Stroke - review when doing neuro

Question 1

What are the two general types of stroke - which is more common?

Answer 1

• haemorrhagic (15-20%)

- ischaemic (80-85%)

Question 2

What is the pathology behind haemorrhagic stroke?

Answer 2

Raised blood pressure
Weakened blood vessel wall due to
- structural abnormalities like aneurysm, arteriovenous malformation(AVM)
- inflammation of vessel wall(vasculitis)

Question 3

What is the pathology behind ischaemic stroke?

Answer 3

-Thrombotic
(atherosclerosis leads to the development of a plaque which causes vessel stenosis and can cause low blood flow and ischaemia in itself or can rupture and thrombosis can superimpose = ischaemia)
-Embolic
-hypoperfusion

Question 4

What are 5 non-modifiable risk factors for stroke?

Answer 4

Age
Family history of stroke
Gender
Race
Previous stroke

Question 5

What are 10 modifiable risk factors for stroke?

Answer 5

Most important:
Hypertension
Hyperlipidaemia
Smoking

Other:
Diabetes                                            
Atrial fibrillation
Congestive heart failure
Alcohol excess
Obesity 
Physical inactivity
Poor socioeconomic status

Question 6

What are 7 rarer causes of stroke especially in the young?

Answer 6

Homocysteinemia

Vasculitis, Antiphospholipid antibody syndrome

Protein S, C, Antithrombin III deficiency

Paradoxical embolism through patent foramen ovale/pulmonary AV shunts

Genetic- Factor V Leiden mutation, common prothrombin mutation, MELAS, CADASIL,Fabry’s disease

Cardioembolic- mural thrombi, infective endocarditis, myxoma

Cervical artery dissection

Question 7

List 6 stroke mimics

Answer 7

Hypoglycaemia

Seizure- postictal states

Migraine

Other metabolic –hyperglycaemia, hyponatremia

Space occupying lesions like brain tumours

Functional hemiparesis

Question 8

For an ischaemic stroke what are the investigations involved:

• what are the investigations aiming to determine?
• what blood tests?
• what imaging?
• what other investigations?

Answer 8

Investigations directed to find cause of thrombosis or embolism
- glucose, lipids, thrombophillia screen in young patients

?atheroembolism- carotid scanning, CT/MR angiography of aortic arch

?cardioembolism

ECG- ?AF, ?old ischaemic changes(mural thrombus)
?LVH (suggests uncontrolled hypertension-commonest cause of AF)

ECHO (transthoracic, transoesophageal, bubble contrast study to look for interatrial connection)

24 hour- 5 day ECG monitor tests (Paroxysmal AF)

Question 9

what is the difference clinically between atheroembolic stroke and cardioembolic stroke?

Answer 9

Atheroembolism: infarcts in same side as carotid artery

Cardioemobilsm: infarcts in more than one arterial territory, bilateral