Ischemic/Hemorrhagic stroke, TIA, Bells Palsy, Ramsay Hunt

Question 1

Stroke
-subtypes

Answer 1

Sudden interruption of blood supply in brain
Ischemic (85%)
-thrombosis of large vessels (carotid)
-embolic from clot/fat/air/septic

Haemorrhagic (15%)
-intracerebral
-subarachnoid

Question 2

Risk factors for
-ischemic stroke
-hemorrhagic stroke

Answer 2

General
-HTN
-age

Ischemic
-smoking
-hyperlipidemia
-DM
-AF

Hemorrhagic
-AVM
-AC

Question 3

Symptoms of stroke

Answer 3

ACUTE SUDDEN FOCAL NEURO LOSS
-unilateral weakness/paraesthesia in face, arm, leg
-dysarthria, expressive/receptive dysphasia
-vision problems
-headache (sudden, severe, unusual)
-ataxia
-vertigo/loss of balance

Question 4

Symptoms of stroke mimics

Answer 4

Neuro symptoms that are gradual in onset, progressive, migratory
-POSITIVE neurological symptoms (flashing lights, tingling, jerking, shaking limbs)
-cognitive impairment
-resp, abdominal or other abnormal signs

Question 5

Management of suspected stroke
-identification of stroke type
-immediate management of ischemic

Answer 5

Can use ROSIER to assess likelihood of stroke

NON CONTRAST CT immediately to assess for ischemic or haemorrhagic

ADMIT TO STROKE UNIT
Supportive - BM, hydration, SaO2, temp

Ischemic - hypodense brain tissue + (hyperdense artery sign from responsible clot)
-aspirin 300mg

U4.5hrs from onset => thrombolyse with alteplase

U6hrs from onset => mechanical thrombectomy for proximal anterior circulation
-can use with thrombolysis if applicable

6-24hrs => thrombectomy if there is potential to salvage brain tissue
-Yes = proximal anterior circ
-Maybe = proximal posterior circ

Question 6

Reducing risk of future TIA/stroke
-lifestyle
-medications
-comorbidities
-if U55

Answer 6

Physical activities
Smoking cessation
Diet
-5fruits+veg
-2portions of oily fish
-reduced sat fats, salt
Alcohol
-max 14 units over 1 week

AP - 75 clopidogrel
-USE WARFARIN OR DOAC AFTER 2WKS IF CAUSED BY AF

Statins - atorvastatin unless hemorrhagic
BP - thiazide/CCB/ACEi
AC - warfarin/Xinh

T2DM
HF
POP/non hormonal contraceptives
Yearly flu vaccines

If U55
-thrombophilia and AI screening (ANA, APL. ACL, LA)
-coagulation factors
-ESR
-homocysteine
-syphilis

Question 7

Management of suspected TIA
-when to refer
-immediate management
-imaging
-if caused by AF

Answer 7

Referrals
-Curremt => emergency admission, imaging to exclude hemorrhagic
-Multiple TIAs => discuss admission with stroke specialist
-Within week => assessment within 24hrs
-More than 1 week => assessment within the week

Immediate
300mg aspirin unless
-has bleeding disorder or on AC/AP => immediate admission for imaging to exclude haemorrhage
-can’t take aspirin
-TIA caused by AF => take DOAC/warfarin

Imaging - MRI
-determine ischemic area/hemorrhage

Carotid doppler - if candidate for carotid endarterectomy (stenosis 70%+)

Question 8

Stroke and TIA mimics

Answer 8

Migraine with aura - positive marching in minutes

Epilepsy - focal, acute, positive sensorimotor spread in minutes.
Stereotypic attacks

TGA - short term acute anteroretrograde amnesia, resolves in hours

Bells palsy

Facial palsy

Question 9

Facial palsy/Bells palsy
-presentation
-how does this differ from a stroke

Answer 9

Weakness/paralysis of facial muscles

Forehead sparing in UMN/stroke
Forehead not spared in facial palsy

Question 10

Bells palsy
-presentation
-investigations
-management

Answer 10

Idiopathic, but related to recent viral infections/stress

Painless unilateral LMN facial weakness, in hours
-cannot close eyes or cry
-increased sensitivity to sound
-metallic taste

Clinical diagnosis
-serology to rule out RHS

Supportive eye care - eye pathc, lubricating drops
Medical - PO steroids within 72hrs + antivirals
Surgical if no change or not Bells

If no change within 3wks => urgent neuro referral

Question 11

Ramsay Hunt Syndrome
-pathophysiology
-presentation
-investigations
-management

Answer 11

Reactivitation of HZV

Ear pain => facial palsy, ipsilateral vertigo, increased sensitivity to sound, blisters on VII region

Clinical diagnosis

Medical - PO pred (5 days) + aciclovir (7 days)

Question 12

Stroke patterns - Anterior cerebral artery

Answer 12

CL M+S loss
L limbs > U limbs

Question 13

Stroke patterns - Middle cerebral artery

Answer 13

CL M+S loss
U limb > L limbs

CL HH
Aphasia if dominant hemisphere affected
Spatial neglect if non dominant hemisphere affected

Question 14

Stroke patterns - Posterior cerebral artery

Answer 14

CL HH with macular sparing
Visual agnosia

Question 15

Stroke patterns - Branches of PCA that supply midbrain

Answer 15

Weber’s syndrome

IL CN3 palsy
CL UL, LL weakness

Question 16

Stroke patterns - Posterior inferior cerebellar artery

Answer 16

Lateral medullary syndrome
Wallenburg syndrome

Spinothalamic - temp/pain loss
IL facial
CL limb/torso

Ataxia, nystagmus

Question 17

Stroke patterns - Anterior inferior cerebellar artery

Answer 17

Lateral pontine syndrome

Spinothalamic - temp/pain loss
IL facial
CL limb/torso

IL facial paralysis and deafness

Question 18

Stroke patterns - retinal artery

Answer 18

Amaurosis fugax

Question 19

Stroke patterns - basilar artery

Answer 19

Locked in syndrome

Question 20

Difference between TIA and stroke

Answer 20

TIA - brief neurological deficit due to focal brain, spinal cord, retinal ischemia without acute infarction

Stroke - acute infarction of focal, brain, spinal cord, retinal ischemia => neurological deficit

Question 21

Management of suspected stroke
-identification of stroke type
-immediate management of hemorrhagic
-complications

Answer 21

Can use ROSIER to assess likelihood of stroke

NON CONTRAST CT immediately to assess for ischemic or haemorrhagic
If U6hrs + normal => alt diagnosis
If 6hrs+ + normal => LP at least 12hrs from onset
-xanthochromia = identify true SAH from traumatic tap
-normal/high opening pressure

Evidence of hemorrhagic stroke
-hyperdense blood surrounded by hypodense edema
=> NEUROSURGERY REFERRAL and CT intracranial angio to identify cause

ADMIT TO STROKE UNIT
Supportive - BM, hydration, SaO2, temp, BP
-reduce DVT risk => pneumatic leg compressions, caval filter

Hemorrhagic
STOP AC, AP
-rebleeding common
PO nimodipine => prevent vasospasm
Reduce BP!

Surgery
SAH - coil, craniectomy and clipping
ICH - craniotomy/craniectomy with evacuation of hematoma

Hydrocephalus - temporary ext ventricular drain or long term ventriculoperitoneal shunt
LowNa from SIADH
Seizures

Question 22

Management of suspected ischemic stroke
-secondary management

Answer 22

Replace aspirin with clopidogrel
If clopi not tolerated => aspirin + MR dipyridamole
If aspirin + clopi not tolerated => MR dipyridamole

Carotid endarterectomy if
-stroke/TIA in carotid region and not severely disabled
-stenosis 50 or 70%+ depending on criteria used

Question 23

Presentation of hemorrhagic strokes (SAH)

Answer 23

Thunderclap occipital headache
-peak severe pain almost instantly
-may be history of less severe headaches leading up to presentation

N+V

Meningism - photophobia, neck stiffness

Seizures

May have ST elevation on ECG
-from autonomic neural stimulation from hypothalamus/elevated levels of circulating catecholamines

Question 24

Bamford/Oxford classification of ischemic strokes
-what is it for
-what are the 4 categories

Answer 24

Categorises ischemic strokes based on initial presenting symptoms and clinical signs

Total anterior circulation infarct - ACA + MCA
All 3 of
-unilateral weakness/sensory deficit of face, arm, leg
-homonymous hemianopia
-higher cerebral dysfunction (aphasia or spatial neglect)

Partial anterior circulation infarct
2 of
-unilateral weakness/sensory deficit of face, arm, leg
-homonymous hemianopia
-higher cerebral dysfunction (aphasia or spatial neglect)

Posterior circulation infarct - cerebellum and brainstem
1 of
-homonymous hemianopia
-dizzy
-drowsy
-dysarthria
-diplopia
-dysphagia

Lacunar infarct - no loss of higher cerebral function
1 of
-pure sensory
-pure motor
-senosirmotor
-ataxic hemiparesis