5.5 Stroke I

Question 1

What happens in a stroke?

Answer 1

Blood supply to the brain (or retina) is interrupted.

Question 2

Stroke V TIA

Answer 2

Stroke – persistence symptoms
o >24 hours
TIA (transient ischemic attack/amaurosis fugax) – transient symptoms.
o A few minutes to up to 24 hours
o A mini stroke which is a warning sign of a full stroke – which requires urgent assessment

Question 3

What does the acronym B.E.F.A.S.T. mean?

Answer 3

• Both
• Eyes
• Face
• Arms
• Speech
• Time

Question 4

What does the acronym Very.F.A.S.T. mean?

Answer 4

• Vision
• Face
• Arm
• Speech
• Time

Question 5

What are the two types of strokes?

Answer 5

Ischemic (clot) (85%)
o Blood supply to the brain abruptly distributed due to a blood clot.
o Subclassified: Bamford Oxford Classification – TACS, PACS, LACS, POCS
Haemorrhagic (bleed) (15%)
o A weakened blood vessel bursts with bleeding within the brain parenchyma, ventricular system, or subarachnoid space
o Further divided into intracerebral (ICH) and subarachnoid (SAH)

Question 6

What is TACS?

Answer 6

Total Anterior Circulation Stroke (anterior cerebral and middle cerebral arteries)

Question 7

What does TACS effect?

Answer 7

• Unilateral weakness +/- sensory deficit face and/or arm and/or leg
• Homonymous hemianopia
• Higher cerebral dysfunction – dysphasia, visuospatial dysfunction (e.g neglect, agnosia)

Question 8

What is PACS?

Answer 8

Partial Anterior Circulation Stroke (anterior cerebral and middle cerebral arteries)

Question 9

What does PACS effect?

Answer 9

2/3 of TACS
* Unilateral weakness +/- sensory deficit face and/or arm and/or leg
* Homonymous hemianopia
* Higher cerebral dysfunction – dysphasia, visuospatial dysfunction (e.g neglect, agnosia)

Question 10

What is LACS?

Answer 10

Lacunar Stroke (deep perforating arteries)

Question 11

What does LACS effect?

Answer 11

• Pure motor hemiparesis
• Pure sensory
• Ataxic hemiparesis
• Dysarthria-clumsy hand syndrome
• Sensorimotor

Question 12

What is POCS?

Answer 12

Posterior Circulation Stroke (Vertebro-basilar arteries)

Question 13

What does POCS effect?

Answer 13

• Brainstem or cerebellar syndrome
• Loss of consciousness
• Isolated homonymous hemianopia
• Diplopia/VF defects
• Dizziness/dysarthria & dysphagia/ataxia
• Brain stem syndromes
  o Wallenberg/Lateral medullary syndrome (posterior inferior cerebellar A)
  o Nystagmus, vertigo, ipsilateral Horners, ipsilateral facial sensory loss, contralateral pain & temp loss
  o Locked-in syndrome/basilar artery occlusion – affects the pons with paralysis of all voluntary muscles except eye movement muscles.

Question 14

What causes thrombus?

Answer 14

Local blockage due to atherosclerosis precipitated by vascular risk factors like hypertension and smoking or small vessel disease like sickle cell and vasculitis etc.

Question 15

What causes embolus?

Answer 15

Propagation of a blood clot leading to obstruction typically due to atrial fibrillation or carotid artery disease

Question 16

What causes dissection? (RARE)

Answer 16

Tearing of the inner layer of an artery typically the internal carotid which can occur spontaneously or related to trauma.

Question 17

What can cause haemorrhagic stoke?

Answer 17

• Commonest cause – hypertension
• Other causes: vascular malformations, brain tumours, vasculitis, or bleeding disorders
• Trauma is also a major cause.

Question 18

List risk factors of stroke

Answer 18

• Hypertension
• Diabetes
• Age
• High cholesterol
• Smoking
• Obesity
• Atrial fibrillation
• Carotid artery disease
• Sickle cell disease
• Thrombophilic disorders e.g. antiphospholipid syndrome
• Cocaine use, trauma, infections, vasculitis, genetics, vascular malformations
• Migraine

Question 19

List signs and symptoms of stroke

Answer 19

• Begin suddenly, vary from person to person, depend on the part of the brain affected and the extent of the damage involved.

o Sudden blurring or loss of vision
o Diplopia
o Confusion
o Dizziness
o Loss of consciousness
o Balance or co-ordination difficulties
o Dysphagia

Question 20

What are the assessments that need to be performed on stroke patients?

Answer 20

o Cranial nerves assessment – look for facial asymmetry
o Vision and VF
o Pupils
o Eye movements
o Motor assessment (arm drift) – sensory deficits, cerebellar testing, gait etc.

Question 21

What are some common presentations of stroke patients?

Answer 21

o Headache
o Altered mental status
o Nausea and vomiting
o Seizures
o Focal neurological deficits
o Visual symptoms/loss of vision/VF deficit

Question 22

What are some physical effects of stroke?

Answer 22

o Pain
o Muscle weakness
o Stiffness/changes in sensation
 Touch
 Temperature

Question 23

What elements of communication are effected by stroke?

Answer 23

o Reading
o Speaking
o Writing
o Understanding

Question 24

List some life effects of stroke

Answer 24

• Emotional
• Memory and thinking
• Hallucinations and delusions
• Sex and relationships
• Behavioural changes
• Memory and thinking
• Neuroplasticity
• Locked- in syndrome
• Vascular dementia

Question 25

What are the stroke scales for NIHSS scoring?

Answer 25

0: No stroke symptoms 1-4: Minor stroke 5-15: Moderate stroke 16-20: Moderate to severe stroke 21-42: Severe stroke

Question 26

What is the clinical relevance of the NIHSS scoring?

Answer 26

<4 - good clinical outcome >22 - Significant brain ischemia with a high risk of a cerebral haemorrhage with thrombolysis >26 - thrombolysis contraindicated in most cases.

Question 27

What management may be considered for Haemorrhagic strokes?

Answer 27

o Neurosurgical intervention may be indicated depending on the extent of the bleeding and suitability for intervention, comorbidities, frailties etc

Question 28

What management may be considered for ischemic strokes?

Answer 28

o If the CT scan does not reveal signs of intracerebral haemorrhage, then decision re thrombolysis is made based on  Timeframe usually within 4.5 hours  Severity NIHSS scale >5 and <26  Contraindications excluded, neurosurgery within 3/12, active internal bleeding

Question 29

What treatment is available for stroke patients?

Answer 29

o Synthetic tPA tissue plasminogen activator Alteplase (“clot busting” drug) o Mechanical thrombectomy is performed according to NICE guidelines by interventional radiologists If thrombolysis/thrombectomy is not appropriate then start on PO aspirin 300mg OD for 2 weeks. After 2 weeks start secondary prophylaxis PO Clopidogrel unless anticoagulation is appropriate eg for atrial fibrillation PO aspirin is started 24-48 hours after thrombolysis/thrombectomy

Question 30

How would orthoptists look at expanding a stroke patients visual field?

Answer 30

Peli prism

Question 31

What are some lifestyle changes that need to be considered following a stroke?

Answer 31

* Improve eating habits – low saturated fat, avoiding trans fat, salt and added sugars * Avoid smoking and second hand smoke * Limit alcohol * Regular BP checks and management if high * Physical activity * Compliance with medications * Reach and maintain a healthy weight * Regular medical check ups to manage underlying health conditions. * Emotional support * Decrease stress levels * Adapting home environment * Counselling * Sex * Driving