List some stroke mimics
Previous/old stroke!
T: brain injury
I: meningitis/encephalitis, abscess
N: (SOL) or neurological e.g. functional syndrome, focal seizures, epilepsy, Bell’s palsy, Todd’s paresis (after seizure)
D: e.g. intoxication or sedating drugs
E: e.g. hypoglycaemia, hyponatremia, Wernicke’s encephalopathy
V: e.g. aneurysm, migraine with aura/hemiplegia
I:
C: e.g. cerebral palsy
A:
Other:
- Transient global amnesia
- BPPV
- Vesitubular neuronitis
- Syncope syndrome
List some important risk factors to ask about in a stroke history
Non-modifiable:
- Check age
- Previous stroke / TIA
- Family history
Modifiable:
- Smoker
- Alcohol intake
- HTN
- Hypercholesterolaemia
PMH:
- Atrial fibrillation
- Carotid artery stenosis
- HTN
- Diabetes
- Ischaemic heart disease
- Migraine with aura / COCP use
State the 5 most common stroke mimics
- Migraine
- Syncope (fainting)
- Seizures
- Sepsis
- Functional neurological disorder (FND)
On a practical level, suggest the most important steps to managing a patient with a history of suspected stroke
After history and examination:
Urgent CT head (non-contrast)
If ischaemic, then give Aspirin 300mg stat AND Clopidogrel 600mg
Later on, can do diffusion weighted MRI for further information
Ensure bloods have been completed e.g. FBC, clotting screen, U&Es, CRP etc.
If haemorrhagic, contact on call neurosurgeons to discuss interventions
State some changes that may be visible on a CT scan following a stroke
Ischaemic stroke:
- Loss of grey / white matter differentiation
- Effacement
- Increased density of affected blood vessel
Haemorrhagic stroke:
- Increased attenuation (tend to be deep in the brain)
List some investigations to do for a patient presenting with a suspected stroke
B: baseline obs: (temp, BP, HR), CBG, ECG + basic swallow assessment
L: FBC, U&E, LFTs, calcium and phosphate, TFTs, clotting screen
I: URGENT CT head +/- CT angiogram, chest x-ray if concerned with aspiration
P
Also carotid doppler, cardiac monitoring (24 hr ECG) +/- echocardiogram
List some complications of strokes
- Recurrent stroke
- Dysphagia / aspiration pneumonia
- Raised ICP (malignant oedema, hydrocephalus, haemorrhagic transformation)
- Infections (chest, UTI)
- Immobility (bed sores, VTE, constipation)
- Post-stroke pain and fatigue
- Secondary epilepsy
- Mood and other cognitive issues
- Death
Outline some management considerations for stroke patients (stroke bundle)
- Admission to stroke unit
- Reperfusion therapy
- Optimising physiology and surveillance, prevention
and early intervention of complications - Nutritional support
- Secondary prevention (management risk factors etc.)
- Rehabilitation
List some secondary prevention measures, to help prevent future strokes
- Antithrombotic therapy e.g. antiplatelet / anticoagulation
- BP control (aim 130/80mmHg)
- Lipid control
- Glycaemic control (HbA1c < 7%)
- Carotid endarterectomy if required
Lifestyle changes:
- Smoking cessation
- Weight loss
- Reduce stress
- Exercise
List some contraindications for thrombolysis in stroke patients (in 4.5 hour window)
- Stroke in the past 3 months
- Recent head trauma
- Intracranial haemorrhage
- GI bleeding
- Recent surgery, acceptable BP, platelet count, and INR
List some contraindications for thrombectomy in stroke patients (in 24 hour window)
- Hypertension
- Coagulopathy
- Stroke in the past 3 months
If thrombolysis or mechanical thrombectomy isn’t perfromed, outline the next treatment steps
Oral Aspirin 300mg (OD) for the next 2 weeks
State the 2 main categories of haemorrhagic stroke
- Intracerebral (within the brain tissue itself or within the ventricles)
- Subarachnoid
Outline the difference between dysarthria and dysphasia
Dysarthria: a motor problen resulting in poor articulation
Dysphasia: difficulties in the generation or comprehension of speech (expressive or receptive dysphasia)
State the target BP in a patient with haemorrhagic stroke
Systolic BP < 140
Can use GTN or Labetalol
State the 2 main types of revascularisation therapy for ischaemic strokes and the time limits for these therapies
- Thrombolysis drugs e.g. IV Alteplase
- Must be within 4.5 hours of symptom onset - Thrombectomy (surgical clot removal)
- Must be within 24 hours of symptom onset
State the name of the scoring system used for strokes presenting to hospital and what it is used for
NIH Stroke Scale/Score (NIHSS)
Used to assess the severity of a stroke (0-42) = guides assessment
Composed of 11 parameters e.g. consious level, eye movements, motor arm & leg movements etc.
For the Oxford-Bamford stroke classification TACS, state the features
3/3 of the following:
- Unilateral weakness +/- sensory deficit
- Homonous hemianopia
- Higher cortical function loss e.g. visuospatial deficit, dysphasia
For the Oxford-Bamford stroke classification PACS, state the features
2/3 of the following:
- Unilateral weakness +/- sensory deficit
- Higher cortical function loss e.g. visuospatial deficit, dysphasia
- Homonous hemianopia
For the Oxford-Bamford stroke classification LACS, state the features
Any 1 of the following:
- Purely motor symptoms
- Purely sensory symptoms
- Mixed sensory-motor stroke (same area affected for both)
- Ataxia
For the Oxford-Bamford stroke classification POCS, state the features
Any 1 of the following:
- Bilateral sensory / motor deficit
- Cranial nerve palsy with contralateral sensory / motor deficit
- Cerebellar dysfunction e.g. ataxia, nystagmus
- Conjugate eye movement disorder
- Isolate homonomyous hemianopia
For a LACS stroke (Oxford-Bamford classification) presenting with purely motor signs - which area of the brain is affected?
Posterior limb of the internal capsule (carries descending corticospinal and corticobulbar tracts)
For a LACS stroke (Oxford-Bamford classification) presenting with ataxia - which area of the brain is affected?
Posterior limb of the internal capsule, basis pontis or corona radiata
For a LACS stroke (Oxford-Bamford classification) presenting with purely sensory signs - which area of the brain is affected?
Ventral posterolateral (VPL) nucleus of the thalamus
