Stroke

Question 1

Possible presentations of stroke

Answer 1

Weakness

Speech disturbance

Visual deficit

Visio-spatial dysfunction

Ataxia

Headache

Coma

Question 2

what weakness is presented in stroke

Answer 2

sudden (over minutes) unilateral weakness with rapid progression in a hemiplegic (paralysis) manner

Question 3

what other symptoms are present if weakness is present

Answer 3

reflexes are reduced initially, then tone and reflexes are increased
also, facial weakness is often present

Question 4

what speech manifestation are present in stroke

Answer 4

Dysphasia - indicates dominant frontal or parietal lobe damage

Dysarthria - caused by weakness, or in-coordination of face and pharyngeal muscles

Question 5

what visual changes could occur in a stroke patient

Answer 5

Monocular blindess - caused by reduced blood flow in the internal carotid or ophthalmic arteries

If transient (amaurosis fugax)

contralateral hemianopia - caused by ischaemic damage occiptal cortex, optic tracts

Question 6

visuo-spatial dysfunction could occur when there is damage to?

Answer 6

Non-dominant cortex

Question 7

what symptoms are associated with visuo-spatial dysfunction

Answer 7

contralateral sensory or visual neglect and apraxia (difficulty performing tasks, “movements when asked”)

Question 8

What is apraxia mistaken for usually

Answer 8

confusion

Question 9

If stroke causes damage to the cerebellum and its connection this could cause

Answer 9

ataxia

sometimes +- diplopia, and vertigo

Question 10

Sometimes stroke presents as headaches

Answer 10

sudden severe headache is a cardinal symptom of SAH

it can also occur in intracerebral haemorrhage or cerebral venous disease

Question 11

what is an unusual symptom in stroke

Answer 11

seizures, but may occur in cerebral venous disease

coma is also uncommon, mostly associated brainstem event

Question 12

what is a focal neurological deficit?

Answer 12

it is problems involving the nerves, brainstem, or brain

it affects specific parts (left sided, tongue)

speech vision and hearing

Question 13

How is stroke usually classified

Answer 13

according to affected vascular territory

Question 14

stroke can be classified by time of deficit

Answer 14

If >24hrs –> stroke
if <24hrs –> TIA

if focal deficit worsens after first presentation it is classified as a “progressing stroke (stroke in evolution)”

if focal deficit is still present but not progressing then it is classified as a “completed stroke”

Question 15

what are the aims of stroke investigation

Answer 15

confirm vascular nature of lesion

distinguish infarction from haemorrhage

Question 16

Hemorrhagic vs ischaemic infarct

Answer 16

hemorrhagic infarct there is leakage from the blood vessels affected and shows a “red” brain if looked at grossly

ischaemic infarct is occlusion of the blood vessel without leakage causing no supply to that region in the brain then which causes a pale appearance when looking grossly

Question 17

Investigation to be undertaken in stroke

Answer 17

CT and MRI in all patients
LP (SAH)
Duplex USS carotids
ECG, Echo --> underlying cause?
magnetic resonance angiography (MRA)
CT angiography
FBC, cholestrol, glucose --> risk factors
ESR, clotting, thrombophilia screen --> rule out

Question 18

most common causes of cardiac embolisom?

Answer 18

AF
prosthetic heart valves
valvular abnormalities
recent MI

Question 19

Management Aims

Answer 19

minimise volume of brain with irreversible damage
prevent complications
reduce disability with rehabilitation

Question 20

management

Answer 20

early IV thromobolysis maximise benefits, use recombinant tissue plasminoge activatior (alteplase –> rt-PA). if later maybe fatal

aspirin (300mg) daily should be started immediately unless (rt-PA) is used, withhold for 24hrs

Heparins are useless and not good in acute stroke

warfarin when cario source

Question 21

risk factors of stroke

Answer 21

HTN, smoking, DM --> same as ACS
heart disease (valvular, ischaemic, AF)
hypercholestrolaemia
alcohol
PVD 
Hx of TIA
the pill
increased clotting

Question 22

stroke causes

Answer 22

small vessel occlusion –> thrombosis
cardiac emboli
atherothromboembolism from carotids
CNS bleeds

Question 23

primary prevention of stroke

Answer 23

this is before a stroke happens
contorl risk factors
encourage exercise

Question 24

secondary prevention of stroke

Answer 24

this is after first event

clopidogrel monotherapy is suggested to be beneficial (more than aspirin)

Question 25

Signs of TIA

Answer 25

AF
murmur from valvular disease
carotid bruits - if no bruits does not rule out carotid stenosis (tight stenosis no bruit)
HTN
fundoscopy may show emboli from retinal artery

Question 26

risk factors of haemorrhagic stroke

Answer 26

Age
HTN
Arteriovenous malformation
Anticoagulation
Substance/drug abuse

Question 27

risk factors of ischaemic stroke

Answer 27

Age
HTN
DM
Hypercholestraemia
smoking 
alcohol
major risk factor - AF

Question 28

Stroke in pathology can be either

Answer 28

Cerebral infarct - 85% of strokes

Intracerebral haemorrhage - 10%

Question 29

What is the commonest cause of cerebral infarct

Answer 29

thromboembolus from atherosclerotic patches in carotids or aortic arch

Question 30

How to manage a Px with haemorrhagic stroke unilateral weakness and reduced GCS?

Answer 30

Blood pressure reduction and consider neuro referal

Question 31

Which arteries are affected in a total anterior circulation infarct

Answer 31

Middle and anterior cerebral arteries

Question 32

What is ABCD2 criteria

Answer 32

The ABCD2 score:
A — age: 60 years of age or more, 1 point.
B — blood pressure at presentation: 140/90 mm Hg or greater, 1 point.
C — clinical features: unilateral weakness, 2 points; speech disturbance without weakness, 1 point.
D — duration of symptoms: 60 minutes or longer, 2 points; 10–59 minutes, 1 point.
D — presence of diabetes: 1 point.

Question 33

When is ABCD2 used

Answer 33

If TIA is suspected

Question 34

What is dysarthria

Answer 34

slow or slurred speech

Question 35

What is dysphasia

Answer 35

Dysphasia can be receptive or expressive. Receptive dysphasia is difficulty in comprehension, whilst expressive dysphasia is difficulty in putting words together to make meaning.