke and may manifest clinically with pure motor stroke, pure sensory stroke (rare), sensorimotor stroke, dysarthria-clumsy hand syndrome, and/or ataxic hemiparesis.

Question 16

What are brainstem syndromes secondary to stroke? What do they involve? Which system is disrupted in the brainstem is there is reduced level of consciousness?

Answer 16

General considerations
Brainstem syndromes involve the cranial nerves and/or their nuclei (produce symptoms ipsilaterally to the lesion) and major brainstem tracts (produce symptoms contralaterally to the lesion unless they are uncrossed or double-crossed).
Disruption of reticular activating system, if present, results in decreased level of consciousness or coma.

Question 17

List 5 types of Brainstem syndromes secondary to stroke?

Answer 17

Overview of midbrain syndromes
1. Ventral midbrain syndrome (Weber syndrome)
2. Claude syndrome
3. Paramedian midbrain syndrome (Benedikt syndrome)
4. Dorsal midbrain syndrome (Parinaud syndrome)
5. Nothnagel syndrome

Question 18

Answer 18

Question 19

List 4 Pontine Syndromes secondary to stroke?

Answer 19

Overview of Pontine Syndromes
1. Ventral pontine syndrome (Millard-Gubler syndrome)
2. Lateral pontine syndrome (Marie-Foix syndrome)
3. Inferior medial pontine syndrome (Foville syndrome)
4. Locked-in syndrome

Question 20

Answer 20

Question 21

Answer 21

Question 22

Answer 22

Question 23

Cortex:
- Frontal lobe?
- Parietal lobe?
- Occipital lobe?
- Temporal lobe?

Answer 23

Question 24

What should be involved in the initial evaluation of a patient with suspected stroke?

Answer 24

Question 25

What is the primary diagnostic method for stroke? First line imaging?

Answer 25

Question 26

Other than imaging, what 6 lab evaluations should be performed in a patient with suspected stroke?

Answer 26

Question 27

Differentials for Stroke:
- 6 Neurologic?
- 6 Toxic/metabolic?
- 6 Infectious?
- 3 ENT?
- 2 Psychiatric?
- 4 Trauma?
- 5 Paraneoplastic syndromes/autoimmune disorders?

Answer 27

Question 28

Approach to the management of patient with a stroke?

Answer 28

If symptoms of a suspected ischemic stroke began less than 4.5 hours prior to presentation and there are no signs of intracranial bleeding, begin reperfusion therapy immediately.

Question 29

Immediate treatment for acute ischaemic stroke - Intravenous thrombolysis?

Answer 29

Question 30

Immediate treatment for acute ischaemic stroke - Endovascular thrombectomy?

Answer 30

Question 31

Immediate treatment for acute ischaemic stroke - Antiplatelet therapy for acute ischaemic stroke?

Answer 31

Question 32

What is Diabetic Ketoacidosis? Aetiology?

Answer 32

Question 33

Diabetic Ketoacidosis - Clinical Features? Treatment? Complications?

Answer 33