Stroke

Question 1

Define Stroke.

Answer 1

Medical condition in which poor blood flow to the brain causes cell death in the affected brain tissue. Results in sudden focal neurological deficit. Classified as either ischemic (lack of blood flow) or hemorrhagic (bleeding). Time-sensitive medical emergency - ‘Time is brain’.

Stroke is a critical condition requiring immediate medical attention.

Question 2

What are the two main types of stroke?

Answer 2

• Ischemic Stroke (~87% of strokes): Caused by blockage/occlusion of blood vessel
• Hemorrhagic Stroke (~13%): Rupture of blood vessel in brain

Ischemic strokes are usually due to thrombosis or embolism, while hemorrhagic strokes lead to bleeding and increased intracranial pressure.

Question 3

What are the major risk factors for stroke?

Answer 3

• Hypertension
• Hyperlipidemia
• Smoking
• Obesity
• Diabetes mellitus
• Atrial fibrillation
• Age
• Male gender
• Family history
• Previous stroke/TIA
• Carotid stenosis
• Excessive alcohol use
• Physical inactivity
• Poor diet

Hypertension is the most important modifiable risk factor.

Question 4

RED FLAG: What is the FAST assessment for stroke recognition?

Answer 4

• Face: Facial weakness/drooping
• Arms: Arm weakness/drift
• Speech: Impaired/slurred speech
• Time: Call emergency services immediately if any sign present

Positive FAST indicates a high probability of stroke and is a public awareness tool for immediate recognition.

Question 5

What is the BE-FAST assessment?

Answer 5

• Balance: Sudden loss of balance/coordination
• Eyes: Vision problems
• Face
• Arms
• Speech
• Time

BE-FAST improves detection of posterior circulation strokes, which FAST misses in over 70% of cases.

Question 6

What is the NIHSS (NIH Stroke Scale)?

Answer 6

Standardized 11-item assessment tool quantifying stroke severity. Scores 0-42 (higher = more severe). Assesses various neurological functions.

It guides treatment decisions and prognosis.

Question 7

RED FLAG: What is the critical time window for IV tPA (alteplase)?

Answer 7

• Standard window: Within 4.5 hours of symptom onset
• Optimal window: Within 3 hours for best outcomes
• Extended window: 4.5-9 hours for selected patients

Door-to-needle goal is <60 minutes; earlier treatment leads to better outcomes.

Question 8

What are the contraindications to IV tPA?

Answer 8

• Absolute: Intracranial hemorrhage, recent stroke, recent major surgery, active bleeding, uncontrolled hypertension, history of ICH, known intracranial malformation, current anticoagulation, platelet count <100,000
• Relative: Minor symptoms, seizure at onset, recent GI/GU bleeding, pregnancy

Contraindications must be carefully evaluated before administering tPA.

Question 9

What is the treatment for acute ischemic stroke?

Answer 9

• IV alteplase (tPA) if within 4.5 hours
• Mechanical thrombectomy for large vessel occlusion if within 6 hours
• Aspirin 160-325mg
• Blood pressure management
• Supportive care
• Stroke unit admission

Treatment should be initiated as quickly as possible to minimize brain damage.

Question 10

What is mechanical thrombectomy?

Answer 10

Endovascular procedure using stent retrievers to mechanically remove clot from large vessel occlusion.

Indicated for NIHSS ≥6 and proximal vessel occlusion, within 6 hours or up to 24 hours with favorable imaging.

Question 11

RED FLAG: What clinical features suggest hemorrhagic stroke?

Answer 11

• Sudden severe ‘thunderclap’ headache
• Decreased level of consciousness
• Nausea/vomiting
• Neck stiffness
• Seizures at onset
• Markedly elevated blood pressure
• Rapid deterioration
• Focal neurological deficits

CT scan is mandatory before tPA to exclude hemorrhage.

Question 12

What is the pathophysiology of ischemic stroke?

Answer 12

Arterial occlusion → reduced cerebral blood flow → oxygen/glucose deprivation → energy failure → neuronal death.

The ischemic core suffers irreversible damage, while the penumbra may be salvageable if reperfused quickly.

Question 13

What are the major stroke syndromes?

Answer 13

• Anterior circulation: Middle cerebral artery (MCA) - contralateral hemiparesis, aphasia
• Anterior cerebral artery (ACA) - contralateral leg weakness
• Posterior circulation: Cerebellar stroke - ataxia, vertigo
• Brainstem stroke - crossed findings

Each syndrome presents with distinct neurological deficits based on the affected area.

Question 14

What imaging is required for acute stroke?

Answer 14

• IMMEDIATE non-contrast head CT
• CT Angiography (CTA)
• MRI with DWI
• Perfusion imaging

Imaging is crucial for excluding hemorrhage and identifying large vessel occlusion.

Question 15

What complications can occur after stroke?

Answer 15

• Early: Cerebral edema, hemorrhagic transformation, seizures
• Subacute: DVT, pulmonary embolism, urinary tract infection
• Long-term: Spasticity, depression, cognitive decline

Complications can significantly affect recovery and quality of life.

Question 16

What is a Transient Ischemic Attack (TIA)?

Answer 16

Temporary episode of neurological dysfunction without acute infarction on imaging. Symptoms resolve completely.

TIAs indicate a high risk for subsequent stroke and require urgent evaluation.

Question 17

RED FLAG: What features suggest large vessel occlusion (LVO) requiring thrombectomy?

Answer 17

• NIHSS ≥6
• Cortical signs
• Dense hemiplegia
• Sudden onset severe deficit

Requires rapid transfer to a comprehensive stroke center for treatment.

Question 18

What is the ASPECTS score?

Answer 18

10-point scoring system assessing early ischemic changes on non-contrast CT in MCA territory.

Score ≥6 is generally required for thrombectomy eligibility.

Question 19

What blood pressure targets are used in acute stroke?

Answer 19

• Ischemic stroke without tPA: Treat only if >220/120mmHg
• Ischemic stroke with tPA: Lower to <185/110mmHg
• Hemorrhagic stroke: Lower to <140/90mmHg

Blood pressure management is crucial to prevent complications.

Question 20

What is secondary stroke prevention?

Answer 20

• Antiplatelet therapy
• Anticoagulation for cardioembolic stroke
• Statin therapy
• Blood pressure control
• Diabetes management
• Carotid endarterectomy/stenting
• Lifestyle modifications

Secondary prevention strategies are essential to reduce the risk of recurrent strokes.

Question 21

What is wake-up stroke?

Answer 21

Stroke discovered upon awakening; represents ~20% of ischemic strokes.

MRI-selected patients can receive tPA up to 9 hours from the midpoint of sleep if salvageable tissue is present.

Question 22

What is the prognosis after ischemic stroke with tPA?

Answer 22

• ~50% independent at 3 months
• 15% moderately dependent
• 20% mortality

Earlier treatment leads to better outcomes; untreated severe strokes have much higher mortality.

Question 23

RED FLAG: What symptoms indicate posterior circulation stroke?

Answer 23

• Vertigo
• Diplopia
• Dysarthria
• Ataxia
• Altered consciousness

Often missed by standard FAST; use BE-FAST for better detection.

Question 24

What is the door-to-needle time goal?

Answer 24

Target: ≤60 minutes from hospital arrival to IV tPA administration.

Every 15-minute delay reduces favorable outcomes.

Question 25

What **supportive care** is provided for acute stroke?

Answer 25

* Stroke unit admission * Airway protection/oxygen * IV fluids * NPO until swallow screen passed * Glycemic control * Fever control * DVT prophylaxis * Early mobilization/rehabilitation ## Footnote Supportive care is essential for improving outcomes and preventing complications.