Stroke

Question 1

A 50 year old man presents to the ED arriving in an ambulance with a 2 hour history of sudden onset left hemiparesis (left arm, leg, and facial droop). It was witnessed by his daughter. The patient has a history of HTN and Dyslipidemia.
State your differentials (Give 4)
What is your initial investigation?

Answer 1

Stroke
Hypoglycemia
Seizure
Hemiplegic migraine
Functional disorder

Initial investigation = Non-contrast CT brain

Question 2

Define Stroke
What is the etiology of stroke along with the relevant causes/RFs?

Answer 2

Stroke is the rapid loss of brain function due to disturbance of blood supply. It may be:
1) Hemorrhagic: Aneurysms, HTN, AV malformation (dural AV fistula/ venous sinus thrombosis = causes of SAH (without trauma ofcourse)
2) Ischemic: Can be thrombotic (atherosclerosis) or Embolic (A.FIB, prosthetic valve, recent MI, atherosclerosis)

Question 3

What is the most common artery of insult causing stroke?
Disturbance of blood supply in this artery causes what symptoms?

Answer 3

Middle cerebral artery
Hemiparesis, hemianesthesia +/- aphasia (if dominant hemisphere)

Question 4

Give the clinical presentation of Stroke

Answer 4

Sudden onset focal neurological defect variable depending on artery:
ACA: Upper limb weakness bilaterally
MCA: Hemiparesis, hemianesthesia +/- aphasia (if dominant hemisphere)
PCA: Homonymous Hemianopia +/- Vertigo
PICA: Lateral Medullary syndrome
=>If posterior circulation it is both Homonymous hemianopia + lateral medullary syndrome

Question 5

What causes Horner’s syndrome? (Give 4/5 for 5/5)
How does it present?

Answer 5

Horner’s syndrome is caused by a disruption in the SNS
1) Brachial Plexus Injury
2) Carotid Artery Ischemia (PICA) => Lateral Medullary Syndrome
3) Apical Lung Tumour (similar to brachial plexus)
4) Migraine
5) Multiple sclerosis
Presents with Triad of Ptosis, Miosis, and facial Anhidrosis

Question 6

What is ptosis?

Answer 6

eyeline drooping

Question 7

What is Miosis?

Answer 7

Constricted pupil

Question 8

What is anhidrosis?

Answer 8

not sweating, dry

Question 9

Obstruction to which artery may lead to Horner’s Syndrome?
Which artery does it come from?
Obstruction of the same artery may cause another syndrome. What is it and give its symptoms.

Answer 9

PICA: Posterior inferior cerebral artery
Vertebral artery
Lateral Medullary Syndrome: Horner’s (Ptosis, miosis, facial anhidrosis), Diplopia, slurred speech, dizziness (vertigo)

Question 10

A patient with a suspected stroke presents to the ED. What investigations (imaging) will you perform to confirm the cause of the stroke and why for each.

Answer 10

Non-contrast CT brain initially to exclude hemorrhage as a contraindication for CT angio and thrombolysis
This is followed by CT angio which will locate the aneurysm and assess need for thrombectomy.

Question 11

What is the definitive treatment for stroke?

Answer 11

IV thrombolysis +/- Thrombectomy

Question 12

What is the cutoff for administration of thrombolysis in a stroke patient?

Answer 12

Cutoff = 4.5 hours from onset of symptoms!!! because the risk of hemorrhage outweighs the benefit of thrombolysis

Question 13

What drug is given during thrombolysis?
What class of drugs is it?
How is it given in a case of stroke (given no contraindications)

Answer 13

Alteplase
tPA: tissue plasminogen activator
IV Alteplase 0.9mg/kg up to a maximum of 90mg => if >100kg just give 90
Given 10% as bolus and 90% as infusion over 1 hour

Question 14

What are the 2 most common cranial arteries to have large vessel occlusionn in stroke?

Answer 14

MCA
Internal carotid (bifurcation)

Question 15

What is the procedure for thrombectomy?
What is the cutoff for conducting a thrombectomy for a stroke patient?
What is the indication for a thrombectomy?
What are the complications of thrombectomy?

Answer 15

Similar to Aneurysm coiling: Patient under GA, sheath placed in femoral artery -> Guide catheter moves up to common carotid/VERTEBRAL arteries -> microcatheter and microwire to access occluded vessel -> Deploy clot retrieval device
12 hours
Indication = Large vessel occlusion
Complications: puncture/failure => bleeding, groin bleeding/vessel damage from femoral sheath, death

Question 16

A patient with a suspected stroke presents to the ED. What is your full management plan assuming this is going to be an ischemic stroke?

Answer 16

1) Initially ABC
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)

Conduct Non-contrast for hemorrhage CT followed by CT angio to test for suitability for thrombectomy

2) Definitive treatment:
ALL ISCHEMIC: Thrombolysis (if no contraindications) within 4.5 hours. IV Alteplase 0.9mg/kg (max 90mg) 10% bolus and 90% infused over 1 hour
If large vessel occlusion => Thrombectomy (within 12 hours)

Question 17

T or F: Hemorrhagic stroke is a CI to thrombolysis

Answer 17

True

Question 18

T or F: Hemorrhagic stroke is a CI to conducting a CT angiogram

Answer 18

True, we should use non-contrast CT brain instead

Question 19

T or F: A patient with an occlusion of Right MCA is an indication for Thrombectomy

Answer 19

True. MCA is a large vessel

Question 20

T or F: A patient with an occlusion of PICA (posterior inferior cerebral artery) is an indication for Thrombectomy

Answer 20

Small artery => not an indication. Thrombolysis is effective enough

Question 21

T or F: CT angio should be performed on all patients receiving thrombolysis

Answer 21

True because everyone receiving thrombolysis already had to have ruled out hemorrhage as well using non-contrast CT brain as is done before conducting CT angio.