Stroke

Question 1

Define stroke

Answer 1

Focal neurological deficit of sudden onset due to ischaemia or haemorrhage

Lasts >24hrs/ death

Question 2

Define Transient ischaemic attack (TIA)

Answer 2

Brief neurological dysfunction due to temporary focal ischaemia

No infarction

Question 3

Define acute neurovascular syndrome

Answer 3

Neurological deficit due to vascular issue but unsure if TIA or stroke

Question 4

What are the causes of stroke?

Answer 4

Ischaemia

• Atherosclerosis (small or large artery)
• Cardioembolism
• Carotid/ vertebral siddection

Haemorrhage

• Intracranial
• Subdural
• Subarachnoid

Question 5

What are risk factors for stroke?

Answer 5

HEADS

• Hypertension/ hyperliipidaemia
• Eldery
• Atrial fibrilation
• Diabetes mellitus/ drugs (cocaine, ORP)
• Smoking/ sex: male

Past TIA obv..

Question 6

Draw the Circle of Willis

Answer 6

Question 7

Draw the vertebral-basilar/ posterior system

Answer 7

Question 8

Draw the carotid/ anterior system

Answer 8

Question 9

Outline the vessel present

• Scalp
• Skull
• Epidural
• Subdural
• Subarachnoid
• Grey mater

Answer 9

• Scalp - Superficial veins
• Skull - Diploic veins
• Epidural - Mid. meningeal artery
• Subdural - Bridgeing veins & sinuses
• Subarachnoid - Circle of Willis
• Grey mater - Cortical vessels

Question 10

Draw the areas of supply in the brain

Answer 10

Question 11

What are the branches of the external carotid?

Answer 11

Some assholes like freaking out potential medical students!!

• Sup. thyroid
• Ascending pharangeal
• Lingual
• Facial
• Occipital
• Post. auricular
• Maxillary
• Superficial temporal

Question 12

Outline the Bamford (oxford) classification of stroke

Answer 12

**TACS **(total ant, circulation stroke) All;

1. New higher cerebral dysfunction (dysphasia, dyscalculia, visiospatial disorder)
2. Homonymous visual field defect
3. Hemiparesis/ hemisensory loss affecting at least 2 body areas (2 out of face, arm & leg)

**PACS **(partial ant. circulation stroke) 2/3

1. 2/3 TACS
2. or Motor/ sensory deficit restricted to face/arm/leg

POCS (posterior circulation stroke)

1. Ipsilateral cranial nerve palsy with contralateral motor/ sensory deficit
2. Bilat motor/ sensory deficit
3. Disorder of conjugate eye movement
4. Cerebellar dysfunction without ipsilateral hemiparesis
5. Isolated homonymous visual field defect

LACS (lacunar syndrome) 1;

1. Pure motor, pure sensory or sensori-motor deficit
2. Ataxic hemiparesis

Question 13

What is amourosis fugax?

Answer 13

TIA syndrome

Emboli through retinal arteries, sudden 1 eye vision loss

1st clinical sign of ICA stenosis

Question 14

How would you calculate the risk of stroke after a TIA?

Answer 14

ABCD₂ score - chance of stroke with 7 days!

• Age >=60 1
• BP >=140sys or >=90dias
• Clinical features
  
  • Unilateral weakness (hemiparesis) 2
  • or Speech problem without hemiparesis 1
• Duration
  
  • >=60min 2
  • 10-59min 1
• Diabetes 1

>4 or crescendo or AF = high risk

C has 2 points!

Theres 2 D’s, and the first D has 2 points!

Question 15

What is lateral medullar syndrome?

Answer 15

aka PICA or Wallenberg syndrome

Injury of lateral part of medulla in the brain

• Acute vertigo
• Other cerebellar signs
• Thromboembolism in PICA, vertebral artery thromboembolism, or dissection

Question 16

Outline the acute investigations & management of an ischaemic stroke

Answer 16

1. Investigations
   
   • Immediate CT scan
     
     • ​​CT angiogram if no infarction on plain CT, <75, <8hrs onset, no haemorrage
     • CT better for ruling haemorrhages in and out, MRI better for ruling in ischaemic
   • Carotid doppler & duplex scanning - carotid/ vertebral stenosis/ occlusion
   • Glucose - hyper/po
   • ECG - AF/ arrythmias
   • FBC - polycythaemia
   • INR - if on warfarin
   • Cholesterol - hypercholesterolaemia
2. <4.5hrs of presentation - Thrombolysis
   
   • ​​recombinant tissue plasminogen activator (rtPA)
   • converts plasminogen ⇒ plasmin
   • plasmina converts fibrin ⇒ soluble firbrin fragments
3. Antihypertensive therapy
   
   • Tension vs Perfusion
   • Lowered slowly
4. Antiplatelet therapy
   
   • Long term aspirin
   • • dipyridamole 200mg = optimal
5. Anticoagulants
   
   • Cardiac issue - heparin & warfarin
   • Dabigatran - thrombin activator
6. Stroke unit
   
   • Mobilise ASAP
   • Haemodynamic & biochemical environment
     
     • BP
       
       • norm = 160-180/90-100
       • hyper = 180/100-105
     • Temp <37.5
     • O2 >95%
     • Blood glucose <10mmol/l
     • Nutrition

Question 17

How would you calculate the risk of stroke with somone with AF?

Answer 17

CHA₂DS₂-VASc

• Congestive heart failure
• Hypertension
• A₂ge 75+
• Diabetes Mellitus
• S₂troke/ TIA previously
• Vascular disease
• Age 65-74
• Sex: female

Max 9.

Question 18

How would you assess the bleeding risk in oral anticoagulation therapy?

Answer 18

HASBLED

• Hypertension
• Abnormal renal/ liver function (2)
• Stroke
• Bleeding
• Labile INR (unstable/ high)
• Elderly age
• Drugs/ alcohol (2)

Max 9

Question 19

When would you decide to/ not to give a patient oral anticoagulation?

Answer 19

CHADSVASc > HASBLED = OAC

HASBLED > CHADSVASc = no, risk outweights benefit

CHADSVASc = HASBLED = clinicians discretion

Question 20

Outline the types of intracranial haemorrhages and their common presentations

Answer 20

• Epi/extradural - between dura & skull
  
  • Middle meningeal artery
  • Rapid LOC, lucid interval, then sudden deterioration
• Subdural - between arachnoid & under dura
  
  • Tearing of bridgeing veins in subdural space
  • Slower
  • CT - crescent shape deformity
• Subarachnoid - between pia & under arachnoid, berry aneurysms
  
  • Thunderclap headache, LOC & death
  • Post. communicating art = 3rd nerve palsy
  • Herald bleed = headache recently
• Intracerebral
  
  • Spontaneously (stroke) or trauma
  • Location determine symptoms
  • Headache & vomitting common
• Cerebellar
  
  • Headache, stupor/ coma
  • Cerebellar signs
  • Gaze deviates towards haemorrhage

Question 21

Outline the common areas of intracranial aneurysms (diagram)

Answer 21

Question 22

Outline the diagnostic investigation for SA haemorrhage & management

Answer 22

• CT scan
  
  • If normal but still suspicious - Lumber puncture
    
    • SAH has
      
      1. Blood stained <24hrs, then;
      2. Yellow (Xanthochromic) in [visual centrifugation]
         
         • Due to haemoglobin breakdown
         • High bilirubin in [spectrophotometry]
• Treatment
  
  • Control V. high BP & intracranial pressure
  • Nimodipine (calcium antagonist) reduces spasms
  • Surgery if stable
  • Deterioration = rebleed, spasm or hydrocephalus, do CT.

Question 23

Outline the artery & pathology involved in A & B

Answer 23

MCA Ischaemia

A - total ischaemia

B - partial ischaemia

Question 24

Outline the artery & pathology involved

Answer 24

ACA occlusion → Ischaemia

Question 25

Outline the artery & pathology involved

Answer 25

PCA occlusion ⇒ Ischaemia

Question 26

Outline the artery & pathology involved

Answer 26

Haemorrhage

Question 27

Outline the artery & pathology involved

Answer 27

Lacunar

Question 28

Outline the histological finds in an infarction area of the brain

Answer 28

* Recent - **inflammed tissue** * **Focal haemorrhage** * **Liqeufactive necrosis** * Old - **Gliosis** (aka fibrosis of brain)