Stroke

Question 1

What type of stroke is more common?

Answer 1

Ischaemic (85%)
Haemorrhagic (15%)

Question 2

What is the first line and definitive investigations for stroke?

Answer 2

CT to exclude bleeding
Diffusion weighted MRI

Question 3

What should you rule out before suspecting stroke?

Answer 3

Hypoglycaemia

Question 4

What is the management of stroke?

Answer 4

Aspirin 300mg post-CT without haemorrhage
<4.5 hours: Alteplase
+ Thrombectomy: if ischaemic + PAC occlusion

Question 5

How does anatomy dictate thrombectomy time?

Answer 5

<=6 hours: Proximal anterior (ACA/MCA)
6-24 hours: As above but with salvageable tissue

+ Consider if < 24hrs if prox posterior (PCA, basilar)

Question 6

What entails secondary prevention of stroke?

Answer 6

Clopidogrel 75mg daily
Atorvastatin 80mg if 48hr cholesterol >3.5
Treat cardiac risk factors
Review antipsychotics in elderly

Question 7

What are the TACS criteria for stroke?

Answer 7

1. Unilateral motor +/- sensory loss in limbs
2. Homonymous hemianopia
3. Slurred speech

Question 8

How do you identify a partial anterior stroke

Answer 8

2/3 TACS

Question 9

How does a lacunar stroke present?

Answer 9

Pure sensory stroke
Clumsy hands
Ataxia
Unilateral sensorimotor loss

Question 10

How does a Posterior circulation stroke differ from anterior circulation?

Answer 10

Homonymous hemianopia can present alone
Loss of consciousness or DANISH symptoms

Question 11

What is the supply of the following stroke areas
TACS
PACS
LACS
POCS

Answer 11

TACS/PACS: ACA, MCA
LACS: Deep perforating MCA
POCS: Vertebrobasilar arteries

Question 12

How can you differentiate between an ACA and MCA occlusion?

Answer 12

Lower limb paralysis greater in ACA
Vision and speech more MCA

Question 13

Wheres the stroke?
Unilateral loss of vision

Answer 13

Retinal, ophthalmic

Question 14

Wheres the stroke?
Homonymous hemianopia + macular sparing
Visual agnosia

Answer 14

Posterior cerebral artery

Question 15

Wheres the stroke?
CL weakness
IL down and out eye

Answer 15

PCA branches to midbrain
Weber’s syndrome

Question 16

Wheres the stroke?
CL body temp, pain loss
IL facial pain loss

Answer 16

Posterior inferior cerebellar artery

Question 17

How does anterior differ from posterior inferior cerebellar artery stroke?

Answer 17

Anterior = PICA stroke + facial motor loss, deafness
PICA: CL body temp and pain loss, IL facial pain loss

Question 18

What does this CT show?

Answer 18

MCA ‘hyperdense artery’ sign

Indicates infarction

Question 19

What scoring tools are used in stroke to

Exclude other differentials

Determine ADL impact

Answer 19

ROSIER (>0 means stroke)

Barthel scoring

Question 20

How can you differentiate between organic and functional leg weakness?

Answer 20

Hoover’s sign

Organic: Raising weak leg causes contraction in other leg

Functional: No contraction

Question 21

What additional testing should be done in those <55yrs without obvious stroke cause?

Answer 21

Thrombophilia and autoimmune screening

Question 22

If a patient can understand but not speak what area is likely affected?

Answer 22

Broca’s area

In most people its on the left side (90% right handers, 60% left)

Question 23

How can you differentiate dizziness caused by stroke and vestibular causes?

Answer 23

More severe dizziness (cant stand up)

Vertical nystagmus rather than horizontal