Stroke

Question 1

Which vessel(s) can be occluded in an anterior circulation stroke?

Answer 1

• Internal carotid artery
• Middle cerebral artery
• Anterior cerebral artery

Question 2

What is the criteria for a total anterior circulation stroke?

Answer 2

1. Motor or sensory deficits (contralateral) in 2 out of 3 of the face, arm, and legs
2. Impaired higher function, apraxia, agnosia, hemispatial neglect, altered consciousness
3. Visual field changes, esp homonymous hemianopia

Question 3

What is the criteria for a partial anterior circulation stroke?

Answer 3

2 out of 3 of:

1. Motor or sensory deficits (contralateral) in 2 out of 3 of the face, arm, and legs
2. Impaired higher function, apraxia, agnosia, hemispatial neglect, altered consciousness
3. Visual field changes, esp homonymous hemianopia

Question 4

Which vessel(s) can be occluded in a posterior circulation stroke?

Answer 4

Vertebral-basilar system or posterior cerebral artery

Question 5

What are the features of a posterior circulation stroke, generally?

Answer 5

• CNS palsy plus contralateral motor/sensory deficits of the body
• Eye movement problems
• Isolated homonymous hemianopia
• Cerebellar lesions

Question 6

What are the features of an anterior cerebral artery stroke?

Answer 6

• Contralateral hemiparesis and sensory loss

- Lower extremity more severely affected than upper extremity

Question 7

What are the features of an middle cerebral artery stroke?

Answer 7

• Contralateral hemiparesis and sensory loss
• Upper extremity more severely affected than lower extremity
• Contralateral homonymous hemianopia
• Aphasia

Question 8

What are the features of an posterior cerebral artery stroke?

Answer 8

• Contralateral homonymous hemianopia with macular sparing

- Visual agnosia

Question 9

Which vessel is occluded in locked-in-syndrome?

Answer 9

Basilar artery

Question 10

What are the features of locked-in-syndrome?

Answer 10

Complete paralysis of voluntary muscles in all parts of the body
Eye muscles and sometimes the big toe may be spared

Question 11

Which vessel is occluded in lateral medullary syndrome/Wallenberg syndrome?

Answer 11

Posterior inferior cerebellar artery

Question 12

What are the features of lateral medullary syndrome/Wallenberg syndrome?

Answer 12

• Cerebellar features (ataxia, nystagmus)
• Ipsilateral face signs (Horner’s, loss of temperature and pain sensation, dysarthria, dysphagia
• Contralateral body signs (loss of temperature and pain sensation)

Question 13

Which vessel is occluded in median medullary syndrome/Dejerine syndrome?

Answer 13

Paramedian branches of the anterior spinal artery

Question 14

What are the features of medial medullary syndrome/Dejerine syndrome?

Answer 14

• Contralateral paralysis of the upper and lower limb
• Contralateral decrease in proprioception, vibration, and/or fine touch sensation
• Ipsilateral deviation of the tongue
• Dysphagia
• May present with vertigo, nausea, and contralateral limb ataxia

Question 15

Which vessel is occluded in lateral pontine syndrome/Marie-Foix syndrome?

Answer 15

Anterior inferior cerebellar artery

Question 16

What are the features of lateral pontine syndrome/Marie-Foix syndrome?

Answer 16

• Ipsilateral limb ataxia
• Ipsilateral loss of pain and temperature sensation of the face
• Ipsilateral facial weakness
• Ipsilateral hearing loss, vertigo, and nystagmus
• Contralateral hemiplegia/hemiparesis
• Contralateral loss of pain and temperature sensation

Question 17

Which vessel is occluded in medial inferior pontine syndrome/Foville syndrome?

Answer 17

Paramedian branches of the basilar artery

Question 18

What are the features of medial inferior pontine syndrome/Foville syndrome?

Answer 18

• Gaze palsy to the side of the lesion
• Ipsilateral abducens and facial nerve palsy
• Contralateral hemiplegia

Question 19

Which vessel is occluded in midbrain/Weber’s syndrome?

Answer 19

Branches of the posterior cerebral artery

Question 20

What are the features of midbrain/Weber’s syndrome?

Answer 20

• Ipsilateral surgical CN III palsy (diplopia, ptosis, RAPD)
• Contralateral hemiplegia/hemiparesis
• Contralateral parkinsonian rigidity

Question 21

Which vessel(s) is occluded in lacunar stroke?

Answer 21

• Lenticulostriate
• Thalamoperforating
• Pontine perforating

Question 22

What are the features of lacunar stroke?

Answer 22

• Unilateral motor and/or sensory deficits
• Ataxic hemiparesis: ipsilateral clumsiness ans weakness, as opposed to cerebellar dysfunction
• Dysarthria and clumsy hand

Question 23

What is first-line imaging in a suspected stroke?

Answer 23

Non-contrast CT head

Question 24

What is the ROSIER score?

Answer 24

ROSIER = Risk Of Stroke In the Emergency Room

• Score >0 means that a stroke is likely
• LOC or syncope: -1 point
• Seizure activity: -1 point
• Acute asymmetric facial weakness: +1 point
• Acute asymmetric arm weakness: +1 point
• Acute asymmetric leg weakness: +1 point
• Speech disturbance: +1 point
• Visual field defect: +1 point

Question 25

Describe the management of TIA.

Answer 25

- 300mg aspirin immediately - Urgent (24h) assessment in outpatient TIA clinic if TIA was in last 7 days - Assessment within 7 days at outpatient TIA clinic if TIA >7 days ago - Antithrombotic therapy: clopidogrel/aspirin + dipyridamole

Question 26

In which situations would you NOT give aspirin immediate for TIA?

Answer 26

- Patient has bleeding disorder - Patient taking anticoagulation - Patient already on low-dose aspirin - Aspirin contraindicated

Question 27

Describe the management of acute stroke.

Answer 27

1. Thrombolysis: - Alteplase - Give up to 4.5h of onset of symptoms 2. Antiplatelet drugs: - Aspirin (300mg loading dose, then 75mg daily) 3. Anticoagulation: - Immediate treatment with heparin reduces DVT and PE 4. Thrombectomy - Admission to stroke unit - O2 therapy - Control of BP - Control blood glucose

Question 28

When should thrombectomy be done and who should it be offered to?

Answer 28

- Offer thrombectomy ASAP and within 6h of symptom onset with thrombolysis to people who have acute ischaemic stroke AND confirmed occlusion of the proximal anterior circulation - Offer thrombectomy ASAP to people who were last known to be well between 6-24h previously and have confirmed occlusion of the proximal anterior circulation IF there is potential to salvage brain tissue (indicated by a limited infarction core of DW MRI)

Question 29

What is the secondary prevention measures after a stroke?

Answer 29

- Clopidogrel 75mg | - Aspirin + MR dipyridamole in people for whom clopidogrel is not tolerated or contraindicated

Question 30

What are the absolute contraindications for thrombolysis?

Answer 30

- Previous intracranial haemorrhage - Seizure at onset of stroke - Intracranial neoplasm - Suspected SAH - Stroke or TBI in preceding 3 months - LP in preceding 7 days - GI bleed in preceding 3 weeks - Active bleeding - Pregnancy - Oesophageal varices - Uncontrolled HTN >200/120