Stroke

Question 1

Bamford classification of a TACS (total anterior circulation stroke)

Answer 1

Hemiplegia (contralateral to lesion)

Homonymous hemianopia (contralateral to lesion)

Higher cortical dysfunction (dysphasia, dyspraxia, neglect)

Question 2

Bamford classification of a PACS (partial anterior circulation stroke)

Answer 2

2/3 of TACS criteria

Question 3

Bamford classification of a LACS (lacunar stroke)

Answer 3

Pure hemi-motor or sensory loss

Question 4

What is the NIHSS?

Answer 4

The NIHSS is a stroke severity scale, a systematic assessment to measure the neurological deficits seen with acute stroke.

Designed to standardise and document an easy to perform, reliable and valid neurological assessment.

Can be used to determine eligibility for thrombectomy, and to assess treatment success. Can be used before and after thrombolysis or thrombectomy.

Question 5

How would you assess speech in a patient you suspect has had a stroke?

Answer 5

Give simple, then 2-step commands.
Ask to repeat phrases ‘42 West Register Street’.
Test naming objects: hold up and ask them to name what you’re holding.

Question 6

What is used to consider eligibility for thrombectomy?

Answer 6

Patient’s overall clinical status
NIHSS (score >5)
Modified Rankin Scale (score >3)
Territories of infarction on brain imaging

Question 7

How is a POCS (posterior circulation stroke) defined? cerebellum + brainstem

Answer 7

Need ONE of:

Cranial nerve palsy + contralateral motor or sensory deficit.
Bilateral motor / sensory deficit.
Gaze palsy.
Cerebellar dysfunction.
Isolated homonymous hemianopia with macular sparing.

Question 8

Investigations and management of suspected acute stroke?

Answer 8

Bedside: A-E assessment, observations, GCS, blood glucose (stroke mimics), ECG (AF), urine dip (infection). Obtain collateral history to determine sx onset for thrombolysis eligibility, bedside speech and swallow assessment.

Bloods: FBC, CRP/ESR (young stroke - arteritis), UE, TFTs, cholesterol / lipid profile.

Imaging: CT head to rule out haemorrhage. MR brain.

Acute management is either thrombolytic or endovascular:
- Thrombolysis with alteplase (tPA) if <4.5 of sx onset and no ICH.
- If outside thrombolysis window, consider whether eligible for thrombectomy (6-12h sx onset)
- If not eligible, give aspirin 300mg OD for 2 weeks then 75mg clopidogrel lifelong

Longer-term management:
- Consider: echo, carotid doppler, CT venogram (to rule out CVST in young pt), clotting screen (thrombophilia), vasculitis screen (young stroke).
- Referral to HASU
- MDT input: SLT, PT, OT, dietetics (consider NG feeding)
- Secondary prevention: statin, HTN management, smoking cessation, consider anticoagulation if AF
- DVT prophylaxis with IPCs
- 1 month off driving for both stroke and TIA, if recovered after 1 month, no need to inform DVLA. Inform if any of the following after 1 month: weakness in arms or legs, visual disturbance, problems with balance, memory or understanding.

Question 9

Why do a carotid doppler following stroke?

Answer 9

To look for evidence of stenosis, to see if it could be the cause of stroke. If suitable for carotid endarterectomy, could arrange that.
(If anterior circulation stroke and >70% stenosed of ipsilateral internal carotid, consider if >50%)

Question 10

What other investigations could you consider if a patient has a normal ECG and carotid doppler following a stroke?

Answer 10

Look more closely for paroxysmal AF using a 24h or 5-day Holter monitor.

Consider a TTE looking for structural cause (PFO - paradoxical embolism).

Question 11

How does the nature of a visual field defect help you localise the lesion?

Answer 11

In an MCA stroke - would expect sensory changes.

Homonymous hemianopia can result from lesions of the optic tract, lateral geniculate body or optic radiation.

A left HH would signify a right-sided lesion.

In a posterior cerebral artery stroke, would expect macular sparing of the visual field defect (due to supply from the MCA)

Question 12

Signs of a dominant parietal lobe cortical infarct?

Answer 12

Dysphasia

Gerstmann’s syndrome: dyslexia, dyscalculia, finger agnosia, left and right disorientation

‘Dominant side - D’s’

Question 13

Signs of a non-dominant parietal lobe infarct?

Answer 13

Dressing and constructional apraxia (difficulty drawing/constructing designs despite full intellectual understanding of task)

Spatial neglect

Question 14

What are the contra-indications for thrombolysis?

Answer 14

Absolute contraindications:

Intra-cranial haemorrhage
Seizure at onset
Stroke/TBI <3m
LP <7d
GI bleed <3w
Active bleeding
Pregnancy
Varices
Uncontrolled HTN

Question 15

What makes up the Modified Rankin Score?

Answer 15

Modified Rankin Score (MRS) of DISABILITY not frailty.

0 = nil
1 = symptoms without disability
2 = Can look after own self for 1 week
3 = Cannot look after own self for 1 week
4 = Needs help with ADL’s
5 = Bed-bound

Question 16

What do you do if a patient is on a DOAC and needs thrombolysis?

Answer 16

Contra-indicated if received DOAC within 24 hours of stroke (move towards 48 hours)

Question 17

How do you manage blood pressure control in a candidate for thrombolysis?

Answer 17

No clear evidence that high blood pressure is a risk - there is a theoretical risk of bleeding.

Blood pressure is a protective mechanism in stroke.

If thrombolysing, - need to bring the blood pressure down

In thrombolysis - Labetolol boluses then infusion (provided HR>60)

Question 18

Can you ever thrombolyse a wake up stroke?

Answer 18

Can thrombolyse if you can get an urgent MRI to look at the T2/DWI mismatch to assess penumbra.

Question 19

What are the indications for thrombectomy?

Answer 19

1. Ischaemic stroke
2. Large vessel occlusion - intra-cranial carotid, MCA (M1, M2), basilar, and most recently posterior circulation strokes.
3. Need CTA!!!! Not just non-contrast CT. Need the scan BEFORE you refer.
4. MRS 0-1 (latest guidelines)
5. NIHSS >6 (or >10 for basilar)

Patients will get thrombolysis + thrombectomy together.

After 12 hours - need CT or MR perfusion scan to assess flow to brain and salvageable brain.

Even the larger strokes with large cores will now get thrombolysed - there isn’t actually as big a risk of bleeding as we predicted, so if there is a potentially salvageable penumbra - thrombolysis is on the table (based on data from 2023 trials)

Question 20

Signs of lateral medullary syndrome?

Answer 20

‘Crossed findings’

Ipsilateral:
- cerebellar signs
- nystagmus
- Horner’s syndrome
- palatal paralysis + decreased gag reflex
- loss of trigeminal pain / temp sensation

Contralateral:
- loss of pain and temp sensation

Question 21

Which artery is commonly occluded to cause lateral medullary syndrome?

Answer 21

The posterior inferior cerebellar artery (PICA).

Question 22

Define stroke and TIA.

Answer 22

Stroke - rapid-onset focal neurological deficit due to vascular lesion lasting >24h
TIA - same but <24h (more often <30 mins)

Question 23

Recite the MRC Power Scale

Answer 23

0 - none
1 - flicker of muscle activity
2 - moves with gravity neutralised
3 - moves against gravity
4 - reduced power against resistance
5 - normal power

Question 24

What are the symptoms and signs of acute stroke?

Answer 24

May present with acute limb weakness, sensory disturbance, visual disturbance or speech/swallow disturbance.

Inspection: walking aids, NG/PEG feed, fixed deformities i.e. flexed upper limbs, extended lower limbs)

CNS: any UMN sign (typically facial weakness with forehead sparing

Speech: spastic dysarthria (slurred /slow speech) or dysphasia (expressive i.e. frontal Broca’s area - difficulty with forming words OR receptive i.e. temporal Wernicke’s speech will be fluent but nonsensical)

Limbs: unilateral or bilateral UMN weakness / sensory loss. (NB: in first 48h of acute stroke, limbs may demonstrate LMN signs due to disruption of neuro signalling i.e. hypotonia/areflexic)

Cerebellar: DANISH

AF? Murmur
Carotid bruit?
Temporal tenderness (if headache)
Neck scars from carotid endarterectomy
Horner’s syndrome (if headache - vertebral / carotid dissection)