Stroke

Question 1

Definition of Stroke

Answer 1

A clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral
function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin
• Symptoms less than 24 hours is considered transient ischaemic attacks (TIA)

Question 2

Stroke epidemiology

Answer 2

• Stroke is 3rd largest cause of death in UK
• Accounts for ~11% of all deaths
• Every 5mins someone in the UK suffers a stroke. 110,000 strokes each year – 25% are recurrent
• Main cause of adult disability

Question 3

Stroke : Risk Factors

Answer 3

• Hypertension •Smoking •Diabetes Mellitus •Hyperlipidaemia •AF
• Carotid Stenosis •Contraceptive Pill •Obesity •Polycythaemia •Excess Alcohol Intake •Physical inactivity •Illicit Drug Use
• Hx of Migraine

No-modifiable
•Age > 60 years
•Family History of stroke/TIA •Male Sex
•Race

Question 4

Types of Stroke

Answer 4

Ischemic 80%

• thrombosis (small and large vessel 50%)
• embolism 30% but may be significantly higher

Hemourragic 20%

• intracebral (hypertension as risk)
• subarachnoid aneurism

Question 5

pathophysiology of ischemic strokes

Answer 5

• Acute ischemic strokes result from vascular occlusion
• Ischemia causes cell hypoxia and depletion of cellular adenosine triphosphate (ATP)
• Influx of sodium and calcium ions and passive inflow of water into the cell lead to cytotoxic oedema.
• Affected regions with cerebral blood flow of lower than 10 mL/100 g of tissue/min are referred to collectively as the core. These cells are presumed to die within minutes of stroke onset
• Zones of decreased or marginal perfusion (cerebral blood flow < 25 mL/100g of tissue/min) the ischemic penumbra. Tissue in the penumbra can remain viable for several hours because of marginal tissue perfusion
• Haemorrhagic transformation represents the conversion of an ischemic infarction into an area of haemorrhage. This is estimated to occur in 5% of uncomplicated ischemic strokes
Post stroke cerebral oedema (10-20%)
seizures occur in 2-23% of patients within the first days after ischemic stroke.

Question 6

Assessment of Stroke

Answer 6

FAST should be used outside hospital to screen for a diagnosis of stroke or TIA.
Facial asymmetry Arm weakness Speech disturbance Time/test

Question 7

Recognition Of Stroke In ER (ROSIER)

Answer 7

Has there been loss of consciousness or syncope?-1
Has there been a seizure? -1
Asymmetric facial weakness? 1
Asymmetric hand weakness? 1
Asymmetric leg weakness? 1
Speech disturbance? 1
Visual field disturbance? 1
Total score if more than zero stroke is likely

Question 8

Specialist assessment for stroke includes

Answer 8

• Full history
• exclusion of stroke mimics
• identification of vascular territory
• identification of likely causes
• appropriate investigation

Question 9

What PMH is relevant for stroke when taking a history?

Answer 9

A focused medical history for patients with ischemic stroke aims to identify risk factors for atherosclerotic and cardiac disease, including the following
• Hypertension
• Diabetes mellitus
• Tobacco use
• High cholesterol
• History of coronary artery disease, coronary artery bypass, or atrial fibrillation
• In younger patients, elicit a history of the following:
• Recent trauma
• Coagulopathies

Question 10

Consider stroke in any patient presenting with acute neurologic deficit or any alteration in level of consciousness such as:

Answer 10

• Abrupt onset of hemiparesis, monoparesis, or (rarely) quadriparesis
• Hemi sensory deficits
• Monocular or binocular visual loss
• Visual field deficits
• Diplopia
• Dysarthria
• Facial droop
• Ataxia
• Vertigo (rarely in isolation)
• Nystagmus
• Aphasia
• Sudden decrease in level of consciousness

Question 11

What symptoms would you expect n a patient with a stroke affecting the Anterior Cerebral Artery?

Answer 11

Behaviour ,personality changes

Question 12

What symptoms would you expect n a patient with a stroke affecting the Middle Cerebral Artery?

Answer 12

• Motor and Sensory symptoms
• Dysphasia in dominant hemisphere
• Neglect and dyspraxia -non dominant hemisphere

Question 13

What symptoms would you expect n a patient with a stroke affecting the Posterior Cerebral Artery?

Answer 13

visual disturbances
Motor or sensory
Cerebellar signs

Question 14

What is involved in a full neurological exam?

Answer 14

• Full Neurological examination
1. Motor function
2. Sensory function
3. Cerebellar function
4. Visual field
5. Gait
6. Language (expressive and receptive capabilities)
7. Mental status and level of consciousness
8. Cranial nerves
• Ocular fundi (retinopathy, emboli, haemorrhage)
• Heart (irregular rhythm, murmur, gallop)
• Peripheral vasculature (palpation of carotid, radial, and femoral pulses; auscultation for carotid bruit)

Question 15

The NIHSS is easily performed; it focuses on the following 6 major areas of the neurologic examination:

Answer 15

• Level of consciousness
• Visual function
• Motor function
• Sensation and neglect
• Cerebellar function
• Language
• The NIHSS is a 42-point scale.
• Patients with minor strokes usually have a score of less than 5.
• An NIHSS score of greater than 10 correlates with an 80% likelihood of proximal vessel occlusions

Question 16

Investigations in stroke

Answer 16

• FBC/ ESR, Urea and Electrolytes, Glucose, Coagulation studies.
• ECG
• Lipid
• CXR

Question 17

Every patient with stroke should have brain imaging as soon as practical. Indications for urgent imaging include:

Answer 17

– Indications for thrombolysis
– On anticoagulant treatment or a known bleeding tendency
- History of head injury
– Depressed level of consciousness (Glasgow Coma Score below 13) – Unexplained progressive or fluctuating symptoms
– Papilloedema, neck stiffness or fever
– Severe headache at onset of stroke symptoms.

Question 18

When is carotid duplex scanning indicated?

Answer 18

Carotid Duplex scanning when carotid artery disease is suspected
MRA of carotid arteries
Echocardiography in patients where cardiogenic embolism is suspected.

Question 19

Initial management of Acute Stroke

Answer 19

 Airway and Breathing 
 Nutrition/ swallowing 
 Antiplatelet
Sao2 above 94%
 Thrombolysis
 Diabetic control aiming 4-10
 Blood pressure control: in acute stage ,185/95, lowering BPs may cause under perfusion of ischaemic penumbra.
 Antipyretics (hyperthermia increases ischaemic neuronal injury)
 Surgery if required

Question 20

Criteria for surgical referral for decompressive hemicraniectomy

Answer 20

• They should be referred within 24 hours of onset of symptoms and treated within a maximum of 48 hours.
• Aged 60 years or under.
• Clinical deficits suggestive of infarction in the territory of the middle cerebral artery, with a score on the National Institutes of Health Stroke Scale (NIHSS) of above 15.
• Decrease in the level of consciousness to give a score of 1 or more on item 1a of the NIHSS.
• Signs on CT of an infarct of at least 50% of the middle cerebral artery territory,

Question 21

Thrombolysis in Acute Ischaemic Stroke: Inclusion criteria

Answer 21

• Acute disabling stroke with a clearly defined time of onset NIHSS
>4
• No sings of acute stroke in CT brain
• Likely disabling with no significant improvement or recovery NIHSS >4
• Treatment initiated within 4.30 hours of symptom onset

Question 22

Procedures PRIOR to t-PA infusion

Answer 22

• History and physical exam consistent with acute ischaemic stroke
• CT brain (axial with 5mm cuts)
• FBC, U+E, glucose, clotting, ECG
• Compatible with inclusion criteria and contraindications

Question 23

Absolute contraindications to thrombolysis

Answer 23

• Any intracranial haemorrhage
• BP>185/110 after 2 attempts to reduce BP
• Surgery or internal trauma in past 14 days
• INR>1.7, APTT>40, or platelets <100,000 mm3
• Arterial puncture at a non compressible site in the past 7 days

Question 24

Secondary Prevention of Ischaemic Stroke

Answer 24

• Antiplatelet Agent
• Reduction in Cholesterol levels
• Anticoagulants in patients with AF
• Reduction in Blood Pressure
• Carotid Endarterectomy

Question 25

Antiplatelet Agents

Answer 25

Aspirin : CAST and IST (£1.50 per annum) Dipyridamole :ESPS 2 ( £120 per annum) Clopidogrel : CAPRIE (£460 per annum)

Question 26

DM recommendation in acute stroke

Answer 26

* In acute stroke keep BM 4-10 * The goal for hemoglobin A1c should be <=7% * In diabetics aim for Total cholesterol< 3.5 * Ezetimibe for those intolerant of Statins

Question 27

CHA2DS2-VASc Score for Atrial Fibrillation Stroke Risk

Answer 27

* Calculates stroke risk for patients with atrial fibrillation, possibly better than the CHADS2 score. * Age in Years <650 65-74+1 ≥75+2 * Sex Male 0 Female+1 * Congestive Heart Failure History YES 1 * Hypertension History YES +1 * Stroke/TIA/Thromboembolism History * Vascular Disease History YES +1 * Diabetes Mellitus YES +1

Question 28

Indication for CAROTID ENDARTERECTOMY

Answer 28

* > 70% stenosis * Symptomatic * Significant physical improvement * 6% risk of stroke

Question 29

Anticoagulants in Stroke.

Answer 29

- Anticoagulation in the first 14 days increase risk of intracerebral bleeding - Balance the risk of bleeding with risk of fatal PE - All Stroke patients with AF should be on warfarin if patient happy and there is no contraindications (INR 2-3)

Question 30

TIAs ABCD2 score

Answer 30

``` • A Age>60yrs = • B BP systolic >140 +/ diastolic >90mmHg • C Clinical features -Unilateral weakness - speech disturbance Without weakness • D duration in mins • D=DM • Scores 0-3: low risk • Scores 4-5: moderate risk • Scores 6-7: high risk ```

Question 31

Ongoing treatment for TIA

Answer 31

TIA continue Every patient with suspected TIA should have Aspirin 300mg immediately and advice not to drive for 4/52 a suspected TIA patients who are at high risk of stroke (that is, with an ABCD2 score of 4 or above) should have: aspirin (300 mg daily) started immediately specialist assessment and investigation within 24 hours of onset of symptoms measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors. People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke (as described in recommendation 5), even though they may have an ABCD2 score of 3

Question 32

Common sites of Haemorrhagic Stroke.

Answer 32

thalamus, putamen, cerebellum and brainstem

Question 33

Presentation of Haemorrhagic Stroke.

Answer 33

headache lowered GCS seizures, nausea and vomiting raised blood pressure similar to ischemic strokes

Question 34

Causes of Haemorrhagic Stroke.

Answer 34

* Anticoagulation * Trauma * AVMs * Dural A-V fistulae • IC aneurysms * IC Neoplasia * Drugs eg cocaine • Vasculitis Hypertension Old age African / Asian descent Cerebral Amyloid Angiopathy

Question 35

Acute management of Haemorrhagic Stroke.

Answer 35

* ICH is stroke with the least satisfactory treatment options * Medical emergency & delays cause worse outcome * Focus on urgent stabilization of cardio respiratory variables and treatment of intracranial complications * Airway management, including endotracheal intubation and mechanical ventilation, is a priority in the unconscious patient or in those with a deteriorating conscious level * Increased ICP can be related to a direct effect of the haematoma, the development of cerebral oedema, or hydrocephalus Haemostatic therapy • Warfarin : INR monitoring • Vit K, prothrombin complex concentrates (eg Beriplex) and FFP • Vit K combine with prothrombin complex concentrate ( PCC) or FFPs adverse reaction + infection have short duration of action