STROKE

Question 1

requirements of the oxford stroke criteria

Answer 1

1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia

Question 2

TACI define

Answer 2

• involves middle and anterior cerebral arteries

- all 3 of the above criteria are present

Question 3

posterior anterior circulation infarcts include

Answer 3

• involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
• 2 of the above criteria are present

Question 4

lacunar infarcts define

Answer 4

• involves perforating arteries around the internal capsule, thalamus and basal ganglia
• presents with 1 of the following:
  1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
  2. pure sensory stroke.
  3. ataxic hemiparesis

Question 5

posterior circulation infarcts

Answer 5

• involves vertebrobasilar arteries
• presents with 1 of the following:
  1. cerebellar or brainstem syndromes
  2. loss of consciousness
  3. isolated homonymous hemianopia

Question 6

lateral medullary syndrome define

Answer 6

(posterior inferior cerebellar artery)
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss

Question 7

webers syndrome

Answer 7

ipsilateral III palsy

contralateral weakness

Question 8

which arteries are affected in TACI

Answer 8

anterior and middle cerebral arteries

Question 9

define stroke

Answer 9

sudden interruption in the vascular supply of the brain.

Question 10

what are the two types of stroke

Answer 10

ischaemic
- more than 24 hours
- less than 24 hours - TIA
haemorrhagic

Question 11

define iscahemic stroke

Answer 11

It is usually caused by blood clot in an artery, which blocks the flow of blood.

• 85%
• clot from atheroma
• embolus from AF

Question 12

define heamorrhagic stroke

Answer 12

damaged or weakened artery may burst and bleed:

• An intracerebral haemorrhage occurs when the blood vessel bursts inside the brain. The blood then spills into the nearby brain tissue. This can cause the affected brain cells to lose their oxygen supply. They become damaged or die.

subarachnoid haemorrhage

Question 13

what is TIA

Answer 13

causes symptoms similar to a stroke but the symptoms last for less than 24 hours. It is due to a temporary lack of blood to a part of the brain. In most cases, a TIA is caused by a tiny blood clot that becomes stuck in a small blood vessel (artery) in the brain. This blocks the blood flow and a part of the brain is starved of oxygen. The affected part of the brain is without oxygen for just a few minutes and soon recovers. This is because the blood clot either breaks up quickly or nearby blood vessels are able to compensate.

Question 14

Symptoms of a stroke

Answer 14

sudden onset - more than 24 hours CANNOT BE EXPLAINED BY ANOTHER CONDITION SUCH AS HYPOGLYCAEMIA

Weakness of one side of the body

visual problems - HOMONYMOUS HEMIANOPIA double vision, visual field loss

speech such as dysphasia/dysarthria and communication difficulties.

swallowing difficulties- do a swallow test before they allowed to eat or drink

Problems with balance and co-ordination.

Confusion, altered level of consciousness and coma.

Difficulties with mental processes. For example, difficulty in learning, concentrating, remembering

Headache – sudden, severe and unusual headache which may be associated with neck stiffness. Sentinel headache(s) may occur in the preceding weeks.

Dizziness, vertigo or loss of balance — isolated dizziness is not usually a symptom of TIA.

Sensory loss – paraesthesia or numbness.

Inappropriate emotions.

tiredness

Question 15

posterior circualation stroke symptoms

Answer 15

acute vestibular syndrome — acute
persistent
continuous vertigo or dizziness with nystagmus
- nausea or vomiting
- head motion intolerance
- new gait unsteadiness.

Question 16

risk factors of stroke

Answer 16

age
hypertension
smoking
hyperlipidaemia
diabetes mellitus

lifestyle

• Smoking.
• Alcohol misuse and drug abuse (for example cocaine, methamphetamine).
• Physical inactivity.
• Poor diet.

Established CVS disease

• Hypertension.
• Permanent and paroxysmal atrial fibrillation (AF)
• Infective endocarditis.
• Valvular disease.
• Carotid artery disease — atheroma and stenosis of the carotid arteries are commonly associated with stroke and TIA.
• Congestive heart failure.
• Congenital or structural heart disease including patent foramen ovale.

other factors
- Age — the risk of having a stroke doubles every decade after the age of 55.

• Gender — Men are more likely than women to have a stroke at younger age. In women, an increased risk of stroke has been associated with current use of oral contraceptives, migraine with aura, the immediate postpartum period, and pre-eclampsia.
• Hyperlipidemia.
• Diabetes mellitus.
• Sickle cell disease.
• Antiphospholipid syndrome and other hypercoaguable disorders.
• Chronic kidney disease.
  Obstructive sleep apnoea
• (OSA) —cardiovascular risk factors such as hypertension, diabetes, smoking, and obesity are common in people with OSA but it is also an independent risk factor for stroke.

Question 17

complications in the early period of stroke

Answer 17

• Haemorrhagic transformation of ischaemic stroke.
• Cerebral oedema.
• Seizures.
• Venous thromboembolism — pulmonary embolism
• Cardiac complications — cardiac complications (myocardial ischemia, congestive heart failure, atrial fibrillation, and arrhythmias)
• Infection
• – aspiration pneumonia
• – urinary tract infection
• – cellulitis from infected pressure sores.

Question 18

long term complications of stroke

Answer 18

mobility

• hemiparesis and hemiplegia
• ataxia
• falls
• spastcity and contractures

sensory
- loss or alteration in sensations such as touch, temperature, and pain.

urinary and faecal incontinence
- urinary incontinence increases skin of breakdown

pain

• neuropathic pain or central post-stroke pain
• MSK pain - prolonged immobility, abnormal posture or pre-existing conditions.
• Shoulder pain - shoulder subluxation, motor weakness and spasticity

fatigue
- ass w depression and anxiety
SEs of meds, disturbed sleep, or respiratory problems.

swallowing, hydration and nutrition

• dysphagia
• poor oral hygiene
• dehydration and malnutrtition

communication

• dysphasia
• dysarthria

sexual dysfunction
altered sensation, limited mobility

skin problems
- pressures sores due to reduced mobility

visual problems
- altered acuity, hemianopia, diplopia, nystagmus, and blurred vision.

Difficulties with activities of daily living (ADL)
- Physical and cognitive impairment following stroke can lead to difficulties with personal care, driving, work, leisure and independent living.

emotional and psych
- depression and anxiety

Question 19

cognitive problems seen in long term stroke complications

Answer 19

Dyspraxia (difficulty in carrying out purposeful actions) can affect activities of daily living such as dressing.

Impairment of attention and concentration can restrict independence.

Impairment of executive function can lead to difficulty in planning and executing tasks, inhibiting inappropriate impulses, regulating emotional responses and predicting consequences of actions.

Problems with spatial awareness such as left-sided neglect or hemianopia.

Question 20

Examination of stroke

Answer 20

• Airway, breathing and circulation (ABC).
• Vital signs including blood pressure, heart rate, oxygen saturation, and temperature.
• The cardiovascular system — look for signs of heart failure, arrhythmias (such as atrial fibrillation), murmurs, valvular heart disease, endocarditis.
• The neurological system — look for clinical signs of stroke or TIA such as unilateral weakness, visual or speech disturbance, ataxia, and nystagmus.
• – The Face Arm Speech Test (FAST test) can be used for rapid assessment — it is positive if one or more of new facial weakness (asymmetry such as the mouth or eye drooping), arm weakness, or speech difficulty (such as slurring or difficulty in finding names for commonplace objects) are present.

— Carry out fundoscopy to identify intraocular haemorrhage (present in one in seven people with aneurysmal SAH).

Question 21

Ix for stroke

Answer 21

non-contrast CT head

check blood glucose to rule out hypoglycaemia as it is a stroke mimic

FBC
exclude anaemia/thrombocytopenia prior to possible initiation of thrombolysis, anticoagulants, or antithrombotics

U&Es
- exclude renal failure as it may contradict some stroke interventions

• exclude electrolyte disturbance ie hyponatraemia causes sudden onset neurological signs

ECG to exclude arrhythmia - AF/ischaemia

carotid doppler
prothrombin time and PTT with INR

Question 22

when do you request a non-enhanced CT head

Answer 22

within 1 hour if any of the following apply:
- indications for thrombolysis or thrombectomy

• On anticoagulant treatment
• A known bleeding tendency
• A depressed level of consciousness (Glasgow Coma Scale score <13)
• Unexplained progressive or fluctuating symptoms
• Papilloedema, neck stiffness, or fever
• Severe headache at onset of stroke symptoms.

Question 23

why is a non contrast CT head even done

Answer 23

Use to exclude intracranial haemorrhage which must be done before starting thrombolysis, and before reversing anticoagulation in anticoagulation-induced intracerebral haemorrhage

Question 24

What would you even see in a non contrast CT head

Answer 24

In people without indications for immediate brain imaging, request scan as soon as possible and definitely within 24 hours of symptom onset

• hypoattenuation (darkness) of the brain parenchyma
• loss of grey matter-white matter differentiation, and sulcal effacement
• hyperattenuation (brightness) in an artery indicates clot within the vessel lumen

Question 25

initial Mx of SUSPECTED ischaemic stroke

Answer 25

Manage any 1) airway 2) breathing - consider endotracheal intubation - -- who are unable to protect their airway - -- GCS (/ 8 - give oxygen only if sats drop below 93% - -- target 94-96 - -- at risk of hypercapnaeic failure aim for 88-92% circulatory insufficiencies requiring urgent treatment admit everyone with sus stroke to a stroke unit within 4 hours - assess swallowing function before administering anything - start nutrition support

Question 26

Mx for confirmed ischaemic stroke within 4.5 hours and thrombolysis not contradicted

Answer 26

1) SUPPORT a) assess GCS b) monitor glucose - 4-11mmol/L c) monitor BP ang give give anti-hypertensive treatment only if there is a hypertensive emergency - Hypertensive encephalopathy - Hypertensive nephropathy - Hypertensive cardiac failure/myocardial infarction - Aortic dissection - Pre-eclampsia/eclampsia. Consider reducing blood pressure to 185/110 mmHg or lower in people who are candidates for intravenous thrombolysis First line IV labetalol, nicardipine and clevidipine d) give oxygen only if sats less than 93 e) hydration - Isotonic saline f) temp g) ICP Repeat the CT head immediately if you suspect elevated ICP, which may present as: - A reducing level of consciousness - Severe headache - Nausea/vomiting - A sudden increase in blood pressure. h) seizures - levetiracetam and sodium valproate are commonly used. 2) IV alteplase - Treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms AND Intracranial haemorrhage has been excluded using appropriate imaging techniques CONSIDERED IN ALL PATIENT GROUPS 3) thrombectomy LOOK LATER 4) antiplatelet agent - 300mg aspirin 5) VTE prophylaxis plus early mobilisation

Question 27

when do you immediately refer to a neurosurgeon

Answer 27

1) with large middle cerebral artery territory infarcts and those with large infarctions affecting the cerebellum. These types of stroke have a very high mortality if urgent neurosurgical intervention is delayed. --- Patients with large middle cerebral artery territory infarcts (at risk of malignant middle cerebral artery syndrome) may need decompressive hemicraniectomy (neurosurgical removal of part of the skull to reduce intracerebral pressure). --- Patients with large infarctions affecting the cerebellum may need ventriculostomy (placement of an external ventricular drain) or posterior fossa craniectomy 2) uncontrolled or recurrent seizures or status epilepticus

Question 28

why is it important to refer anyone with large infarctions or MCA

Answer 28

at risk of developing oedema and elevated intracranial pressure. If left unchecked, the oedema compromises blood flow and causes brain herniation, which is frequently fatal.

Question 29

contradictions to thrombolysis with alteplase

Answer 29

Exclude hypoglycaemia and hyperglycaemia before giving thrombolysis; hypoglycaemia is a stroke mimic and hyperglycaemia is associated with intracerebral bleeding and worse clinical outcomes ABSOLUTE - Previous intracranial haemorrhage - Seizure at onset of stroke - Intracranial neoplasm - Suspected subarachnoid haemorrhage - Stroke or traumatic brain injury in preceding 3 months - Lumbar puncture in preceding 7 days - Gastrointestinal haemorrhage in preceding 3 weeks - Active bleeding - Pregnancy - Oesophageal varices - Uncontrolled hypertension >200/120mmHg Relative - Concurrent anticoagulation (INR >1.7) - Haemorrhagic diathesis - Active diabetic haemorrhagic retinopathy - Suspected intracardiac thrombus - Major surgery / trauma in the preceding 2 weeks

Question 30

dose of alteplase

Answer 30

0.9 mg/kg intravenously (maximum 90 mg/dose); give 10% of the total dose by intravenous bolus initially, then give the remainder of the dose by intravenous infusion over 60 minutes

Question 31

when to consider mechanical thrombectomy

Answer 31

A pre-stroke functional status <3 on the modified Rankin scale (mRS), and A score >5 on the National Institutes of Health Stroke Scale (NIHSS). 1) 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have: acute ischaemic stroke and -- confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) 2) Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes): - - confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and -- if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume Consider thrombectomy together with intravenous thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes): -- who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and -- if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Question 32

what antiplatelet is offered and when

Answer 32

Offer an antiplatelet agent as soon as possible but certainly within 24 hours (unless contraindicated) to any patient presenting with acute stroke who has had intracerebral haemorrhage excluded by imaging - - Aspirin orally (for those with no dysphagia), or - - Aspirin rectally or by enteral tube (for those with dysphagia). ALLERGIC give clopidegrol give PPI if anyone had dyspepsia Continue aspirin daily until 2 weeks after the onset of stroke symptoms, then start definitive long-term antithrombotic treatment

Question 33

what VTE prophylaxis is one

Answer 33

Give intermittent pneumatic compression within 3 days of admission for the prevention of deep vein thrombosis and pulmonary embolism Help the patient to sit out of bed, stand, or walk as soon as their clinical condition permits, as part of an active management programme in a specialist stroke unit

Question 34

When do we start statin therapy

Answer 34

if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. safe to start statins after 48 hours high intensity statin therapy

Question 35

subtypes of ischaemic stroke

Answer 35

Thrombotic stroke - thrombosis from large vessels e.g. carotid Embolic stroke - usually a blood clot but fat, air or clumps of bacteria may act as an embolus - atrial fibrillation is an important cause of emboli forming in the heart

Question 36

Cerebral hemisphere infarcts may have the following symptoms

Answer 36

- contralateral hemiplegia: initially flaccid then spastic - contralateral sensory loss - homonymous hemianopia - dysphasia

Question 37

brainstem infarction

Answer 37

may result in more severe symptoms including quadriplegia and lock-in-syndrome

Question 38

lacunar infarcts

Answer 38

- small infarcts around the basal ganglia, internal capsule, thalamus and pons - this may result in pure motor, pure sensory, mixed motor and sensory signs or ataxia

Question 39

what Sx are more common is haemorrhagic stroke

Answer 39

- decrease in the level of consciousness: seen in up to 50% of patients with a haemorrhagic stroke - headache is also much more common in haemorrhagic stroke - nausea and vomiting is also common - seizures occur in up to 25% of patients

Question 40

what is FAST

Answer 40

Face - 'Has their face fallen on one side? Can they smile?' Arms - 'Can they raise both arms and keep them there?' Speech - 'Is their speech slurred?' Time - 'Time to call 999 if you see any single one of these signs.'

Question 41

Mx for haemorrhagic strokes

Answer 41

Anticoagulants (e.g. warfarin) and antithrombotic medications (e.g. clopidogrel) should be stopped to minimise further bleeding.

Question 42

tools used for stroke

Answer 42

FAST | ROSIER

Question 43

What is ROSIER

Answer 43

Exclude hypoglycaemia Assessment - Loss of consciousness or syncope - 1 point - Seizure activity - 1 point ``` New, acute onset of: • asymmetric facial weakness + 1 point • asymmetric arm weakness + 1 point • asymmetric leg weakness + 1 point • speech disturbance + 1 point • visual field defect + 1 point ```

Question 44

when to arrange a follow up

Answer 44

arrange a follow up at 6 months east annually to review health, social care needs (such as access to benefits, community participation, housing and return to work), ongoing risk factors, and secondary prevention. Arrange review of carers of people with stroke at 6 months and then annually to assess their health and social care needs.

Question 45

lifestyle measures for stroke

Answer 45

Encourage physical activity every day Advise smokers to stop and non-smokers to avoid passive smoking Eat at least five portions of fruit and vegetables (from a variety of sources) per day and two portions of oily fish per week. Reduce intake of saturated fats. Keep salt intake low Alcohol intake should be limited to 14 units a week, spread over at least three days. Advise against routine dietary supplementation B vitamins or folate; vitamins A, C, or E; selenium; and calcium with or without vitamin D unless required for other medical conditions.

Question 46

medications used in secindary prevention of stroke

Answer 46

1) ANTIPLATELET THERAPY clopidegrol 75mg daily ASPIRIN/CLOPIDEGROL CONTRADICTED Modified-release dipyridamole 200 mg twice daily Aspirin 75mg daily may be used if both clopidogrel and modified-release dipyridamole are contraindicated or cannot be tolerated. 2) LIPID MODIFICATION DRUG Tx high intensity statin (such as atorvastatin 20–80mg daily) will be offered at diagnosis of ischaemic stroke or TIA by secondary care. The aim of statin therapy is to reduce non-HDL cholesterol by more than 40%. needs to be acheived within 3 months Fibrates, bile acid sequestrants, nicotinic acid and omega-3 fatty acid compounds should not be prescribed

Question 47

When may dual therapy may be started

Answer 47

aspirin and clopidogrel may be initiated in secondary care for the first three months following ischaemic stroke or TIA due to severe symptomatic intracranial stenosis or for another condition such as acute coronary syndrome.

Question 48

problems with hypovolaemia in stroke

Answer 48

can worsen the ischaemic penumbra, as well as increase risk of other complications such as infection, deep vein thrombosis, constipation and delirium Conversely, over-hydration can also complicate matters by leading to cerebral oedema, cardiac failure and hyponatraemia, therefore it is important to regularly review fluid status in these patients

Question 49

why shouldnt we lower bp too much

Answer 49

potentially compromise collateral blood flow to the affected region, and possibly hasten the time to complete and irreversible tissue infarction

Question 50

disability is most commonly measured using

Answer 50

Barthel index (BI), an outcome measure for stroke Describes 10 tasks, and is scored according to amount of time or assistance required by the patient for each given task Tasks: feeding, moving from wheelchair to bed, personal toileting, getting on/off toilet, bathing, walking on level surface, ascending/descending stairs, dressing, controlling bowels and controlling bladder The total score is from 0 to 100, with 0 being completely dependent, and 100 being completely independent assess the functional status of a patient post stroke, and to monitor their improvement with ongoing rehabilitation to regain independence after the event

Question 51

lesion in anterior cerebral artery

Answer 51

Contralateral hemiparesis and sensory loss, lower extremity > upper

Question 52

lesion in middle cerebral artery

Answer 52

- Contralateral hemiparesis and sensory loss, upper extremity > lower - Contralateral homonymous hemianopia - Aphasia

Question 53

lesion in posterior cerebral artery

Answer 53

- Contralateral homonymous hemianopia with macular sparing | - Visual agnosia

Question 54

Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain) lesion

Answer 54

Ipsilateral CN III palsy | Contralateral weakness of upper and lower extremity

Question 55

Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome) lesion

Answer 55

Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus

Question 56

Anterior inferior cerebellar artery (lateral pontine syndrome) lesion

Answer 56

Symptoms are similar to Wallenberg's (see above), but: | Ipsilateral: facial paralysis and deafness

Question 57

Retinal/ophthalmic artery lesion

Answer 57

Amaurosis fugax

Question 58

Basilar artery lesion

Answer 58

'Locked-in' syndrome

Question 59

lacunar strokes

Answer 59

present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia strong association with hypertension common sites include the basal ganglia, thalamus and internal capsule

Question 60

what should a rehab plan iclude

Answer 60

basic demographics, including contact details and next of kin diagnosis and relevant medical information list of current medications, including allergies standardised screening assessments (see screening and assessment) the person's rehabilitation goals multidisciplinary progress notes a key contact from the stroke rehabilitation team (including their contact details) to coordinate the person's health and social care needs discharge planning information (including accommodation needs, aids and adaptations) joint health and social care plans, if developed follow-up appointments

Question 61

what is CHADVASC scores

Answer 61

AF stroke risk

Question 62

what is HASBLED

Answer 62

score for major bleeding risk

Question 63

what does vertical nystagmus mean

Answer 63

central cause of vertigo