Stroke (1&2)

Question 1

Lifetime prevalence of stroke?

Answer 1

1 in 4 people (25%)

Question 2

Major stroke subtyp

Answer 2

Ischaemic

Haemorrhagic

Cerebral Venous sinus thrombosis

Aneurysmal subarachnoid haemorrhage

Question 3

L MCA stroke pattern?

Answer 3

Right hemiparesis (face/ arm > leg)

aphasia

right inattention (sensory and visual)

right hemianopia

Question 4

R MCA stroke pattern?

Answer 4

Left hemiparesis (face/ arm > leg)

dysarthria

left inattention (sensory and visual)

left hemianopia

Question 5

Pure motor stroke symptoms/ vessel

Answer 5

Contralateral isolated face/ arm/ leg weakness (with circumduction gait)

+/- dysarthria

Lenticolostriate arteries (most common type of lacunar stroke - 50%)

Question 6

6 Lacunar stroke syndromes

Answer 6

Pure motory

Pure sensory

Sensorimotor

Dysarthria - clumsy hand syndrome

Ataxic

Hemiballismus

Question 7

Brain region affected in pure sensory stroke

Answer 7

Thalamus

May also involve posterior limb of internal capsule, pontine tegmenjtum, corona radiata

Question 8

Brain region involved in Sensorimotor stroke?

Answer 8

Posterior limb of internal capsule

Question 9

Brain region involved in ataxic hemiparesis

Answer 9

Posterior limb of internal capsule

May also involve corona radiate, thalamus, cerebral peduncle, pons

Question 10

Brain region involved in dysarthria - clumsy hand syndrome?

Answer 10

Caudate, posterior limb of internal capsule, putamen, base of pons

Question 11

Brain region involved in hemiballismus stoke?

Answer 11

Caudate nucleus, putamen, thalamus, globus pallidus, corona radiata, subthalamic nucleus

Question 12

Symptoms of hemiballismus stroke?

Answer 12

Contralateral involuntary flinging movements of the arm or leg

Question 13

Hyperdense things on CT brain?

Answer 13

Acute Blood

Ca: choroid plexus, pineal, basal ganglia, bone etc

Question 14

Prefusion parameters on CT Brain perfusion?

Answer 14

MTT - Mean Transit TIme

TTP - Time To Peak

CBF - Cerebral Blood Flow

CBV - Cerebral Blood Volume

Question 15

Interpretation of TTP on CT Brain perfusion?

Answer 15

delayed TTP = collateral territory

Question 16

Interpretation of CBV on CT Brain perfusion?

Answer 16

Low CBV = likely irreversible damage

Question 17

Major benefit to CT brain perfusion?

Answer 17

Guiding thrombolysis > 4.5h or thrombectomy > 6h

Question 18

Risk of stroke in week after TIA?

Answer 18

10%

Question 19

Investigations for TIA?

Answer 19

Vascular imaging - CT angio or US carotids

Ix for cardiac embolism

• ECG, Holter
• TTE +/- TOE +/- Bubble study

Consider Ix for rare causes
- thrombophilia screen, vasculitis screen, Fairy’s disease

Question 20

Indication for bubble study in TIA patients?

Answer 20

<60 and no other cause found

Question 21

Mechanism of thrombolysis?

Answer 21

Stops conversion of plasminogen to plasmin

Question 22

Thrombolysis contraindications

Answer 22

• hemorrhage on CT brain
• extensive hypodensity on CT brain (subacute infarct) – re-check onset time
• active non-compressible systemic bleeding
• recent GI/GU bleeding, surgery or trauma – relative CI – risk vs benefit, ?suitable for thrombectomy
• BP >185/105 or BSL <2.7mmol/L– fix then treat
• infective endocarditis, aortic dissection, malignant brain tumour, INR>1.7, platelets<100, DOAC<48hr

Question 23

Frequency of haemorrhage after thrombolysis for stroke?

Answer 23

Haemorrhage transformation almost universal (some studies associate with favourable prognosis as correlates with reperfusion)

Haematoma with mass effect = bad

Symptomatic ICH 1.7% in stroke registies

(imaging risk factors: CT hypodensity, severe leukoaraiosis, large core and severe hypoperfusion, delayed reperfusion)

Question 24

Idiosyncratic AE of thrombolysis?

Answer 24

Orolingual angioedema

• 2% of cases (5% if on ACEi)
• ? bradykinin related
• give hydrocortisone

Question 25

Cerebral vessels emendable to endovascular clot retrieval in acute stroke?

Answer 25

ICA + M1 (good evidence)

?M2

?? M3/4, ACA, PCA,

unclear: Basilar (trials ongoing)

Question 26

MRS and ADL correlation

Answer 26

MRS 1: asymptomamtic

MRS 2: symptomatic but indeendent

MRS 3: dADLs assist

MRS: 4 pADLs assist

MRS 5: dead

Question 27

Treatment for intra-cerebral haemorrhage

Answer 27

Intensive BP lowering (~ 140 but not much lower)

Reverse anticoagulation

Stroke unit care

?haematinics,
?surgery - yes if posterior fossae

Question 28

Carotid stenosis indication for carotid endarterectomy?

Answer 28

70-99% stenosis in a symptomatic vessel

Modest benefit in 50-69% stenosis

No evidence of benefit in asymptomatic vessels

Question 29

DOACs vs Warfrarin for stroke prevention in AF

Answer 29

DOACs largely replace warfarin except in:

• mechanical heart valves
• ‘Valvular’ AF (moderate to severe MS)
• significant renal impairment

Question 30

Non-medical option for stroke prevention in AF?

Answer 30

Left atrial appendage closure

Question 31

DOAC with most evidence for reversal in acute stroke?

and reversal agent

Answer 31

Dabigatran

Idarucizumab (Praxbind)

Question 32

Reversal agent for Xa inhibitors?

Answer 32

Andexanet alfa

Question 33

Anti-platelets after stroke/ TIA

Answer 33

Good evidence for mono therapy at least
- aspirin
OR
- clopidogrel

Increasing use of DAPT
- aspirin + clopidogrel for 21 days then mono-therapy

Trials with other anti-platelets ongoing
- ticagrelor (THALES study positive - not yet published)

Not really evidence for upgrading/ changing if stroke occurs on anti-platelet (but probably reasonable)