Stroke

Question 1

What is a stroke

Answer 1

A stroke (also known as cerebrovascular accident, CVA) represents a sudden interruption in the vascular supply of the brain

Question 2

Two main types of strokes

Answer 2

Ischaemic

Haemorrhagic

Question 3

Subtypes of ischaemic stroke

Answer 3

Thrombotic

Embolic

Question 4

What is an important risk factor for embolic stroke

Answer 4

AF

Question 5

General risk factors for ischaemic stroke

Answer 5

age
hypertension
smoking
hyperlipidaemia
diabetes mellitus

Question 6

General risk factors for haemorrhagic stroke

Answer 6

age
hypertension
arteriovenous malformation
anticoagulation therapy
Alcohol

Question 7

Features of cerebral hemisphere infarcts

Answer 7

contralateral hemiplegia: initially flaccid then spastic
contralateral sensory loss
homonymous hemianopia
dysphasia

Question 8

Features of brainstem infarction

Answer 8

may result in more severe symptoms including quadriplegia and lock-in-syndrome

Question 9

Features of lacunar infarcts

Answer 9

small infarcts around the basal ganglia, internal capsule, thalamus and pons
this may result in pure motor, pure sensory, mixed motor and sensory signs or ataxia

Question 10

Which criteria are assessed in the Oxford stroke classification

Answer 10

1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia

Question 11

Arteries affected by total anterior circulation infarcts(TACI)

Answer 11

Middle and anterior cerebral arteries

Question 12

Criteria for TACI

Answer 12

1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia

Question 13

Arteries affected in partial anterior circulation infarcts(PACI)

Answer 13

involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery

Question 14

Criteria for PACI

Answer 14

2 of the Oxford criteria are present

Question 15

Arteries affected by lacunar infarcts

Answer 15

involves perforating arteries around the internal capsule, thalamus and basal ganglia

Question 16

How do lacunar infarcts present

Answer 16

presents with 1 of the following:

1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis

Question 17

Arteries affected by posterior circulation infarcts(POCI)

Answer 17

involves vertebrobasilar arteries

Question 18

Presentation of POCI

Answer 18

presents with 1 of the following:

1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia

Question 19

What features are patients with haemorrhagic strokes more likely to have

Answer 19

decrease in the level of consciousness

Headache

Nausea and vomiting

Seizures

Question 20

Blood pressure management in strokes

Answer 20

Blood pressure should not be lowered in the acute phase unless there are complications e.g. Hypertensive encephalopathy

Question 21

Criteria for thrombolysis in acute ischaemic stroke

Answer 21

it is administered within 4.5 hours of onset of stroke symptoms

haemorrhage has been definitively excluded

Question 22

Absolute contraindications to thrombolysis

Answer 22

Previous intracranial haemorrhage

Seizure at onset of stroke

LP in preceding 7 days

GI haemorrhage preceding 3 weeks

Active bleeding

Uncontrolled HTN

Question 23

when should thrombectomy and IV thrombolysis be offered

Answer 23

As soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:

acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

Question 24

Criteria for just offering thrombectomy

Answer 24

as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):

confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and

if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Question 25

Recommended patient clinical status for thrombectomy

Answer 25

A pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS)

Question 26

Anticoagulation in secondary prevention of stroke

Answer 26

Clopidogrel

Question 27

Alternatives for anticoagulation in secondary prevention of stroke

Answer 27

Aspirin plus MR dipyridamole is now recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated

Question 28

When should carotid artery endarterectomy be considered for stroke management

Answer 28

recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled should only be considered if carotid stenosis > 70% according ECST** criteria or > 50% according to NASCET*** criteria

Question 29

Why is mortality raised in patients with poor glycemic control post-stroke

Answer 29

This is likely due to increased tissue acidosis from anaerobic metabolism, free radical generation, and increased blood brain barrier permeability post injury

Question 30

What can mimic stroke-related neurological deficits

Answer 30

Hypoglycaemia

Question 31

Why should anti-hypertensive therapy only be initiated in certain co-morbidities in stroke management

Answer 31

This is because lowering blood pressure too much can potentially compromise collateral blood flow to the affected region, and possibly hasten the time to complete and irreversible tissue infarction

Question 32

Recommended anti-hypertensive therapy in stroke management if appropriate

Answer 32

intravenous labetalol, nicardipine and clevidipine as first-line agents, due to the possibility for rapid and safe titration to control blood pressure

Question 33

Why should BP be reduced in thrombolytic therapy candidates

Answer 33

Elevated BP can affect thrombolytic eligibility and delay treatment Recommended 185/110mmHg

Question 34

NICE advice regarding SALT assessment following stroke

Answer 34

This should preferably within 24 hours of admission and not greater than 72 hours after Prior to assessment is undertaken, a patient should remain nil by mouth to prevent complications

Question 35

Management of feeding post stroke in patients deemed unsafe for oral intake

Answer 35

NG within 24 hrs unless thrombolytic therapy Nasal bridle tube/gastrostomy if NG not tolerated

Question 36

Index used to measure disability

Answer 36

Barthel index This index should be used to assess the functional status of a patient post stroke, and to monitor their improvement with ongoing rehabilitation to regain independence after the event

Question 37

Recommended tool for assessment of stroke

Answer 37

ROSIER score

Question 38

1st line ix for suspected stroke

Answer 38

Non-contrast CT head

Question 39

Recommended anticoagulation for AF following a stroke

Answer 39

Warfarin or direct thrombin or factor Xa inhibitor In the absence of haemorrhage, anticoagulation therapy should be commenced after 2 weeks

Question 40

Anterior cerebral artery lesion effects

Answer 40

Contralateral hemiparesis and sensory loss, lower extremity > upper

Question 41

Middle cerebral artery lesion effects

Answer 41

Contralateral hemiparesis and sensory loss, upper extremity > lower Contralateral homonymous hemianopia Aphasia

Question 42

Posterior cerebral artery lesion effects

Answer 42

Contralateral homonymous hemianopia with macular sparing | Visual agnosia

Question 43

What is weber's syndrome(branches of the posterior cerebral artery that supply the midbrain)

Answer 43

Ipsilateral CN III palsy | Contralateral weakness of upper and lower extremity

Question 44

Posterior inferior cerebellar artery lesion effects aka lateral medullary syndrome, Wallenberg syndrome

Answer 44

Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus

Question 45

Anterior inferior cerebellar artery(lateral pontine syndrome) lesion effects

Answer 45

Symptoms are similar to Wallenberg's ,but: | Ipsilateral: facial paralysis and deafness

Question 46

Retinal artery/ophthalmic artery lesion effects

Answer 46

Amaurosis fugax

Question 47

Basilar artery lesion effects

Answer 47

'Locked-in' syndrome

Question 48

What are lacunar strokes associated with

Answer 48

HTN

Question 49

When should oxygen be given in acute stroke

Answer 49

If less than 95%

Question 50

General advice for secondary prevention of stroke

Answer 50

``` Physical activity Smoking cessation Balanced diet Alcohol intake limited to 14 units/week Advise against routine dietary supplementation ```

Question 51

Medications used in secondary prevention of stroke

Answer 51

Clopidogrel Statins - Aim to reduce non-HDL cholesterol by >40% Anti-hypertensives

Question 52

How long is anticoagulation deferred for in patients with a stroke

Answer 52

Treatment is deferred until at least 14 days from onset in people with disabling ischaemic stroke. In the interim aspirin 300 mg daily will be used