Stroke

Question 1

Define stroke

Answer 1

Stroke – acute neurological deficit lasting >24hr
Ischaemic (85%) – lack of perfusion due to vessel occlusion or critical stenosis
Haemorrhagic (15%) – bleeding into brain parenchyma due to vessel rupture

Question 2

What are the causes/risk factors of stroke?

Answer 2

ischaemic
• Large artery atherosclerosis e.g.
intracranial, carotid, aortic arch
• Small vessel disease e.g. lacunar infarcts
• Cardioembolic e.g. AF, MI, valve disease
• Other e.g. dissection, vasculitis,
hypercoagulable states (sickle cell, APL
syndrome)

Haemorrhagic
• Hypertension
• Rupture of aneurysm or AVM
• Haemorrhagic necrosis e.g. tumour
• Vasculitis 

Risk factors
Ischaemic
• Male
• Increasing age
• Diabetes
• Family history

Haemorrhagic
• Male
• Increasing age
• Hypertension
• AVM
• Hereditary bleeding disorders

Question 3

What are the symptoms of stroke?

Answer 3

• Stupor/coma
• Confusion/agitation
• Memory loss
• Seizure
• Delirium
• Diplopia
• Loss of vision
• Poor balance
• Clumsiness
• Difficulty walking
• Slurred speech
• Dysphagia
• Head/neck pain
• Facial droop
• Limb weakness/paralysis
• Loss of sensation
• Hearing loss
• Nausea & vomiting

Question 4

What are the signs of stroke?

Answer 4

anterior
anterior cerebral artery:
• Apraxia – inability to perform learned motor tasks
• Contralateral weakness (leg > arm)
• Contralateral sensory loss
• Confusion

middle cerebral artery:
• Apraxia
• Contralateral hemiparesis/hemiplegia (arm > leg)
• Contralateral sensory loss
• Contralateral homonymous hemianopia
• Left hemispheric: receptive or expressive dysphasia
• Right hemispheric: Visual perceptual deficits
including left hemineglect
• Wernicke’s and Brocca’s

Posterior
posterior cerebral artery:
• Homonymous hemianopia
• Visual agnosia
• Memory loss
• Hemisensory loss
• Wernicke's and Brocca's

vertebrobasilar:
• Bilateral visual and cranial nerve problems
• Vertigo
• Dysarthria
• Dysphagia
• Diplopia
• Facial numbness or paraesthesia
• Hemiparesis or quadriparesis
• Ataxia
• Hemi- or bilateral sensory loss

lacunar
• Pure sensory deficit
• Pure motor deficit
• Ataxic hemiparesis
• Dysarthria

intracerebral haemorrhage
• Headache
• Meningism – neck stiffness
• Focal neurological signs
• N&V
• Raised ICP – pain on straining
• Seizure

Question 5

What investigations are carried out for stroke?

Answer 5

• Bloods
- FBC – exclude anaemia
- U&Es – exclude electrolyte imbalances
- Glucose – exclude hypoglycaemia
- Lipids
- Cardiac enzymes – exclude MI
- Clotting profile
• ECG – exclude arrhythmia or ischaemia
• Echocardiogram – identify cardiac thrombus, IE, VSD (bubble contrast study)
• Carotid Doppler –exclude carotid artery disease
• CT head – identify haemorrhagic stroke (hyperdensity)
• MRI brain – high sensitivity for ischaemic stroke
• CT/MRI angiography – identify intra/extracranial occlusion/stenosis

Question 6

What is the management for stroke?

Answer 6

• Swallowing assessment
• DVT prophylaxis e.g. heparin
• Early mobilisation

MDT rehabilitation
• SALT
• Occupational therapy
• Physiotherapy

Ischaemic stroke hyperacute:
• IV thrombolysis
e.g. alteplase
• Aspirin after 24h
acute:
• 300mg aspirin or
clopidogrel
Surgery:
• Carotid endarterectomy <2 weeks of
stroke or TIA

Intracerebral haemorrhage
• BP control
• Reduce ICP
- IV mannitol
- Hyperventilation
• Evacuation of haematoma
• Ventricular drainage

Question 7

What are the complications of stroke?

Answer 7

• Cerebral oedema and raised ICP
• Immobility
• Infection e.g. pneumonia, UTI, from pressure sores
• Seizure
• DVT
• Arrhythmia
• MI
• Cardiac failure
• Death