Stroke & TIA

Question 1

What are the 4 main causes of Stroke?

Answer 1

Cerebral microangiopathy/small blood vessel occlusion
Cardiac Emboli (from AF, endocarditis, MI)
Atherosclerotic thrombotic emboli (from carotid artery)
Haemorrhage (Inc BP, aneurysm, trauma, anticoagulation)

Question 2

Modifiable Risk Factors for stroke

Answer 2

BP control, Smoking, Diabetes, Cholesterol, Heart Disease (valvular, ischaemic and AF), PVD, Carotid bruit, Inc PCV, The pill.

Question 3

What are the pointers to haemorrhage

Answer 3

Meningism, Severe Headache, Coma within hours.

Question 4

CT scan showing for haemorrhage:

Answer 4

Initially dark grey on CT overtime becomes black.

Question 5

What are the pointers to Infarct.

Answer 5

Carotid bruit, AF, Past TIA IHD.

Question 6

3 types of infarcts and %?

Answer 6

Cerebrum infarcts (50%)
Brainstem infarcts (25%)
Lacunar infarcts (25%)

Question 7

What % of strokes are infarcts and haemorrhage?

Answer 7

15% - Haemorrhage

85% - Ischaemic

Question 8

What % of Ischaemic strokes become Haemorrhagic?

Answer 8

33% 1/3 of ischaemic strokes.

Question 9

1. ) Most common brain stem stroke?

2. ) How do you interpret brain stem strokes?

Answer 9

1. )Lateral medullary syndrome]

2. ) Rule of 4.

Question 10

1. ) What are Lacunar Infarcts?

2. ) What structures do they effect?

Answer 10

1.) Small occlusions of distal arteries.

Usually clinically silent, however over time repeated offences can cause vascular dementia.

Question 11

Brain Stroke Syndromes

1. ) Middle Cerebral Artery
2. ) Posterior Cerebral Artery
3. ) Anterior Inferior Cerebellar Artery
4. ) Posterior Inferior Cerebellar Artery
5. ) Basilar Artery
6. ) Vertebral Artery

Answer 11

1.)
Ataxic Hemiparesis
Gerstmann Syndrome (Gerstmann Syndrome)
Middle Cerebral Artery - Inferior Division
Middle Cerebral Artery - Superior Division

2.)
Posterior Cerebral Artery - Unilateral Occipital
Thalamic Pain Syndrome
Weber Syndrome

3.)
Lateral Pontine Syndrome

4.)
Lateral Medullary Syndrome

5.) 
Ataxic Hemiparesis
Cortical Blindness 
Inferior Medial Pontine Syndrome 
Lateral Pontine Syndrome 
Locked-in Syndrome
Medial Medullary Syndrome 
Ventral Pontine Syndrome 
Ventral Pontine Syndrome 

6.)
Lateral Medullary Syndrome
Medial Medullary Syndrome

Question 12

Management: Acute

Answer 12

Protect airway
Pulse, BP and ECG - Is it an embolus from AF?
Blood glucose - 4-11mmol/l

Urgent CT/MRI - IF:
Thrombolysis considered
Cerebellar stroke
Unusual presentation OR HIGH risk of Haemorrhage (from Hx):
Meningism, severe headache, Dec GCS, Inc ICP, anti-coagulated, PMH of bleeding.
Otherwise imaging can wait.

Thrombolysis:
if <4.5 hours and no Contraindications exist.
IV tpa - tissue plasminogen factor. 0.9mg/kg over 1hr.

Always do CT 24 hours post tpa treatment.

C/I: 
Recent birth, surgery, trauma. 
Major infarct or Haemorrhage on CT
INR > 1.7 or on Anticoagulants. 
Aneurysm 
Past CNS bleeds 
Platelets <100 
Severe liver disease, varices, portal hypertension

Question 13

Primary prevention of Stroke

Secondary prevention of stroke

Answer 13

PRIMARY
No Smoking. 
Lipids - Statins. 
Folic acid (reduces Homocysteine), 
Exercise (Glucose tolerance and HDL inc)
DM - control of glucose - medication. 
AF or Prosthetic heart valve on left --> Anticoagulants. 

SECONDARY
Control RiskF’s as above.
Medications, assuming no haemorrhage: Clopidogrel.

Question 14

1. ) Tests for cause of stroke
2. ) Prognosis
3. ) complications

Answer 14

Hypertension (don’t treat in acute setting)
ECG - look for AF
CXR - Large left atrium.
Echo - Post MI or Valvular disease, mural thrombus from AF.
Carotid doppler - artery stenosis >70% is significant.

2.) 60,000/year die. 
Mortality 20% at one month
<10%/year. 
Full recovery - <40% 
Drowsiness - poor prognosis. 

3.) aspiration pneumonia - Keep nil by mouth.
pressure sores
constipation

Question 15

After Stroke Care

Answer 15

Enablement Approach

6 points of early management
Swallowing, falls risk, bladder and bowel, minimise spasticity, time taken to sit up, emotional liability.

Tests 
Perceptual function - name body part 
Spatial ability - matching matchsticks 
Apraxia - copying a clock. 
Agnosia - picking objects. 
Depression - screen for it. 

Physio

End of life decisions

Question 16

Post stroke surgery treatment

Answer 16

Levetiracetam

Question 17

3rd nerve palsy, with ipsilateral pupillary dilatation - Cause?

Answer 17

A posterior communicating aneurysm.

Question 18

Retinal Artery emboli from stroke, causes what condition?

Answer 18

Amaurosis Fugax

Question 19

Differentials

Answer 19

Hypoglycaemia 
Migraine Aura 
Focal Epilepsy
Hyperventilation 
Retinal bleeds

Question 20

Tests

Answer 20

Find the cause of TIA 
Define vascular risk 
FBC, U&E's, Lipids, Glucose, ESR 
Chest Xray
ECG 
Doppler +/- angiography 
CT
Echo

Question 21

Treatment

Answer 21

Control CV RFs. BP, smoking, hyperlipidaemia, glucose.
Clopidogrel - 75mg/d.
OR
Aspirin and Dipyridamole

Warfarin indication - if cardiac emboli from AF, post MI, Mitral stenosis.

Carotid Endarterectomy - surgery performed within 2 weeks. If more than 70% severely blocked.

Question 22

DVLA

Answer 22

avoid driving for one month, if multiple attacks in short period inform DVLA or residual effects of TIA.

Question 23

ABCD2 - prediction of stroke.

Answer 23

Score over 4 should be assessed by specialist within 24 hours.
All patients with TIA should be seen within 7 days by specialist.

Age - 60 years old (1) 
BP - >140/90 (1) 
Clinical Features 
            Unilateral weakness (2)
            Speech disturbance without weakness (1)
Duration of Sx 
            Sx lasting >1hr (2)
            Sx lasting 10-59mins (1)
Diabetes (1)