Limb Weakness 2

Question 1

Why might the weakness be greater in arm and face than the leg? Which arteries supply these?

Answer 1

1. ACA: supplies leg and foot primary motor cortex
2. MCA: supplies rest of primary motor cortex
   - so MCA affected in stroke

Question 2

What else does the MCA supply?

Answer 2

right posterior paritetal cortex, where damage can cause a contralateral hemineglect

Question 3

If the signs resolve in less than 24hr what is it?

Answer 3

TIA not stroke

Question 4

What are the first line investigations for suspected right sided MCA stroke?

Answer 4

1. Non contrast CT head
2. FBC
3. Blood glucose
4. Blood clotting
5. ECG

Question 5

Why would you do a non-contrast CT head?

Answer 5

1. determine if stroke is ischaemic or haemorrhagic

2. Help rule out other diagnosis

Question 6

Why do you do a FBC?

Answer 6

can show cause for arterial occlusion (e.g. polycythaemia, thrombocytosis) or heamorrhage (thrombocytopenia)

Question 7

Why do you measure blood glucose?

Answer 7

rule out hypoglycaemia

Question 8

Why do you measure blood clotting?

Answer 8

esp if patient on warfarin - also to exclude haemophilia or coagulopathy

Question 9

Why do you do an ECG?

Answer 9

looking for AF as cause of emboli

Question 10

Which type of stroke is more common?

Answer 10

ischaemic (80%)

Question 11

Why is it important to know if ischaemic or haemorrhagic stroke?

Answer 11

ischaemic potentially treatable with thrombolysis e.g. tPA

Question 12

What is an ischaemic stroke caused by?

Answer 12

embolism or in situ thrombosis occluding a cerebral artery

Question 13

How would you manage a haemorrhagic stroke?

Answer 13

suppportive therapy to aid rehabilitation and RF reduction

Question 14

What is the acute management of MCA ischaemic stroke outside of the 4.5hr window for thrombolysis?

Answer 14

1. antiplatelet drugs
2. stroke unit/specialist ward
3. VTE prophylaxis

Question 15

Which antiplatelet drug do you prescribe?

Answer 15

aspirin - as soon as confirmed ischaemic stroke but delayed 24hr is thrombolysis given

Question 16

Why do you transfer to stroke unit/specialist ward?

Answer 16

looked after by MDT, SALT

Question 17

Why do you need to do VTE prophylaxis?

Answer 17

patient mostly immobile

Question 18

How can you manage VTE prophylaxis?

Answer 18

1. LMWH can be given if haemorrhagic stroke excluded and patient low risk of ischaemic stroke becoming haemorrhagic
2. can give intermittent pneumatic compression device to calves

Question 19

Should you use a neuroprotective agent?

Answer 19

not enough evidence safe or beneficial

Question 20

What are 2nd line investigations for someone with ischaemic stroke or TIA?

Answer 20

1. carotid doppler US

2. ECHO

Question 21

Why do you do a carotid doppler US?

Answer 21

identify or exclude carotid artery atheromas that could be source of emboli causing stroke

Question 22

Why do you do an ECHO? When indicated?

Answer 22

Help identify cardiac source of embolil such as arterial thrombus
(e.g. indicated by AF, recent MI, abnormal infarction, abnormal ECG, heart murmur, ischaemic events affect more than one cerebral artery) or patent foramen ovale

Question 23

What medical complication of stroke can be managed in acute setting?

Answer 23

1. pressure ulcers
2. aspiration pneumonia
3. VTE and recurrent ischaemic stroke

Question 24

How do you prevent pressure ulcers?

Answer 24

regularly moving patient or special inflatable mattresses

Question 25

How do you prevent aspiration pneumonia?

Answer 25

carry out swallowing assessment and if necessary NG tube

Question 26

What are the elements of the disability screen in stroke?

Answer 26

1. GCS score 2. Swallow 3. Speech and language 4. Visual fields 5. Gait - can walk or not

Question 27

After the acute phase of a stroke what is the management needed?

Answer 27

1. risk factor reduction 2. drug prophylaxis 3. discharge with community care 4. follow up by GP

Question 28

How would you manage the RF or carotid artery disease?

Answer 28

e.g if has right carotid bruit, should have duplex US or carotid arteries within a week to determine if referral to vascular surgeons necerssary

Question 29

What drug prophylaxis is needed lifelong?

Answer 29

1. Daily antiplatelet prophylaxis: started before discharge e.g. clopidogrel 2. Daily statin: even if cholesterol levels normal 3. Daily ACE inihibitor and/or thiazide diuretic, aiming for a lower BP