Stroke (Ischemic and hemorrhagic)

Question 1

Define stroke

Answer 1

Rapidly developing clinical signs of focal disturbance of cerebral function lasting more than 24 hours or leading to death with vascular origin.

Question 1

What is the aetiology of ischaemic stroke?

Answer 1

Blood supply to cerebral vascular territory is critically reduced due to occlusion or stenosis of cerebral artery .

Question 2

How can ischaemic be classified?

Answer 2

Primary vascular pathology - atherosclerosis, dissection, vasculitis, embolism. (Reduce cerebral perfusion)
Cardiac pathologies - AF, MI, patent foramen ovale (these lead to occlusion due to embolism)
Haem pathologies - Prothrombotic hypercoagulable states precipitating embolism

Question 3

What are modifiable risk factors of stroke?

Answer 3

BP, smoking, DM, heart disease, peripheral vascular disease, combined OCP, alcohol

Question 4

What are some differentials for stroke?

Answer 4

head injury
hypo/hyperG
Subdural haemorrhage
Intracranial tumour
Hemiplegic migraine

Question 5

What are some key signs of stroke?

Answer 5

Unilateral weakness or paralysis in face/arm/leg
Dysphasia
Ataxia - points to cerebellar involvement
Visual disturbance

Question 6

What will you get for sure if it is middle cerebral affected?

Answer 6

Hemiparesis

Question 7

What are posterior circulation strokes typically associated with

Answer 7

Difficulty with fine motor coordination and gait.
Diplopia also.

Question 8

What is dysarthria?

Answer 8

Trouble speaking because muscles are weak

Question 9

What is epidemiology of stroke?

Answer 9

1 every 3.5 mins
1 in 4 die in a year
half of survivors have a perm disability/

Question 10

What is the acute management of stroke?

Answer 10

Protect the airway
Maintain haemostasis - BMs, if hypertensive crisis treat
Screen swallow - NBM
CT/MRI within 1hr, (headache, consciousness, signs of ICP can point to bleed)
Aspirin 300mg once haemorrhage excluded 2 weeks
Alteplase if within 4.5hrs of symptoms
Thrombectomy if visualized

Question 11

Where should stroke patients be admitted?

Answer 11

Acute stroke unit

Question 12

What gives you idea brainstem involvement/

Answer 12

Quadriplegia
Gaze disturbance and vision
Locked in syndrome

Question 13

What are secondary prevention measures?

Answer 13

Control modifiable risk factors
long term clopidogrel monotherapy after 2 weeks of aspirin
Statin therapy
Antihypertensive.

Question 14

What is prognosis of stroke?

Answer 14

Overall mortality of 60k a year
20% at 1 month and then 10% at year
Less than 40% recovery fully
Drowsy = poor prognosis.

Question 15

What are some imperatives for re-enablement after stroke?

Answer 15

Swallowing - speech therapist should assess if struggles with a sip of water
Minimise fall risk
Ensure good bladder and bowel care - catheter can prevent continence
Prompt physiotherapy to avoid spasticity
Monitor mood

Question 16

What are some complications of stroke?

Answer 16

DVT
Haemorrhagic transformation
Depression
Fatigue
Aspiration pneumonia

Question 17

Anterior cerebral artery stroke

Answer 17

Contralateral hemiparesis and sensory loss, lower extremity > upper

Question 18

Middle cerebral artery

Answer 18

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

Question 19

Posterior cerebral artery

Answer 19

Contralateral homonymous hemianopia with macular sparing
Visual agnosia

Question 20

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

Answer 20

Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity

Question 21

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

Answer 21

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

Question 22

Anterior inferior cerebellar artery (lateral pontine syndrome)

Answer 22

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

Question 23

Retinal/ophthalmic artery

Answer 23

Amaurosis fugax

Question 24

Basilar artery

Answer 24

‘Locked-in’ syndrome

Question 25

Lacunar strokes

Answer 25

present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
Association with hypertension
basal ganglia, thalamus and internal capsule are common sites

Question 26

Quadriplegia

Answer 26

Pontine haemorrhage

Question 27

What is wernicke’s dysphasia

Answer 27

Speech fluent, comprehension abnormal and repetition impaired

Question 28

Brocas dysphasia

Answer 28

Non fluent speech, poor repetition, normal comprehension

Question 29

Conductive dysphasia

Answer 29

Word finding difficulties and difficulty repeating phrases