Stroke

Question 1

What are the risk factors for stroke and the two main types of stroke

Answer 1

Risk factors - Age, male sex, family history, hypertension, smoking, diabetes mellitus and AF and hypercholesterolaemia.
Two main types are either ischaemic or haemorrhagic .

Question 2

What are the classifications of ischaemic strokes

Answer 2

Large vessel strokes - Look for cortical signs (TACS or PACS)
Small vessels - No cortical signs (Lacunar strokes)
Posterior circulation (crossed signs and cranial nerve findings (POCI)

Question 3

Describe features of a middle cerebral artery stroke

Answer 3

• Arm weakness which is greater than leg weakness.
• Conjugate eye deviation (looking towards side of lesion)
• LMCA stroke will have aphasia.
• RMCA stroke will have hemineglect, apraxia, constructional impairment or anosognosia (lack of insight into neuro deficit)

Question 4

Describe features of an anterior cerebral artery stroke

Answer 4

• Leg weakness is greater than arm weakness.
• Muteness, abulia (absence of willpower),
• Personality change

Question 5

Describe features of a posterior cerebral artery stroke

Answer 5

• Hemianopia
• Memory loss/confusion and alexia (difficulty reading),
• If bilateral then cortical blindness,
• If in non dominant hemisphere then prosopagnosia

Question 5

A total anterior circular infarct/stroke (TACS) is defined by?

Answer 5

• Contralateral hemiplegia/hemiparesis AND,
• Contralateral homonymous hemianopia AND,
• Higher cerebral dysfunction (aphasia/neglect)
• A TACI involved anterior AND middle cerebral artery

Question 6

A partial anterior circular infarct/stroke is defined as?

Answer 6

• 2 of the criteria for PACS or only having higher cerebral dysfunction.
• It is cause involvement of the anterior OR middle cerebral artery

Question 7

What is a lacunar artery stroke defined as?

Answer 7

• Pure motor stroke,
• Pure sensory stroke,
• Sensorimotor stroke or,
• Ataxic hemiparesis.
• This is caused by small vessel strokes. There should be no visual disturbances or higher cerebral dysfunction

Question 8

How is a posterior circular infarct (POCI) defined by?

Answer 8

• 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

Question 9

What are the symptoms of brainstem stroke syndromes?

Answer 9

• Double vision,
• Facial numbness and/or weakness,
• Slurred speech,
• Difficulty swallowing,
• Ataxia,
• Vertigo,
• Nausea and Vomiting,
• Hoarsness

Question 10

What is Wallenberg’s syndrome (lateral medullary syndrome)

Answer 10

It is a posterior stroke syndrome which causes:
- Ipsilateral Horner’s syndrome,
- Ipsilateral loss of pain and temperature on face,
- Contralateral loss of pain and temperature on body

Question 11

What is the initial management of a stroke?

Answer 11

• DR ABCDE.
• If GCS is below 8 then intubate.
• Avoid hyper/hypoventilation
• Nil by mouth till swallow assessment,
• Non contrast CT stat (very sensitive in ability to rule out haemorrhagic stroke but less sensitive in ruling in an ischaemic stroke. Diffusion weighted MRI is most sensitive but is slow. Used if diagnostic uncertainty)

Question 12

What is the treatment for ischaemic strokes?

Answer 12

• 300mg as soon as haemorrhagic stroke is excluded.
• Alteplaste (tpA) if under 4.5hours from onset of symptoms and no contraindications.
• Mechanical thrombectomy

Question 13

What are the stroke mimics?

Answer 13

5’S: Seizure, Syncope, Space occupying lesion, Sepsis and somatisation

Question 14

What are the contraindications for treatment with tpa/alteplase?

Answer 14

• Haemorrhagic stroke,
• Systolic BP > 185
• Diastolic BP >110
• Recent surgery, trauma or stroke,
• Coagulopathy,
• Seizure at onset of symptoms
• Glucose < 2.2