Stroke

Question 1

Anti-hypertensives in TIA

Answer 1

ACEi and diuretics

Question 2

Types of stroke

Answer 2

TIA: stroke syndrome + neuro sx lasting mins - 24hrs w/ complete resolution
Ischemic: embolic or thrombotic
Lacunar
Non lacunar (large artery atherosclerosis, cardioembolic, cryptogenic)
Hemorrhagic: intracerebral or subarachnoid

Question 3

RF

Answer 3

Age
Obesity
Fam hx
HTN
MI
AFin
DM
Dyslipidemia
Smoking
OCP

Question 4

Sx Right hemispheric stroke

Answer 4

Hemispatial neglect
Deficit + neglect of left visual field
Right gaze preference
Impulsive

Question 5

Sx Left hemispheric stroke

Answer 5

Aphasia, agraphia, alexia
Slow behaviour
Deficit in right visual field
Left gaze preference

Question 6

Sx Anterior cerebral

Answer 6

Contralateral sensorimotor deficit (foot + leg)
Arm paresis
Gait ataxia
Bladder incontinence
Personality changes
Amnesia

Question 7

Sx Middle cerebral

Answer 7

Contralateral sensorimotor deficit (face, arm, leg)
Contralateral homonymous hemianopsia
Contralateral hemispatial neglect
Aphasia, alexia, agraphia
Dysarthria

Question 8

Sx Posterior cerebral

Answer 8

Pure homonymous hemianopsia
N/V
Ataxia, vertigo
Weakness, sensory loss, dysarthria

Question 9

Sx Vertebro basilar

Answer 9

Vertigo
Limb + gait ataxia
Cranial nerve dysfunction
Coma
Diplopia
Bilateral motor deficits
Dysarthria, dysphagia

Question 10

Sx Thalamic

Answer 10

Altered senses
Loss of pain sensation
Contralateral hemiplegia
Hyper-sensitivity to stimuli
Amnesia

Question 11

Sx Lacunar

Answer 11

Pure motor hemiparesis
Ataxic hemiparesis
Dysarthria + clumsy hand syndrome
Pure sensory stroke

Question 12

Lifestyle management

Answer 12

Diet: fruit, veg, fibre, low saturated fat + cholesterol (Mediterranean)
Moderate intensity exercise
Smoking cessation
Maintain healthy wt
Limit alcohol
DC OCP + HRT

Question 13

Primary prevention

Answer 13

HTN: keep BP <140/90
Lipids: Rosuvastatin
AFib: anticoagulant
Carotid stenosis: ASA + carotid endarterectomy

Question 14

Secondary prevention

Answer 14

HTN: thiazide + ACEi target <140/90 or <130/80 if DM
Lipids: statin, target LDL <1.8
DM: metformin, GLP1 (ASCVD) or SGLT2i (HF or CKD), A1C <7%
AFib: apixaban
Carotid stenosis: carotid US within 24hrs, carotid endartectomy if symptomatic + >50% stenosed
ABCD score >4 = ASA + clopidogrel for 1 mo, then ASA 81mg forever

Question 15

Management

Answer 15

Non contrast CT or MRI
If arrival within 6hr: + CTA
BW: CBC, INR, PTT, BG, Cr, lytes, ALT, trop, ECG
NPO + swallowing assessment within 24hrs
Alteplase:
<4.5hrs from onset of sx
0.9mg/kg, max 90mg over 60mins
MDT: PT, OT, SW, physiatry, neuro
Evaluate need for supports
Cane/ walker
Home care

Question 16

Complications

Answer 16

Screen for depression: CBT, SSRI
Vascular cognitive impairment: MOCA, cholinesterase inhibitors or NMDA
Post stroke fatigue
Swallowing/ dysphagia/ aspiration PNA
Bedridden/ decubitus ulcers
Balance/ mobility/ falls
Urinary/ bowel incontinence
Spasticity

Question 17

Ddx

Answer 17

TIA, brain tumor, hypoglycemia, subdural hematoma, SAH

Question 18

Complications of stroke

Answer 18

pressure ulcers, aspiration PNA, depression, muscular atrophy, dementia, incontinence, sz, disability

Question 19

Bells vs stroke difference

Answer 19

Strokes spares forehead

Question 20

Rx for Bells palsy

Answer 20

lubricant eye drops, steroids, antivirals if severe

Question 21

What is the Ramsay Hunt triad?

Answer 21

Ipsilateral facial paralysis, ear pain, vesicles in auditory canal

Question 22

What would you examine in ?Ramsay Hunt?

Answer 22

Auditory canals

Question 23

TIA ABCD2 score

Answer 23

age >60
BP >140/90
clinical features (uni weakness, speech disturbance)
duration of TIA (10-59 mins = 1, >60 mins = 2)
DM

Question 24

Ischemic vs hemorrhagic sx stroke

Answer 24

ischemic is early, focal sx, hemorrhagic often starts w/ HA, vomiting then late focal effects

Question 25

How to answer acute management scenarios

Answer 25

ABC MOVIES w/ actions: airway - check patency and use adjuncts if needed, breathing - apply O2, circulation - 2 wide bore IV, vitals inc neuro vitals, fluids, ECG, sugar check

Question 26

Acute stroke management in ED

Answer 26

ABC MOVIES
stroke scale
labs (Na, K, Hb, iNR, apTT, Cr, trop, glucose)
2 noncontrast head CTs
- if 4.5-6hrs after sx, add CT angiogram from vertex to arch
- if 6-24hrs add CT angio + CT perfusion, treat fever + BP

Question 27

Aside from thrombolytics, what else can be used to treat a stroke?

Answer 27

Endovascular thrombectomy (aspiration, vacuum or removable stent)

Question 28

Indications for thrombolytics

Answer 28

stroke dx + neuro deficit, treatment within 3-4.5hrs, >18y/o

Question 29

Indications for thrombectomy

Answer 29

acute ischemic stroke, ant circulation, large vessel