stroke

Question 1

how would an anterior cerebral artery stroke present?

Answer 1

contralateral hemiparesis + sensory loss

LOWER extremity > upper extremity

Question 2

how would a middle cerebral artery stroke present?

Answer 2

contralateral hemiparesis + sensory loss
UPPER > lower extremity

contralateral homonymous hemianopia
aphasia - speech probs

Question 3

how would a posterior cerebral artery stroke present visually?

Answer 3

contralateral homonymous hemianopia with macula sparing
visual agnosia - can’t recognise/identify objects

Question 4

how would a posterior inferior cerebellar artery stroke present?

Answer 4

lateral medullary syndrome/Wallenberg syndrome

ipsilateral - facial pain + temp loss

contralateral - limb/torso pain + temp loss

ataxia, nystagmus

Question 5

how would an anterior inferior cerebellar artery stroke present?

Answer 5

similar to posterior inferior (Wallenburgs)

+ ipsilateral facial paralysis + deafness

Question 6

how would a basilar artery stroke present?

Answer 6

“locked-in” syndrome
characterised by quadriplegia and bulbar palsy
Cognition and eye movements are preserved in many patients

Question 7

how would a stroke affecting basal ganglia, thalamus or internal capsule present?

Answer 7

lacunar stroke

either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia

strong assoc with hypertension

best prognosis of all strokes

Question 8

define a TIA

Answer 8

<24hrs of symptoms with complete resolution however 50% of these episodes will show damage on MRI, ischaemia without infarction

True TIA last less than an hour – usually 10-15mins
Any residual symptoms suggests stroke not TIA

Question 9

what can cause the disruption in blood supply in stroke?

Answer 9

thrombus/embolus - patients with AF
atherosclerosis
shocl
vasculitis
drugs - heroin, cocaine
haem problems - antiphopholipid, leukamia
infection - HIV, meningitis
septal defects

Question 10

total anterior circulation syndrome (TACS)

Answer 10

hemiplegia involving at least 2 of face, arm, and leg +/- hemisensory loss contralateral to the lesion

homonymous hemianopia
cortical signs - dysphasia, neglects

occurs in 20% of infarcts

most severe type of stroke with only bput 5% of patients being alive + independent at 1 year

Question 11

Watershed areas

Answer 11

(areas between 2 arterial territories) sensitive to hypoxia

Some brain regions more sensitive (e.g. neocortex and hippocampus

Question 12

how long post stroke/TIA can you drive a car and lorry?

Answer 12

car = 4wks

lorry =1yr

Question 13

what are those with haemorrhagic stroke more likely to have?

Answer 13

decrease level of consciousness in 50%
headache
N+V
seizures in 25%

Question 14

risk factors for haemorrhagic stroke

Answer 14

elevated systolic BP overweight
- High fasting glucose
- High cholesterol
- Alcohol, smoking
- Atrial fibrillation – 1 in 6 strokes due to AF

Question 15

stroke scoring systems

Answer 15

Rosier - score >0 stroke is likely

FABS - >3 suggests stroke mimic

modified rankin scale - used to look at outcomes

NIHSS - severity scale

ABCD2 - early risk of stroke/TIA

Question 16

CT differences between ischaemic + haemorrhagic

Answer 16

Ischaemic
- Areas of low density in grey + white matter of territory
- Hyperdense artery corresponding with responsible arterial clot

Haemorrhagic
 Areas of hyperdense material blood surrounded by low density oedema

Question 17

FAST

Answer 17

public health campaign, recognize stroke symptoms

o Face – has fallen on one side, can they smile?
o Arms – can they raise both arms + keep them there?
o Speech – is there speech slurred?
o Time – time to call 999 if you see any of these

Question 18

management of strokes

Answer 18

CT to determine ischaemic or haemorragic

thrombectomy
 offer asap + within 6hrs of symptom onset
 together with thrombolysis (if no contraindications
 if confirmed occlusion to proximal anterior circulation shown by angiography

thrombolysis
 if no contraindiactions (lots)
 within 4.5hrs of onset of stroke symptoms
-> thrombolyse with IV alteplase (IV tPA)

aspirin 300mg asap after stroke, wait 24hrs if been thrombolysed

Question 19

contraindications to thrombolysis

Answer 19

on anticoagulant
previous haemorrhage or untreated anneurysm
pregnancy/postpartum
recent surgery
severe co-morbidities - liver disease/malignancy

seizure
recent stroke
recent head injury
low platelets (<100)
severe hypertension - can be treated first

Question 20

lowering BP pre thrombolysis

Answer 20

Only indicated in 2 scenarios (acutely)
* For safe thrombolysis
* ICH as attempt to reduce haematoma expansion

options
* IV labetalol, IV GTN

Question 21

management of mild stroke

Answer 21

NIHSS <=3

give aspirin + clopidogrel for up to 3 weeks

Question 22

management of haemorrhagic stroke

Answer 22

Most not suitable for surgical intervention

STOP
- anticoagulants – warfarin
- antithrombotic – clopidogrel

Reverse – vit K/prothrombin complex for warfarin
Lower bp

Question 23

complications of strokes

Answer 23

lots but

malignant MCA syndrome
post stroke pneumonia
hypertensive encephalopathy

Question 24

malignant MCA syndrome

Answer 24

• Rare syndrome seen in very large anterior territory stroke
• Occurs 2-5days post stroke, can be <24hrs
• Problematic in young
• 80% mortality
• Treatment = hemicraniotomy
   May be left with significant disability

Question 25

post stroke pneumonia

Answer 25

• In 15% of patients, commonly occurs within first week
• Due to immunosuppression secondary to stroke + dysphasia
• Dysphasia management – swallow screen
  o If abnormal, assessment by speech + language
  o May need NG tube, thickened fluids etc

Question 26

hypertensive encephalopathy

Answer 26

• Severely hypertensive
• Symptoms of raised ICP
  Pathological finding
• Global cerebral oedema
• Tentorial + tonsillar herniation
• Arteriolar fibrinoid necrosis
• petechiae

Question 27

strokes on CT

Answer 27

haemorrhage appears bright

infarct may not show immediately - often see resultant oedema (dark area)

may see blocked artery - hyperdense MCA sign