Stroke (1)

Question 1

What is the most common type?
→ What is typically due to?
→ What else can it be due to?

What is the other type?

What are the risk factors?

Answer 1

➊ Ischaemic stroke (80%)
→ Thrombus formation in large vessel atherosclerosis e.g. carotid, and subsequent embolus
→ Can also be due to cardio-embolism e.g. in AF, or multiple intracranial small vessel atherosclerosis

➋ Haemorrhagic stroke (20%) - Due to bleeding within brain parenchyma or ventricular system (Intracerebral) or into arachnoid space (Subarachnoid)

➌ • CVD e.g. Angina, MI, PVD
• Previous TIA/Stroke
• AF
• Atherosclerosis
• HTN, DM. Smoking
• COCP, Thrombophilia

Question 2

Stroke Classification:
What does a Total Anterior Circulation Infarct (TACI) involve?
→ How does it present?

What does a Partial Anterior Circulation Infarct (PACI) involve?
→ How does it present?

How does a Posterior Circulation Infarct (POCI) present?
→ What is a main differential here and how is it checked for?

How does a Lacunar infarct present?
→ What won’t they present with?

Answer 2

➊ Anterior and middle cerebral arteries
→ • Contralateral hemiparesis (weakness) or hemiplegia (paralysis) AND
• Contralateral homonymous hemianopia AND
• Higher cerebral dysfunction (e.g. aphasia, neglect)

➋ Anterior or middle cerebral arteries
→ • 2/3 of the above OR
• Higher cerebral dysfunction alone

➌ • Cerebellar dysfunction OR
• Conjugate eye movement disorder OR
• Bilateral motor/sensory deficit OR
• Ipsilateral cranial nerve palsy with contralateral motor/sensory deficit OR
• Cortical blindness/isolated hemianopia
→ Vestibular dysfunction, tested for with HINTS Plus

➍ Pure motor, pure sensory, sensorimotor stroke, or ataxic hemiparesis
→ Visual field defect, higher cerebral dysfunction, or brainstem dysfunction

Question 3

Posterior Stroke Syndromes:
What are the 4 main ones to remember?
→ How do is present?

Answer 3

Medial Midbrain Syndrome (Weber’s Syndrome)
→ * Ipsilateral CN 3 palsy (complete ptosis)
* Contralateral hemiparesis

Lateral Pontine Syndrome due to an occlusion of the Anterior Inferior Cerebellar Artery (AICA)
→ Similar to Wallenberg’s, but + involvement of CN 5-8 (e.g. vertigo, nausea)

Lateral Medullary Syndrome (Wallenberg’s Syndrome) due to an occlusion of the Posterior Inferior Cerebellar Artery (PICA)
→ * Ipsilateral Horner’s syndrome (partial ptosis)
* Ipsilateral facial loss of pain and temp sensation
* Contralateral loss of pain and temp sensation of the body.

N.B. Remember the origin of the cranial nerves by the “rule of 4”. Midbrain = CN 1-4. Pons = CN 5-8. Medulla = CN 9-12.

Basilar Artery Occlusion
→ Locked-in syndrome (quadraperesis with preserved consciousness and ocular movements), loss of conciousness, or sudden death.

Question 4

What are the initial management options to do?

What should the pt be started on?

What other secondary measures may be done?

Should DVLA be informed?

Answer 4

➊ • CT Head (within 1 hr) to exclude haemorrhage
• Once excluded, if < 4.5 hrs - Thrombolysis with Alteplase (tPA)
• Thrombectomy within 6-12 hrs
• NBM until swallowing assessment done

➋ • Immediate Aspirin 300mg for 14 days
• Switch to Clopidogrel 75mg OD for long-term prevention
• Atorvastatin 20-80mg

➌ • Carotid endarterectomy/stenting if pt has carotid artery disease
• Manage modifiable risk factors, like HTN, DM, Smoking

➍ Only if the patient’s still having problems 1 month after the stroke