Stroke

Question 1

What is a Stroke ?

Answer 1

• A Stroke is a cerebrovascular event that is caused by abnormal perfusion of cerebral tissue characterised by sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death

Question 2

What are the two types of Stroke?

Answer 2

• Ischaemic Stroke
• Haemorrhagic Stroke

Question 3

What is an Ischaemic Stroke?

Answer 3

• Ischaemic Strokes are due to occlusion of blood vessels that supply the brain parenchyma leading to infarction

Question 4

What is an Haemorrhagic Stroke?

Answer 4

• Haemorrhagic Strokes are the result of bleeding within the brain parenchyma, ventricular system or subarachnoid space

Question 5

What is Haemorrhagic Stroke typically split into?

Answer 5

• Intracerebral Haemorrhage
• Subarachnoid Haemorrhage

Question 6

What is the pathophysiology of an Ischaemic Stroke?

Answer 6

• Thrombosis (Atherosclerosis, Hypertension, Smoking, Vasculitis, Sickle Cell)
• Emboli ( Atrial Fibrillation or Carotid Artery Disease)
• Dissection (spontaneous or secondary to trauma)

Question 7

What is the Pathophysiology of Haemorrhagic Stroke?

Answer 7

• Hypertension most common cause
• brain tumour, vasculitis, bleeding disorders

Question 8

What are the risk factors for stroke?

Answer 8

• Smoking
• Diabetes Mellitus
• Hypertension
• Hypercholestrolaemia
• Obesity
• Atrial Fibrillation
• Age
• Carotid Artery Disease
• Thrombophilic Disorders
• Sickle Cell Disease

Question 9

What are the three main Cerebral Vessels?

Answer 9

• Anterior Cerebral Artery
• Middle Cerebral Artery
• Posterior Cerebral Artery

Question 10

What makes up the Circle of Willis?

Answer 10

• Carotid System ( Internal Carotid System - Anterior Cerebral, Middle Cerebral and Posterior Communicating Artery)
• Vertebrobasilar System ( two vertebral arteries join to form the basilar artery,

Question 10

What makes up the Circle of Willis?

Answer 10

• Carotid System ( Internal Carotid System - Anterior Cerebral, Middle Cerebral and Posterior Communicating Artery)
• Vertebrobasilar System ( two vertebral arteries join to form the basilar artery,

Question 10

What makes up the Circle of Willis?

Answer 10

• Carotid System ( Internal Carotid System - Anterior Cerebral, Middle Cerebral and Posterior Communicating Artery)
• Vertebrobasilar System ( two vertebral arteries join to form the basilar artery,

Question 10

What makes up the Circle of Willis?

Answer 10

• Carotid System ( Internal Carotid System - Anterior Cerebral, Middle Cerebral and Posterior Communicating Artery)
• Vertebrobasilar System ( two vertebral arteries join to form the basilar artery,

Question 11

What makes up the Circle of Willis?

Answer 11

• Carotid System ( Internal Carotid System - Anterior Cerebral, Middle Cerebral and Posterior Communicating Artery)
• Vertebrobasilar System ( two vertebral arteries join to form the basilar artery,

Question 12

What makes up the Circle of Willis?

Answer 12

• Carotid System ( Internal Carotid System - Anterior Cerebral, Middle Cerebral and Posterior Communicating Artery)
• Vertebrobasilar System ( two vertebral arteries join to form the basilar artery, the basilar artery gives off the posterior cerebral artery)

Question 13

What is the Ischaemic Stroke Classification System?

Answer 13

• Bamford/ Oxford Classification

Question 14

What is a Total Anterior Circulation Stroke - TACS ?

Answer 14

• Large Cortical Stroke
• Vessel = ACA or MCA
• 3/3 TACS Criteria (1. Unilateral Weakness/ sensory deficit within the face and arm/leg, 2. Homonymous Hemianopia 3. Higher Cerebral Dysfunction (dysphasia))

Question 15

What is a Partial Anterior Circulation Stroke - PACS?

Answer 15

• Cortical Stroke
• Vessel = ACA or MCA
• 2/3 TACS Criteria (1. Unilateral Weakness/ sensory deficit within the face and arm/leg, 2. Homonymous Hemianopia 3. Higher Cerebral Dysfunction)

Question 16

What is a Lacunar Stroke - LACS?

Answer 16

• Subcortical
• Vessel = Deep Perforating Arteries
• Lacunar Syndrome (1. Pure Motor Hemiparesis, 2. Pure Sensory, 3. Ataxic Hemiparesis 4. Dysarthria-clumsy hand syndrome 4. Sensorimotor)

Question 17

What is a Posterior Circulation Stroke - POCS?

Answer 17

• Cortical, Cerebellum, Brainstem
• Vessel = Vertebrobasilar Arteries
• Posterior Syndrome (1. Brainstem or Cerebellar Syndrome, 2. Loss of Consciousness 3. Isolated Homonymous Hemianopia)

Question 18

What is Wallenberg’s Syndrome?

Answer 18

• Lateral Medullary Syndrome (Posterior inferior cerebellar artery)
• Ipsilateral: Facial Sensory loss, Crainal Nerve Palsy (Horner’s Syndrome)
• Contralateral: Limb Sensory Pain and Temperature Loss
• Nystagmus, Vertigo, Dysarthria, Dysphagia, Diplopia

Question 19

What is Weber’s Syndrome?

Answer 19

• Ipsilateral III nerve palsy
• Contralateral Weakness

Question 20

What is the FAST test (Face Arm Speech Time Test)

Answer 20

• New Facial Weakness
• New Arm Weakness
• New Speech Difficulty

Question 21

How do you make a Diagnosis of Stroke?

Answer 21

• Using NIHSS score
• Urgent CT head +/- CT angiography

Question 22

What is the NIHSS score?

Answer 22

• A scoring system out of 42 which has been designed as a predictive score of clinical outcome in stroke
• A score <4 is associated with a good clinical outcome
• A high score >22 indicates a significant proportion of the brain is affected by ischaemia and therefore higher risk of cerebral haemorrhage with thrombolysis
• A score of >26 is often considered a contraindication to thrombolysis

Question 23

What bedside investigations would you do for Stroke?

Answer 23

• Observation, Blood Glucose, ECG (AF)

Question 24

What blood investigations would you do for Stroke?

Answer 24

• FBC, U+E, Bone Profile, LFT, ESR, Coagulation, Lipid Profile, HbA1c

Question 25

What imaging would you do for Stroke?

Answer 25

• CT head +/- CT angiography +/- MRI head

Question 26

What special Investigations would you do for Stroke?

Answer 26

• ECHO, Carotid Dopplers, 24 hour tape, young stroke screen

Question 27

What is the managment for an Ischaemic Stroke?

Answer 27

• Thrombolysis: Tpa activator (Alteplase)
• Contraindications: neurosurgery last 3 months, active internal bleeding
• NIH stroke scale: consider if score >5 and <26
• Time Frame: within 4.5 hours
• If thrombolysis started aspirin started 24-48 hours following treatment
• If thrombolysis not appropriate, patients should be started on 300mg of aspirin for 2 weeks, afterwards a secondary prophyalxis is started with 75mg clopidogrel

Question 28

When would you consider Thrombectomy for a Stroke?

Answer 28

• Offer Thrombectomy asap within 6 hours of symptom onset with IV thrombolysis to: Acute confirmed proximal anterior circulation stroke seen with a CTA or MRA
• Offer Thrombectomy asap to people who were last known to be well between 6/24 hours to: confirmed proximal anterior circulation demonstrated by CTA or MRA and potential to salvage brain tissue (as shown by imagine such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume)
• Consider thrombectomy with IV thrombolysis within 4.5 hours asap for people last known to be well up to 24 hours previously to: acute proximal posterior circulation (basilar, posterior cerebral artery) stroke seen on CTA or MRA and potential to salvage brain tissue as seen by CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume