Stroke

Question 1

What is the definition of a stroke?

Answer 1

A sudden or rapidly developing loss of cerebral function due to a vascular cause, including both infarcts and haemorrhages.

Question 2

What is the classical definition of stroke in terms of duration of symptoms?

Answer 2

Symptoms last more than 24 hours, except in cases of early death.

Question 3

What is the key feature of stroke onset?

Answer 3

Sudden onset of symptoms and signs, occurring all at once (within seconds) or developing over minutes.

Question 4

How do stroke symptoms typically evolve over time?

Answer 4

They often worsen over minutes to hours, then stabilize and improve over time.

Question 5

What is meant by “focal” symptoms in stroke?

Answer 5

Symptoms that can usually be explained by a single lesion in the brain.

Question 6

What is the exception to stroke symptoms being focal?

Answer 6

In cases of multiple strokes or a history of previous strokes, symptoms may arise from different vascular territories.

Question 7

What are the typical “negative” symptoms of stroke?

Answer 7

Loss of function such as weakness, numbness, loss of vision, or speech difficulties.

Question 8

What are less common “positive” symptoms that can occur in stroke?

Answer 8

Seizures, jerks, flashing lights, or hallucinations.

Question 9

What motor symptoms may suggest stroke?

Answer 9

Weakness or clumsiness of one side of the body (hemiplegia or hemiparesis), which may affect part or all of that side.

Question 10

What sensory symptom is commonly seen in stroke?

Answer 10

Decreased sensation on one side of the body or part of one side.

Question 11

What language disturbances (aphasia) can occur in stroke?

Answer 11

Problems with speaking, understanding conversation, reading, and writing.

Question 12

What is visuospatial neglect, and which side does it usually affect in stroke?

Answer 12

Failure to attend to one side of space, usually the left side, associated with left hemiplegia and hemianopia.

Question 13

What visual disturbances may occur in stroke?

Answer 13

• Monocular blindness (loss of vision in one eye)
• Hemianopia or quadrantanopia (partial vision loss)
• Bilateral blindness with anosognosia (lack of awareness of blindness)

Question 14

What are some other focal neurological symptoms of stroke?

Answer 14

• Dysphagia (difficulty swallowing)
• Ataxia (lack of coordination)
• Paraparesis or paraplegia (weakness/paralysis of both legs)
• Dysarthria (slurred speech)
• Diplopia (double vision)
• Rotational vertigo (spinning sensation)
• Acute unilateral hearing loss (sudden loss in one ear)
• Acute amnesia (sudden memory loss)

Question 15

What are the key diagnostic features of a Lacunar Syndrome (LACS)?

Answer 15

• No visual field defect
• No higher cortical or brainstem dysfunction
• One of the following:
• Pure motor hemiparesis
• Pure sensory deficit
• Sensorimotor hemiparesis
• Ataxic hemiparesis (e.g., dysarthria–clumsy hand syndrome)
• Involves at least two of three areas (face, arm, leg), with limb involvement in its entirety

Question 16

What are the key diagnostic features of a Posterior Circulation Syndrome (POCS)?

Answer 16

Any one of the following:
• Cranial nerve impairment
• Unilateral or bilateral motor or sensory deficit
• Disorder of conjugate eye movement
• Cerebellar dysfunction
• Homonymous hemianopia
• Cortical blindness

Question 17

What are the key diagnostic features of a Total Anterior Circulation Syndrome (TACS)?

Answer 17

• Hemiplegia and homonymous hemianopia (contralateral to lesion)
• Either aphasia (dominant hemisphere) or visuospatial disturbance (non-dominant hemisphere)
• ± Contralateral sensory deficit

Question 18

What are the key diagnostic features of a Partial Anterior Circulation Syndrome (PACS)?

Answer 18

One or more of the following:
• Unilateral motor or sensory deficit
• Aphasia
• Visuospatial neglect (with or without homonymous hemianopia)
• Deficits may be less extensive than in LACS (e.g., affecting only the hand)

Question 19

What is the definition of a Transient Ischaemic Attack (TIA)?

Answer 19

An acute loss of focal cerebral or monocular function with symptoms lasting less than 24 hours, caused by inadequate blood supply, with no other explanation

Question 20

How long do most TIAs last, and what can imaging sometimes show?

Answer 20

Most TIAs last only minutes, but MRI can sometimes show brain lesions.

Question 21

Why is the term “brain attack” used at the onset of TIA symptoms?

Answer 21

At onset, it is unclear whether symptoms will persist beyond 24 hours, so it is safest to treat as a brain attack.

Question 22

Why is early recognition of TIA important?

Answer 22

• Patients may not treat TIAs as emergencies because symptoms resolve
• TIA is a warning sign of ischaemic stroke
• Half of strokes after TIA occur within a week and may be preventable
• Like stroke, TIAs must be treated as emergencies, especially in the first few days

Question 23

How does a migraine aura differ from a TIA?

Answer 23

• Typically starts at 15–20 years old, often with family history
• Has positive symptoms (flashing lights, tingling)
• Develops gradually over 5–20 minutes, lasts <1 hour
• Often followed by headache
• May be linked to CADASIL or mitochondrial diseases

Question 24

How can focal epilepsy mimic a TIA?

Answer 24

• Todd’s paralysis (post-ictal weakness) can resemble TIA
• Sometimes limb shaking occurs during TIA, causing confusion

Question 25

What is transient global amnesia (TGA) and how is it distinguished from TIA?

Answer 25

• Sudden, temporary memory loss, lasting a few hours • No other neurological deficits • Requires witness confirmation

Question 26

Which structural brain lesions can mimic TIA?

Answer 26

Chronic subdural haematoma, meningioma, and venous thrombosis — distinguished by brain imaging.

Question 27

How can hypoglycaemia mimic TIA?

Answer 27

It may cause focal neurological symptoms, often with hunger, dizziness, sweating, palpitations, and confusion.

Question 28

How can multiple sclerosis (MS) be confused with TIA?

Answer 28

MS can cause sudden focal symptoms, but typically occurs in younger patients and has a different disease course.

Question 29

How can labyrinthine disorders mimic posterior circulation TIA?

Answer 29

They can present with vertigo, hearing loss, or tinnitus.

Question 30

How can mononeuropathies mimic TIA?

Answer 30

Transient nerve compression can cause focal symptoms resembling TIA or stroke.

Question 31

What is the immediate antithrombotic therapy for ischaemic stroke?

Answer 31

Aspirin 300 mg immediately, then 75–150 mg daily.

Question 32

What is the benefit of aspirin in acute ischaemic stroke?

Answer 32

Prevents about 15 deaths or dependencies per 1000 patients.

Question 33

When should aspirin be started if thrombolysis has been given?

Answer 33

At least 24 hours after thrombolysis.

Question 34

Why are heparins (unfractionated or LMWH) not routinely used in acute ischaemic stroke?

Answer 34

They increase the risk of haemorrhagic transformation and offer no routine benefit, even in atrial fibrillation.

Question 35

What drug is used for thrombolytic therapy in ischaemic stroke?

Answer 35

Intravenous recombinant tissue plasminogen activator (rt-PA).

Question 36

What is the time window for best outcomes with rt-PA?

Answer 36

• Within 90 minutes → 8x increased odds of favourable outcome • 91–180 minutes → 2x increased odds of favourable outcome • Can be given up to 270 minutes (4.5 hours), but benefit decreases and risk increases after 3 hours

Question 37

What factors increase the risk of haemorrhagic transformation with rt-PA?

Answer 37

Older age and large infarcts.

Question 38

What is the standard dose of rt-PA for ischaemic stroke?

Answer 38

0.9 mg/kg: • 10% as IV bolus • 90% as continuous IV infusion over 1 hour

Question 39

What are some contraindications to thrombolysis in stroke?

Answer 39

Recent surgery, active bleeding, and other major bleeding risks.