Stoke and TIA

Question 1

What are the different types of strokes and their risk factors?

Answer 1

Ischeamic - age, hypertension, smoking, hyperlipidaemia, diabetes, AF
Haemorrhagic - Age, hypertension, arteriovenous malformation, anticoagulation therapy

Question 2

Describe features of a total anterior circulation infarct?

Answer 2

Involves middle and anterior cerebral arteries. Hass all 3 of the following:
1. Unilateral hemiparesis or hemisensory loss.
2. Homonymous hemianopia.
3. Higher cognitive dysfunction eg, dysphagia.

Question 3

describe features of a partial anterior circulation infarct?

Answer 3

Involves smaller arteries of anterior circulation. Has any two of the following:
1. Unilateral hemiparesis or hemisensory loss.
2. Homonymous hemianopia.
3. Higher cognitive dysfunction eg, dysphagia.

Question 4

Describe features of a lacunar infarct

Answer 4

Involves perforating arteries around the internal capsule, thalamus and basal ganglia. Presents with 1 of the following:
1. Pure motor stroke,
2. Pure sensory stroke,
3. Sensorimotor stroke,
4. Ataxic hemiparesis.

Question 5

Describe features of a posterior circulation infarct?

Answer 5

Involves vertebrobasilar arteries and presents with one of the following:
1. Cerebellar/brainstem syndromes,
2. Cerebellar dysfunction,
3. Conjugate eye movement disorder,
4. Bilateral motor/sensory deficit,
5. Ipsilateral cranial nerve palsy with contralateral motor/sensory deficit,
6. Cortical blindness/isolated hemianopia

Question 6

What are the symptoms of an anterior, middle and posterior cerebral artery infarct?

Answer 6

Anterior - Contralateral hemiparesis and sensory loss with lower extremities > upper.
Middle - Contralateral hemiparesis, sensory loss with Upper extremities > lower. Contralateral homonymous hemianopia and aphasia.
Posterior - Contralateral homonymous hemianopia with macular sparing and visual agnosia

Question 7

Describe features of Weber’s syndrome?

Answer 7

Infarct affecting branches of PCA which supply midbrain.
Presents with Ipsilateral CN III palsy, contralateral weakness of limps

Question 8

Describe features of Wallenberg syndrome?

Answer 8

Infarction of posterior cerebellar artery.
Presents with ipsilateral facial pain loss and Hornor’s syndrome and contralateral loss of pain and temperature on the body.

Question 9

Describe features of lateral pontine syndrome?

Answer 9

Symptoms are similar to Wallenberg’s but with ipsilateral facial paralysis and deafness

Question 10

What are features of retinal/ophthalmic arteryinfarct?

Answer 10

Amaurosis fugax - Transient darkening

Question 11

What are the features of basilar artery infarct?

Answer 11

Locked in syndrome, loss of consciousness and sudden death

Question 12

What are the investigations for stroke?

Answer 12

Immediate - Exclude hypoglycaemia.
Then - Non contrast head CT. Ischaemic stroke - Low density. Haemorrhagic stroke - Hyperdense material (blood) surrounded by low density (oedema)

Question 13

What scoring system is used in the assessment of stroke?

Answer 13

ROSIER score

Question 14

What is the initial management of acute ischaemic stroke?

Answer 14

Once haemorrhage has been ruled out give 300mg of aspirin oral/rectal and continue for two weeks. Then decide whether to do thrombolysis or thrombectomy.

Question 15

When should you do thrombolysis?

Answer 15

If patient presents within 4.5 hours of onset of symptoms and haemorrhage has been excluded. Give alteplase or tenectoplase.

Question 16

What are some absolute and relative contraindications for thrombolysis?

Answer 16

Absolute - Previous intracranial haemorrhage, seizure at onset of stroke symptoms, intracranial neoplasm, stroke or traumatic brain injury in past 3 months.
Relative - Concurrent anticoagulation, major surgery in past two weeks.

Question 17

What are the indications for thrombectomy?

Answer 17

1. Within 6 hours of onset (in additon to thrombolysis if presented within 4.5 hours of onset) for confirmed occlusion of proximal anterior circulation.
2. Patients presenting within 6-24 hours of onset if occlusion of proximal anterior circulation and/or there is salvageable brain tissue

Question 18

What is the secondary prevention for stroke?

Answer 18

1. Clopidogrel 75mg OD (If contraindicated or not tolerated then give aspirin and dipyridamole but only for two years).
2. Atorvastain 80mg (delayed for 48h)
3. Blood pressure and diabetes control,
4. Address modifiable risk factors

Question 19

What are some other important factors to manage in patients with stroke?

Answer 19

1. Fluid status - Oral rehydration for patient’s with a safe swallow.
2. Glycaemic control - Maintain sugars 4-11mmol/L (hyperglycaemia can increase mortality).
3. Only give antihypertensives if there is a hypertensive emergency or one of following: Hypertensive encephalopathy, hypertensive nephropathy, MI, aortic dissection or pre-eclampsia.
4. Must have SALT assessment before resuming oral intake

Question 20

What is a Transient Ischaemic attack?

Answer 20

Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without acute infarction.

Question 21

What are the clinical features of a TIA?

Answer 21

Sudden onset of unilateral weakness/sensory loss, aphasia, dysarthria, ataxia or vertigo or visual problems which typicall resolve within an hour

Question 22

What is the management of a TIA?

Answer 22

1. 300mg of aspirin started immediatley unless contraindications or already on antiplatelets.
2. Referral for specialist assessment within 24 hours (if TIA in past 7 days, if over 7 days ago then assessment within 7 days)- diffusion weighted MRI is usually the scan of choice.
3. Carotid doppler

Question 23

What is the secondary management of a TIA?

Answer 23

1. Clopidogrel (unless contraindicated then aspirin and dipyridamole).
2. Atorvastatin
3. Carotid artery endarterectomy if artery is stenosed > 70%.

Question 24

What is the management of a haemorrhagic stroke?

Answer 24

1. Neurosurgical evaluation.
2. Admission to neuro ICU or stroke unit.
3. Blood pressure control - maintain BP < 140/80

Question 25

When should you start anticoagulation in stroke/TIA patients?

Answer 25

If they have AF, otherwise keep on antiplatelet.
If had TIA then start DOAC/warfarin immediately. If had stroke then wait two weeks, give aspirin during this time.