Stroke Medicine

Question 1

What is a stroke?

Answer 1

Infarction or bleeding into brain manifests with sudden onset focal CNS signs due to hypoperfusion and action potential arrest

Question 2

What are the types of stroke?

Answer 2

Ischaemic (85%), haemorrhagic (15%)

Question 3

What are some causes of stroke?

Answer 3

Small vessel occlusion or thrombosis in situ
Cardiac emboli (AF, endocarditis, MI)
Atherothromboembolism
CNS bleeds

Question 4

What are some risk factors for stroke?

Answer 4

HTN, smoking, DM, heart disease, peripheral vascular disease, carotid bruit
COCP, hyperlipidaemia, alcohol excess, ↑clotting

Question 5

Describe the features of signs seen in stroke:

Answer 5

Worst at onset

Sudden, focal, predominantly negative

Question 6

What scale can be used to assess the severity of a stroke?

Answer 6

NIH stroke scale

Question 7

What conditions would be suggested by stereotyped stroke symptoms?

Answer 7

Capsular warning syndrome (intermittent hypoperfusion of lenticulostriate end arteries when MCA flow reduced)
Intracranial stenosis

Question 8

What is the OCSP classification?

Answer 8

Classifies stroke into 4 syndromes:
Total Anterior Circulation Syndrome
Partial Anterior Circulation Syndrome
Posterior Circulation Syndrome
Lacunar Syndrome

Question 9

What are the features of a TACS?

Answer 9

Hemiparesis AND higher cortical dysfunction AND homonymous hemianopia

Question 10

What are the features of a PACS?

Answer 10

Isolated higher cortical dysfunction OR

any two of: hemiparesis, higher cortical dysfunction, hemianopia

Question 11

What are the features of a POCS?

Answer 11

Isolated hemianopia, brainstem or cerebellar syndromes

Question 12

What are types of lacunar stroke?

Answer 12

Pure motor
Pure sensory
Sensorimotor
Ataxic hemiparesis
Clumsy hand dysarthria

Question 13

Which vessels tend to be occluded in TACS?

Answer 13

Proximal MCA or ICA

Question 14

Which vessel tends to be occluded in PACS?

Answer 14

Branch MCA

Question 15

Which vessels tend to be occluded in POCS?

Answer 15

Vertebral, basilar, cerebellar or PCA

Question 16

Which vessels tend to be occluded in LACS?

Answer 16

Small penetrating arteries (usually lenticulostriate)

Question 17

What is the acute management for stroke (scan, meds etc.)?

Answer 17

Protect airway
Screen swallow
Non contrast CT head or MRI head within 1hr
Aspirin 300mg once haemorrhagic stroke is excluded (continue for 2w)

Question 18

Describe thrombolysis treatment and the indications:

Answer 18

Alteplase
Consider as soon as haemorrhage has been excluded and providing onset of symptoms was <4.5 hours ago
Best results within 90 mins

Question 19

What should be done 24h after thrombolysis?

Answer 19

CT to identify bleeds

Question 20

What are the complications of thrombolysis?

Answer 20

ICH, anaphylaxis, GI bleed

Question 21

What are some contraindications to thrombolysis?

Answer 21

Haemorrhage, recent surgery or trauma, previous CNS bleed, aneurysm, stroke in past 3m, known clotting disorder, anticoagulants or INR > 1.7, BP > 180/105, intracranial neoplasm, LP in last 7d

Question 22

How should intracerebral haemorrhage be managed?

Answer 22

BP control, correcting clotting derangement

Consider neurosurgery

Question 23

What is act FAST?

Answer 23

Facial asymmetry, Arm/leg weakness, Speech difficult, Time to call 999

Question 24

What are some examples of stroke mimics?

Answer 24

Subdural haematomas, brain tumours, MS

Migraine with aura, focal seizures, transient global amnesia, hypoglycaemia, sepsis, dehydration

Question 25

What are some examples of stroke chameleons?

Answer 25

Venous infarcts, limb shaking TIA, occipital stroke

Question 26

What are some post-stroke complications?

Answer 26

``` Recurrent stroke Immobility RICP Infections Mood and other cognitive issues Post stroke fatigue and pain ```

Question 27

What is primordial prevention in regards to stroke?

Answer 27

Prevent onset of rf in general pop. e.g. stop smoking campaigns

Question 28

What is primary prevention in regards to stroke?

Answer 28

Control rf in at risk groups Look for and treat HTN, DM, hyperlipidaemia, cardiac disease, anticoagulation in AF Help quit smoking, ↑exercise

Question 29

What is secondary prevention in regards to stroke?

Answer 29

Control rf, lower BP and cholesterol (even if not particularly raised) Antiplatelets after stroke - 2w aspirin, then long term clopidogrel

Question 30

What is the MoA of aspirin?

Answer 30

COX1 inhibitor, suppressing prostaglandin and thromboxane synthesis

Question 31

What is the MoA of clopidogrel?

Answer 31

Inhibits platelet aggregation by modifying platelet ADP receptors

Question 32

What is the MoA of dipyradimole?

Answer 32

↑cAMP and ↓thromboxane A2

Question 33

What is the target BP in stroke prevention?

Answer 33

130/80

Question 34

How should carotid artery stenosis be investigated and when should pts have surgery?

Answer 34

Carotid Doppler US | If stenosis >70% (ECST) or >50% (NASCET), likely need carotid endarterectomy

Question 35

What is the target HbA1c in stroke prevention?

Answer 35

<7%

Question 36

What is the target total cholesterol in stroke prevention?

Answer 36

<3.5mmol/L

Question 37

If cardiac source of emboli is suspected in stroke, what investigations can be done?

Answer 37

24h ECG for AF, echo

Question 38

What score can be used to guide whether anti-coagulation is needed in AF patients due to risk of stroke?

Answer 38

CHA2DS2 VASc

Question 39

What is a transient ischemic attack?

Answer 39

An ischaemic (usually embolic) neurological event with symptoms lasting <24h and without acute infarction

Question 40

What are some causes of TIA?

Answer 40

Atherothromboembolism from carotid (primary causes) Cardioembolism: mural thrombus, post MI, AF, valves Hyperviscosity: polycythaemia, sickle cell Vasculitis

Question 41

What investigations should be performed in suspected TIA?

Answer 41

FBC, U+Es, glucose, lipids, CXR, ECG, carotid Doppler, CT/MRI, echo

Question 42

What is the management for a TIA?

Answer 42

Control CV rf: HTN, lipids, DM, smoking 300mg aspirin for 2w then 75mg clopidogrel Anticoagulation if cardioembolism Carotid endarterectomy: within 2w if >70% stenosis No driving for at least 1m

Question 43

When can thrombectomy be used?

Answer 43

Within 6 hours of onset | Large artery occlusion in proximal anterior circulation