Stroke

Question 1

What are the different types of Stroke?

Answer 1

• Ischaemic (85%)
• Haemorrhagic (15%)

Question 2

What is the urgent management of a suspected stroke?

Answer 2

Urgent non-contrast CT to distinguish between an Ischaemic stroke and a Haemorrhagic stroke.

Question 3

What is the Ischaemic Penumbra?

Answer 3

It describes the cerebral area surrounding the ischaemic event where there is ischaemia without necrosis. This areas is amenable to recovery with thrombolysis.

Question 4

What causes the majority of Ischaemic strokes?

Answer 4

50% due to Large Vessel Atherosclerosis e.g. Carotid Artery Stenosis.
Causing a Thrombus and then Emboli to get stuck in a smaller cerebral Artery.

Question 5

What are other causes of Ischaemic stroke?

Answer 5

25% cause by intracranial small vessel Atherosclerosis.
20% are Cardio-Embolic, e.g. in AF there is a thrombus formed in the LA and subsequent embolisation to the brain.
Rare causes include Primary Vascular causes (vasculitis and Atrial dissection)

Question 6

How does a Haemorrhagic stroke occur?

Answer 6

Occurs when there is rupture of a cerebrospinal artery.

Question 7

What is the Stroke Classification called?

Answer 7

Bamford/Oxford Classification

Question 8

What is a TACI defined by?

Answer 8

• Contralateral Hemiplegia or Hemiparesis, AND
• Contralateral Homonymous Hemianopia, AND
• Higher cerebral dysfunction (e.g. aphasia, neglect)

Question 9

Which Vessels Does a TACI Involve?

Answer 9

The Anterior AND middle Cerebral Arteries on the affected side.

Question 10

What is a Partial Anterior Circulation Infarct defined by?

Answer 10

2 of Contralateral hemiplegia or hemiparesis,
Contralateral homonymous hemianopia,
Higher cerebral dysfunction (e.g. aphasia, neglect)

OR

Higher Cerebral Infarct Alone

Question 11

What Vessels could be involved in a PACI?

Answer 11

The Anterior OR Middle cerebral Cerebral Artery on the affected side.

Question 12

What is A Lacunar Infarct (LACI) defined by?

Answer 12

A pure motor stroke,
Pure sensory stroke,
Sensorimotor stroke,
Ataxic Hemiparesis,
Or Dysarthria-Clumsy Hands syndrome.

Question 13

Which Vessels are affected by a LACI?

Answer 13

Affects the small deep perforating arteries, typically supplying the internal capsule or thalamus.

Question 14

What defines a Posterior Circulation Infarct (POCI)?

Answer 14

• Cerebellar Dysfunction, OR
• Conjugated eye movement disorder, OR
• Bilateral motor/Sensory deficit, OR
• Ipsilateral Cranial Nerve Palsy with Contralateral motor/sensory deficit, OR
• Cortical Blindness/Isolated Hemianopia.

Question 15

What vessels are involved in a POCI?

Answer 15

The Vertebrobasilar Arteries and Associated branches (supplying the cerebellum, Brainstem, and Occipital Lobe)

Question 16

What are Posterior Stroke Syndromes?

Answer 16

Also known as posterior circulation strokes, refer to strokes that affect the posterior circulation of the brain, which includes the brainstem, cerebellum, and posterior cerebral arteries.

Question 17

What Posterior Stroke Syndrome refers to Complete Loss of Movement with Preserved Consciousness and Preserved Occular movements (often only vertical gaze)?

Answer 17

Locked In Syndrome - Caused by an Acute basilar Artery Occlusion.

Question 18

What Posterior Stroke Syndrome - Causes ipsilateral Horner’s syndrome, Ipsilateral loss of pain and Temperature sensation on the face, and contralateral loss of pain and temperature sensation over the body?

Answer 18

Wallenberg’s syndrome (Lateral Medullary Syndrome or Posterior Inferior Cerebella Artery Stroke (PICA))

Question 19

What Posterior Stroke syndrome - results in lateral pontine syndrome, a condition similar to the medullary syndrome but with additional involvement of the pontine cranial nerve nuclei?

Answer 19

An Anterior Inferior Cerebella Artery Infarct results in Lateral pontine syndrome.

The additional Involvement of the pontine cranial nerve nuclei (located in the pons) includes affecting the facial nerve causing ipsilateral facial droop, and affecting the vestibulocochlear nerve causing deafness

Question 20

What Posterior Stroke syndrome - causes an ipsilateral oculomotor nerve palsy and contralateral hemiparesis?

Answer 20

Weber’s syndrome / Medial Midbrain Syndrome (Paramedian branches of the upper basilar and proximal posterior cerebral arteries)

Question 21

What is the acute management of a stroke?

Answer 21

• DR ABCDE manner.
• Airway protection and aspiration precautions in patients with either depressed consciousness or presenting with swallowing impairment.
• Non-Contrast CT

Question 22

What is the most sensitive test for confirming ischaemic infarcts?

Answer 22

A diffusion weighted MRI - This is generally used if the Diagnosis is unclear but is not normally possible in the emergency setting.

Question 23

What are some contraindications to Thrombolysis?

Answer 23

• Recent head trauma
• GI or Intracranial Haemorrhage
• Recent surgery
• Acceptable BP
• Platelet count
  -INR

Question 24

What treatment is indicated in patients presenting within 4.5 hours of symptom onset with no contraindications to Thrombolysis?

Answer 24

Alteplase (tissue plasminogen activator)

Question 25

If Hyper-acute treatments are not offered what should patients be treated with?

Answer 25

Aspirin 300mg orally OD for 2 weeks.

Question 26

If Hyper-acute treatments are offered when is Aspirin usually started>

Answer 26

24 hours after the treatment following a repeat CT head excluding any new Haemorrhagic Stroke.

Question 27

What Investigations in Ischaemic Stroke are done post-Acute?

Answer 27

- Carotid US (to identify critical Carotid A stenosis) - CT/MR Angiography (to identify intracranial and extracranial stenosis) - Echocardiogram (If a Cardio-embolic source is suspected.

Question 28

What investigations in Haemorrhagic stroke are done post-acute?

Answer 28

Serum toxicology screen (sympathomimetic drugs e.g. cocaine are strong risk factors Haemorrhagic stroke)

Question 29

What is the long term anti-platelet of choice in Chronic Stroke management?

Answer 29

Clopidogrel. Warfarin or DOACs would be started in ischaemic strokes secondary to AF.

Question 30

What should be screened for in all patients who have a stroke?

Answer 30

- Diabetes Mellitus (OGTT or Fasting plasma glucose) - Serum Lipids should also be checked. (all post stroke patients started on high dose atorvastatin irrespective of Cholesterol level)

Question 31

When should Patients with Carotid Artery stenosis be referred for Carotid endarterectomy?

Answer 31

With Ipsilateral Carotid artery stenosis >50%

Question 32

What occurs in Horner's Syndrome?

Answer 32

Ptosis, miosis and anhidrosis are signs of Horner's syndrome which occurs due to a lesion to the sympathetic trunk.