Stroke

Question 1

meningeal signs: rapid onset of headache with nuchal rigidity, headache and photophobia

Answer 1

subarachnoid haemorrhage or meningitis

Question 2

initial evaluation

Answer 2

primary survey
identify risk factors for stroke, including presence of carotid bruits
determine time of onset and last known normal

Question 3

investigations

Answer 3

serum glucose, vitals
ECG
FBC, INR, APTT, UECs, trops
?urine drug screen and BAL
lab studies should not delay imaging for patients with acute stroke

Question 4

imaging

Answer 4

Non-contrast head CT to rule out haemorrhage before administering thrombolytic therapy
diffusion-weighted MRI
or CTA

Question 5

if imaging is negative but suspicion for sub arachnoid haemorrhage remains high

Answer 5

Lumbar puncture - CSF may show xanthochromia
the presence of bilirubin in the CSF secondary to the breakdown of RBCs resulting in yellow discolouration
may be falsely negative in the first 12 hours of symptoms onset as xanthochromia is a late sign

Question 6

findings of ischaemic stroke on non contrast CT

Answer 6

hyperdense MCA sign (suggesting presence of a thrombus)
effaceemnt of sulci
loss of cortico-medulllary differentiation
oedema

Question 7

findings on CT for intracranial haemorrhage

Answer 7

hyperdense lesion within cerebral parenchyma

Question 8

findings on non contrast head CT for subarachnoid haemorrhage

Answer 8

extensive area of hyperdense signals around the circle of willis

Question 9

treatment options for ishcaemic stroke

Answer 9

• tPA (tissue plasminogen activator) if within 4.5 hours on onset of symptoms
• endovascular thrombectomy within 6 hours
• aspirin within 48 hours

Question 10

tissue plasminogen activator

Answer 10

a serine protease found on endothelial cells of blood vessels
catalyses the conversion of plasminogen to plasmin, which is the main enzyme responsible for clot breakdown
recombinant tissue plasminogen activators (eg. alteplase, reteplase, tenecteplase) are used as thrombolytics in patients with acute coronary syndrome, pulmonary embolism, or ischaemic stroke

Question 11

intravenous thrombolysis process

Answer 11

IV alteplase
if within 4.5 hours of onset of symptoms and as soon as possible
lower BP to below 185/110

Question 12

endovascular thrombectomy

Answer 12

when the stroke is due to the occlusion of a large vessel
within 6 hours of symptom onset

Question 13

what kinds of patients usually get endovascular thrombectomy

Answer 13

eligible patients are usually a subset of those for whom alteplase is indicated, and they can have both surgery and alteplase
endovascular thrombectomy may also be appropriate for those for whom alteplase is contraindicated (eg. patients taking anticoagulants) or those presenting too late for alteplase (between 4.5 hours and 6 hours)
endovascular thrombectomy may also be used for some patients who present up to 24 hours if there is occluded large vessel and salvageable brain tissue

Question 14

general measures in acute ischemic stroke

Answer 14

assess swallow ability before giving oral drugs, if the patient has difficulty swallowing then make them nil by mouth and refer to speech pathology
avoid blood pressure lowering drugs except for patients with malignant hypertension or to lower blood pressure for alteplase
give supplimental oxygen if hypoxic
VTE prophylaxis

Question 15

treatment for intracerebral haemorrhage

Answer 15

reversal of coagulopathy eg. cease anticoagulant
urgently lower BP to reduce hematoma expansion to <140
surgical intervention to evacuate the hematoma may be considered

Question 16

symptoms of subarachnoid haemorrhage

Answer 16

75% present with acute severe headache, the rest present with LOC
mortality is high
many patients die before reaching the hospital

Question 17

sentinel bleed

Answer 17

minor subarachnoid bleed occurring before the main rupture
sudden headache several weeks before the acute event

Question 18

treatment of subarachnoid haemorrhage

Answer 18

patients are managed with a neurosurgeon
most subarachnoid haemorrhages are due to ruptured intracranial aneurysm

Question 19

inconclusive non contrast CT with thunderclap headache

Answer 19

lumber puncture for sub arachnoid haemorrhage

Question 20

if a non contrast CT shows no haemorrhage

Answer 20

ischaemic stroke
is the patient elligible for tPA
is it <4.5 hours from symptom onset -> IV tPA
then consider antiplatelet therapy and supportive management
and initiate secondary prevention

Question 21

if non contrast CT shows haemorrhage

Answer 21

intracranial haemorrhage
neurovascular imaging: CTA, carotid duplex sonography
consider neurosurgery
treat hypertension
stop anticoagulation
supportive management

Question 22

MCA stroke

Answer 22

contralateral weakness and sensory loss more marked in upper limbs and lower half of face than lower limbs
gaze deviated toward the side of infarction (ipsilateral)
aphasia if in dominant hemisphere
contralateral homonymous hemianopia without macular sparing
hemineglect if in nondominat hemisphere

Question 23

broca aphasia

Answer 23

language comprehension intact
non-fluent, grammatically incorrect speech
supplied by superior division of the MCA

Question 24

wernicke aphasia

Answer 24

affected patients speak fluently but produce nonsensical phrases
supplied by inferior division of the MCA

Question 25

damage to optic radiations in MCA stroke

Answer 25

contralateral homonymous hemianopia without macular sparing (or contralateral superior or inferior quatrantanopsia)

Question 26

Anterior cerebral artery stroke

Answer 26

contraletral weakness and sensory loss in the lower limbs more marked than in upper limbs abulia (disinterest/slowed mental state) urinary incontinence dysarthria transcortical motor aphasia frontal release signs limb apraxia

Question 27

abulia

Answer 27

a milder from of akinetic mutism that is characterised by disinterest and slowed mental state when asked to perform centrain motor or verbal tasks, patients display a delay in the motor and/or verbal response, or fail to continue the assigned task after intiially complying usually results from damage to frontal lobe or its connections

Question 28

posterior cerebral artery stroke

Answer 28

contralateral homonymous hemianopia with macular sparing due to occipital lobe involvement contralateral sensory loss due to lateral thalamic involvement - light touch, pinprick, and positional sense may be reduced memory deficits vertigo, nausea

Question 29

PCA territory stroke in the dominant hemisphere

Answer 29

(usually left hemisphere) alexia without agraphia (can't read) anomic aphasia (word finding for nouns and verbs) agnosia: impairment of recognition of sensory stimulus (most commonly visual)

Question 30

PCA territory stroke in the non dominant hemisphere

Answer 30

usually right hemisphere prosopagnosia

Question 31

features of thalamic injury

Answer 31

because the thalamus contains various nuclei with distinct functions, symptoms depend on the exact location of the lesion decreased arousal variable sensory loss aphasia visual feild losses apathy, agitation, personality changes

Question 32

prosopagnosia

Answer 32

inability to recognise familiar faces, but still able to name parts of the face or identify known individuals by clothes or voices

Question 33

stroke mimics

Answer 33

tumour subdural hematoma migraine hypoglycaemia postictal paralysis cerebral abscess

Question 34

an episode is considered to be a TIA if

Answer 34

symptoms resolve completely in 24 hours and there is no brain infarction

Question 35

intravenous thrombolysis

Answer 35

intravenous alteplase (recombinant tissue plasminogen factor) is effective when given within 4.5 hours of onset of symptoms of ischaemic stroke earlier treatment has better outcomes

Question 36

immediate treatment options for acute ischaemia stroke

Answer 36

Iv thrombolysis (alteplase) endovascular thrombectomy antiplatelet therapy neurosurgery

Question 37

endovascular thrombectomy

Answer 37

when stroke is due to occlusion of a large vessel, endovascular thrombectomy is highly effective when performed within 6 hours of symptom onset physical retrieval or apsiration of the occluding thrombus via th femroal artery using a stent retriever and/or aspiration catheter

Question 38

when is endovascular thrombectomy used

Answer 38

used in some patients in combination with alteplase when alteplase is contraindicated (eg. the patient is taking an anticoagulant) or when patients present too late for alteplase

Question 39

who is eligible for endovascular thrombectomy

Answer 39

within 24 hours of symptom onset has an occluded large vessel and salvageable brain tissue, as detected by CT or MRI perfusion

Question 40

antiplatelet therapy for acute ischaemic stroke

Answer 40

aspirin has modest benefit when given within 48 hours of acute ischaemic stroke and is routinely used do not give aspirin util brain imaging has excluded intracranial haemorrhage if the patient has recieved alteplase, withhold aspirin for 24 hours and do not start unntil follow up imaging has excluded haemorhage

Question 41

main adverse effects of alteplase

Answer 41

bleeding, including symptomatic intracranial haemorrhage

Question 42

do not give aspirin until

Answer 42

imaging excludes intracranial haemorhage

Question 43

neurosurgery for acute ischameic stroke

Answer 43

due to the effects of cerebral oedema, extensive hemispheric infarct s fatal in over 80% in a few highly selected patients, hemicraniotomy saves lives and reduces disability

Question 44

dysphagia management during acute ischaemic stroke

Answer 44

assess patient's aability to swallow before giving oral ddrugs maintain as nil by mouth and refer to speech pathology dysphagia often improves rapidly

Question 45

blood pressure during acute ischaemic stroke

Answer 45

do not lower blood prssure uring first 48 hours of stroke unless the patient has malignant hypertension, hypertensive encephalopathy, or patients neeing bloow pressure lowering to recieve alteplase

Question 46

oxygen and fever

Answer 46

give oxygen if the patient is hypoxic, lower fever with panadol

Question 47

hyperglycaemia

Answer 47

hyperglycaemia is associated with a worse outcomes after stroke, so avoid IV fluids contaning glucose 20% of patients with acute stroke have unrecognised diabetes monitor blood glucose and maintain euglycaemia

Question 48

mobilisation

Answer 48

early mobilisation, adequate hydration and antiplatelet therapy can help prevent DVT if a patient is immobilised, give enoxeparin

Question 49

how to decide whether to give tPa

Answer 49

no evidence of stroke mimic or intracranial haemorrhage acute symptoms consult neurology first unclear symptoms onset >4.5 hours from last known baselines state: MRI findings will determine whether thrombolysis is indicated

Question 50

absolute contraindications for tPa

Answer 50

recent ischaemic stroke or severe head trauma (<3 months ago) revent intracranial or intraspinal surgery history of intracranial heamorrhage GI malignancy or recent GI bleed acute haemorrhage acute bleeding diathesis severe uncontrolled hypertension >185/110