Stroke

Question 1

Definition

Answer 1

Rapidly developing clinical signs of focal disturbance of cerebral function, last >24hrs or leading to death with no appararent cause of the vascular origin

Question 2

Types

Answer 2

Ischaemic - 80%
Intra-cranial haemorrhage
Sub-arachnoid haemorrhage

Question 3

Ischaemic stroke

Answer 3

blocakge of blood vessels to the brain by a clot

Question 4

Ichaemic stroke can occur by?

Answer 4

Thrombosis: A clot may form in an artery that is already very narrow.

Embolic: A clot may break off from another place in the blood vessels of the brain, or from some other part of the body, and travel up to the brain.

Systemic hypoperfusion - global hypoxia

Question 5

Thrombotic stroke

Answer 5

Large vessel - Atheosclerosis artery

Small vessel disease - liphyalnosis (wall thickenging and reduced lumen) –> lacunar type stroke

Question 6

Embolic stroke

Answer 6

cardiac 
-AF
-MI 
Aortic 
>3mm atheroma 
Arterial 
-atheroma 
-dissection

Question 7

Circle of willis !

Answer 7

• Four blood vessels supply the brain
• 2 carotids supply front
  o Split into the anterior and middle cerebral arterys
• 2 artery’s supply back
  o 2 vertebral combine to form the basilar artery
  o The split to form posterior cerebral arterys

Question 8

Pathophysiology of ischaemic stroke

Answer 8

• Embolism or thombus present
• Depending on size of clot, it lodges into relevant size of vessel (large vessel, large clot)
• Rapid decline in cerebral blood flow
• Results in excitotoxicity:
  o Neurons release glutamate (excitatory neurotransmitter)
  o Glutamate activates calcium and sodium entry into the cell
  o Sodium entry, water follows, cell swells and dies
  o Calcium entry
   Activates enzymes and proteases
   Apoptosis
   Oxidative damage
   Inflammation
  o Leads to cell death

Question 9

Anterior cerebral artery supplies

Answer 9

Anterior and Medial side of brain

Question 10

Middle cerebral artery supplies

Answer 10

lateral side of the brain

Question 11

Posterior cerebral artery supllies

Answer 11

occiptal lobes

Question 12

Map of tissue death

Answer 12

Core- tissue that has died
Penumbra - damaged, but slvageable tissue
Oligaemia - area of low flow

Question 13

Risk factors for ischaemic stroke

big 5

Answer 13

• hypertension
• smoker
• diabetes
• hypercholesterolaemia
• famil history

Question 14

Intracerebral haemorrhage pathophysiology

Answer 14

• Blood pressure, tends to cause deep haemorrhage (haemorrhage aound basal ganglia)
• Blood pressure is high around the base of the brain, as vessles extend out towards the edge, pressure drops
• Small BVs are at high risk of rupture in the presence of high blood pressure

Question 15

Risk factors for intracerebral haemorrhage

Answer 15

• Hypertension!!!!!!!
• Anticoagulants, anti-platelet, warfarin
• Dementia
• Amyloid deposits (cerebral amyloid angiopathy)
• Vascular malformations (drug abuse in youn

Question 16

Clinical manifestations of stroke

Answer 16

Face 
Arms 
Speech 
Time
(FAST) 

TACS, PACS, POCS, LACS

Question 17

TACS (total anterior circulation syndrome)

Artery affected

Answer 17

Total anterior circulation syndrome (TACS)
It is diagnosed when it causes all 3 of the following symptoms:
1) Contra-lateral hemiparesis
2) Contra-lateral hemianopia
3) Higher dysfunction (e.g Dysphasia, Visuospatial disturbances)
+- contralateral hemisensory loss

proximal middle cerebral, or internal cereral artery

Question 18

PACS (partial anterior circulation syndrome)

Answer 18

Partial anterior circulation stroke (PACS)
When 2 of the above 3 are present or when higher dysfunction alone.

Branch of middle cerebral artery

Question 19

POCS (Posterior circulation stroke)

Answer 19

It can cause the following symptoms:
•	Cranial nerve palsy (ipsilateral) with contralateral motor/sensory defect 
•	Bilateral motor or sensory defect 
•	Eye movement disorder 
•	Cerebellar signs 
•	Isolated homonymous hemianopia 
.
Posterior, basilar, cerebellar and vertebral arteries

The hallmark of posterior circulation stroke is that of crossed findings; with
cranial findings on the side of the lesion and motor or sensory findings on the
opposite side

Question 20

LACS (lacunar stroke)

Answer 20

Lacunar stroke (LACS)
Can have the following presentations:
•	Pure motor stroke/hemiparesis
•	Ataxic hemiparesis
•	Dysarthria/clumsy hand
•	Pure sensory stroke
•	Mixed sensorimotor stroke

Internal capsule (pure motor), Thalamus (pure sensory) or Pons (ataxia, Contralateral hemiparesis and ipsilateral cerebellar signs)

Perforating artery/small vessel disease

Question 21

Transient Ischaemic Attack (TIA)

Answer 21

Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia, without acute infarction and over within 24hours

Question 22

Baseline investigations

Answer 22

Glucose

• too high dont treat with thromboylsis
• hypoglycaemia (neurological deficit)

FBC, U7Es, LFTS, blood glucose, coagulation profile

ECG- look for atrial fibrillation

CT- easy & quick (eclude mimics, distinguish between haemorrhagic/ischaemic, confrim diagnosis, detects complications and salvagebale tissu)

Vascular
-CT angiogram/MR angiogram/doppler ultrasound

Question 23

Ichaemic vs haemorrhagic

Answer 23

Cannot distinguish clinically 
ICH more likely if: 
-	Decreased conscious level 
-	Vomiting 
-	Severe headache 
-	Warfarin 
-	Systolic BP >220 mmHg 
-	Progressive symptoms 
These results are not absolute, cannot without scan

Question 24

Treatment of stroke

ACUTE THERAPY

Answer 24

1. admitt to stroke unit
2. thrombolysis if within 4.5 hours
   - give IV alteplase
   - only for ischaemic stroke
3. after 4.5 hours
   - aspirin 300mg at FRONT DOOR
4. neurointervention - if thromboylsis fails (retrieve the clot)

NOTE- if AF give warfarin

Question 25

Treatment of stroke | Damage limitation

Answer 25

decompress hemicranectomy - to relieve pressure - young patients

Question 26

Treatment of stroke | Further prevention

Answer 26

aspirin + dipyridamole = clopidogrel Antihypertensives- ACEI- stable patient Statins

Question 27

Other rehabilitation

Answer 27

``` Rehab - physio -speech therapy -occupation therapy Smoking cessation Dietician Pyschology ```

Question 28

Prognosis ischaemic

Answer 28

``` early mortality - 20% independence at 6 motnhs - 60% risk of recurrence -10% at 1 month -18% at 3 months ```

Question 29

Prognosis haemorrhagic stroke

Answer 29

- Early mortality = 60% - Independence at 6 months = 20% - Risk of recurrence – 2 % per year

Question 30

Intracerebral Haemorrhage treatment

Answer 30

1. ABCs 2. Admitt stroke unit 3. prevent haemotoma expansion - reverse anticoagulants (prothrombin complex concentrate preferreed) - lower bP ?? 4. Neurosurgery only indicated if posterior fossa haemotoma 5. treat pyrexia 6. DVT prophylaxis 7. Nutrition 8. Early rehab

Question 31

Complications of stroke

Answer 31

``` Brain oedema Pneumonia Urinary tract infections Seizures Clinical depression Bedsores DVT ```