F - Stroke

Question 1

What is a stroke?

Answer 1

Stroke is where a portion of the brain is deprived of oxygen due to ischaemia or haemorrhage resulting in rapid onset of focal signs and loss of function lasting longer than 24 hours

Question 2

How does a TIA differ from a stroke?

Answer 2

A transient ischaemic attack is a temporary disruption in blood supply to the brain resulting in focal neurological defectit lasting less than 24 hours

Question 3

There are three types of stroke Haemorrhagic, Infarct and subarachnoid haemorrhage Which stroke is most common and by what percentage?

Answer 3

Ischaemic strokes are most common accounting for roughly 85% of all strokes Haemorrhagic strokes account for 10% of all strokes - by haemorrhagic stroke - referring to a intracerebral haemorrhage and Subarachnoid haemorrhages account for 5% of all strokes

Question 4

What are the signs of a stroke? (FAST)

Answer 4

Face - they may have face drooped on one side or be unable to smile or open an eye Arms - person with suspected stroke may be unable to lift both arms due to weakness in one of the arms Speech - their speech may be slurred or gargled or unable to speak at all despite appearing awake T - time to call 999 F = face droping A = arm weakness S = speech difficulty T = time to call 999

Question 5

Which imaging modality is usually used as urgent action for a stroke?

Answer 5

Urgent CT scan

Question 6

What colour does blood show up as on a CT scan of head and neck?

Answer 6

CT is very sensitive for blood – blood shows up as a white on CT – can see this man has a haemorrhage

Question 7

Which factors contribute when deciding whether or not thrombolyse the patient if ischaemic stroke ?

Answer 7

Age Onset since symptoms Previous intracerbral haemorrhage or infarct Blood pressure Diabetes

Question 8

How long after time since onset of stroke are you able to thrombolyse? what is the drug given known as?

Answer 8

Able to thrombolyse if onest of symptoms less than 4.5 hours Give IV tPA (recombinant tissue plasminogen - alteplase) - plasminogen breaks down the clot

Question 9

What is an alternative / additional therapy for patients who respond poorly to thrombolysis?

Answer 9

This would be endovascular therapy - is a type of surgery to remove a blood clot from inside an artery or vein where a stent is passed into the artery and the clot is attempted to be removed manually

Question 10

If the patient has recieved thrombolysis, when should anti-platelet therapy be started?

Answer 10

Do not start antiplatelet before 24 hours after administering r-tPA and only if the post lysis CT comes back showing absence of intracranial haemorrhage

Question 11

After thrombolysis, how long is waited usually before repeating a CT scan to identify for bleeds?

Answer 11

Usually carry out a CT scan 24hours post lysis to identify if there have been any bleeds before starting the antiplatelet therapy

Question 12

What assessment is always carried out after a stroke for the patient?

Answer 12

Carry out a swallow assessment on the patient

Question 13

If the patient presents 4.5 hours after time of onset or thrombolysis is contraindicated in an ischamic stroke, what is given?

Answer 13

Give aspirin and supportive care ie fluids

Question 14

The facial drooping, arm weakness, speech slurring occur in both ischaemic and haemorrhagic stroke What signs/symptoms/previous conditions point towards one or the other?

Answer 14

Haemorrhagic - severe headache and coma within hours Ischameic - history of IHD, AF, carotid bruit, TIA

Question 15

What type of treatment is recommended for DVT prophylaxis in a patient who has had a strke? high risk of DVT formation due to immobility

Answer 15

Intermittent pneumatic compression reduces risk of DVT compared to control - therapeutic technique used in medical devices that include an air pump and inflatable auxiliary sleeves, gloves or boots in a system designed to improve venous circulation in the limbs of patients who suffer edema or the risk of deep vein thrombosis

Question 16

If a patients swallow screen assessment is abnormal, they need to be seen by a speech and language therapist What may they need in order to be hydrated and fed then?

Answer 16

May need an NG tube or textured diets

Question 17

Patients with acute stroke should be screened for risk of malnutrition on admission and how aften thereafter?

Answer 17

They should be screened weekly for malnutrition using MUST (Malntrition universal screeing tool) thereafter

Question 18

MUST score takes into account patients BMI, weight loss in last 3-6 months, whether they have eaten in the last 5 days How are each of the three sections scored?

Answer 18

• BMI
  
  • * >20 - 0 points
  • * 18.5-20 - 1 point
  • <18.5 = 2 point
• * Weight loss in the last 3-6 months
  
  • <5% - 0 points
  • 5-10% - 1 point
  • * 10% - 2 points
• Eaten in last 5 days -
  
  • * yes - 0 pints, no then 2 points

Question 19

What MUST score warrants nutritional support?

Answer 19

A MUST score of 2 or more So one of: -

• BMI <18.5
• 10% weight loss in the last 3-6 months that was not intentional -
• BMI 18.5-20 + 5-10% weight loss in last 3-6 months that was not intentional -
• Unable to eat for the last 5 days

Question 20

Secondary prevention of a stroke includes medication and lifestyle factors What should be carrid out ASAP for lifestyle facotrs?

Answer 20

Rehabilitation of the patient and exercise to reduce risk of DVT and promote recovery

Question 21

What is the most common cause of hemorrhagic stroke and what is the other type of cause?

Answer 21

Most common cause of haemorrhagic stroke is uncontrolled hypertension Hemorrhagic stroke can also be caused by structural abnormality in the vessels

Question 22

In general if a stroke occurs, should antihypertensives be administered?

Answer 22

No they should not be administered as a drop in blood pressure could further underperfuse the brain

Question 23

What are the three main types of ischaemic stroke?

Answer 23

Atheroembolic Cardioembolic and small vessel - the vessel is just too small a size

Question 24

How does a stroke occur in cardioembolic stroek? Is cardioembolic stroke fibrin or platelt dependent and what colour is the thrombus?

Answer 24

Usually patient will have a history of atrial fibrillation and there will be a blood clot that has travelled in the internal carotid artery and into branches and blocked them It is fibrin dependent and described as a red thrombus Fibrin due to blood stasis

Question 25

Atheroembolic causes of ischaemic stroke are said to be platelet dependent, how do these occur and what colour is the thrombus?

Answer 25

atheroembolic – clot forms on the vessel of atherosclerotic vessel eg carotids, when the plaque ruptures platelets come and therefore a clot is formed, if this clot moves it becomes a thrombus which travels to the brain and causes infarct Generally a white thrombus

Question 26

Aim to identify: the type of stroke, Presence infarct/haemorrhage CT scan, MRI scan What investigations can be carried out to determine the aetiology of the stroke? ie if infarct then what is causing it

Answer 26

Carotid scan ECG to look for AF or MI and if nothing then 24 hour tape for AF? Also an echo Measure BP Angiogram to see if atheroembolic

Question 27

Mr S has a carotid scan that shows a 30% stenosis of his left internal carotid artery. His ECG shows SR but his 72 hour cardiac monitor shows episodes of atrial fibrillation. His BP averages 150/90 over the first 10 days of his admission. What medication do you want to start him on and when? What is the aim of the medication you give him at this point?

Answer 27

Initially start antiplatelet for the first 10 -14 days - aspirin before continuing on anticoagulant - warfarin for life long treatment after this The aim of this medication is to prevent a clot developing from his AFib

Question 28

If the patient has an ischameic stroke due to cardioemboli, what is the secondary prevention treatment? What is the secondary prevention if it is atheroemboli?

Answer 28

Cardioemboli - aspirin for first 10-14 days then warfarin life long Atheroemboli - aspirin-14 for first 10 days then continue on different antiplatelt - clopidogrel first line and Aspirin+ dipyridamole second line

Question 29

AF is associated with a 5 fold increase in risk of ischaemic stroke How many strokes are roughly due to AF?

Answer 29

1 in 6 strokes are due to AF

Question 30

What is the scoring system used to calculate the stroke risk factor for patients with atrial fibrillation? What is the maximum score on the system?

Answer 30

This is the CHA2-DS2-VASc scoring system Incorporates CHF Hypertension Age >/= 75 = 2 points Diabetes Stroke/TIA = 2 points Vascular disease Age 64-75 Sex category (ie female) = maximum score is 9

Question 31

If the patient has a chadsvasc score of 1 or more, what is the recommended treatment? (or 2 if a woman)

Answer 31

recommended treatment would be oral anti-coagulation therapy

Question 32

5 days after his stroke Mr S still as a dense right sided weakness and has word finding difficulties. He has a right homonomous hemianopia. His swallow is still unsafe and the SLT recommends he remains nil by mouth. What must be affected to cause a right homonomous hemianopia?

Answer 32

There would be a lesion in the left optic tract