Stroke

Question 1

Definition

Answer 1

Sudden onset neurological deficits of vascular basis with infarction of CNS tissue

Question 2

Pathophysiology of ischemic stroke

Answer 2

1. Arterial thrombosis
   a. Large vessel->occlusion, stenosis of carotid, vertebral, IC arteries->insufficient flow beyond lesion->atherosclerosis, vasculitis, dissection
   b. Small vessel->chronic HTN and diabetes= wall thickening and -ve luminal diameter->small penetrating= basal ganglia, internal capsule and thalamus
2. Cardioembolic->AF, RHD, prosthetic heart, recent MI, endocarditis
3. Systemic hypoperfusion= global cerebral ischemia->affects watershed zones

Question 3

Pathophysiology of hemorrhagic

Answer 3

1. Intracerebral hemorrhage
   a. HTN most commonly->rupture of small microaneurysms (Charcot Bouchard) in putamen, thalamus, cerebellum, pons
   b. Trauma
   c. Amyloid angiopathy
   d. Vascular malformation
   e. Vasculitis
   f. Drug use->cocaine
2. SAH

Question 4

What is hypertensive encephalopathy

Answer 4

Acute severe HTN (typically dBP >130
or sBP >200) can cause hypertensive
encephalopathy – abnormal fundoscopic
exam (papilledema, hemorrhages,
exudates, cotton-wool spots), focal
neurologic symptoms, nausea, vomiting,
visual disturbances and change in LOC.

Question 5

Stroke syndrome with ACA

Answer 5

Contralateral leg paresis and sensory loss

Question 6

Stroke syndrome with MCA

Answer 6

1. Contralateral weak/sensory loss of face and arm
2. Cortical sensory loss
3. CL homonymous hemianopia or quadrantonopia
4. If left: aphasia
5. If right: neglect
6. Eye deviation to the side of the lesion and away from the weak side

Question 7

Stroke syndrome with PCA

Answer 7

1. CL homonymous hemianopia or quadrantonopia
2. Midbrain findings: CN 3/4 palsy, pupillary changes, hemiparesis
3. Thalamic findings: sensory loss, amnesia, -ve LOC
4. If bilateral->cortical blindness or prosopagnosia

Question 8

Stroke syndrome with basilar

Answer 8

“Locked in”

1. Quadriparesis
2. Dysarthria
3. Impaired eye movement

Question 9

Stroke syndrome with PICA

Answer 9

Lateral medullary/Wallenburg

1. Ipsilateral ataxia
2. Ipsilateral horners
3. Ipsilateral facial sensory loss
4. CL limb impaired pain/temperature
5. Nystagmus
6. Vertigo
7. NV
8. Dysphagia
9. Dysarthria
10. Hiccups

Question 10

Stroke syndrome with anterior spinal artery

Answer 10

Medial medullary

1. CL hemiparesis
2. CL propioC and vibration
3. IL tongue weakness

Question 11

Lacunar infarcts

Answer 11

Deep hemispheric white matter

1. Pure motor hemiparesis->posterior limb of Internal capsule, CL arm, face, leg
2. Pure sensory
3. Ataxic hemiparesis: IL ataxia, leg paresis
4. Dysarthria-clumsy hand syndrome: dysarthria, facial weak, dysphagia, mild hand weak/clumsiness

Question 12

Stroke mimics

Answer 12

SAH
SDH
Hypoglycemia
IE
Tumor
Fitting
Vasculitis
Encephalitis
Dural sinus thrombosis

Question 13

Acute management

Answer 13

1. ABC
2. Vital sign monitoring, oxygen, IVF (without glucose), NBM, NGT
3. Check glucose, IV cannula
4. Urgent help->specialist, consultant
5. AMPLE: onset, when last well, mimics: post ictal, hypoglycemia, migraine, conversion, recent stroke/epilepsy/MI/AF/Surgery/Trauma/Bleeding/Hx hemorrhagic/HTN, DM/current drugs/Medicine-anticoagulation, insulin, antiHTN
6. Investigations: non contrast CT, ECG, CBC, UEC, Cr, Coagulation, glucose, Troponins
7. Indications for thrombolysis->alteplase
8. Aspirin 150-300mg PO via NGT
9. Admit to stoke unit
10. TEDs?
11. Monitor regularly- vitals, blood glucose levels
12. Assessment of swallowing
13. Do not lower BP unless >220/110
14. oxygen if hypoxic
15. Paracetamol if fever
16. Early mobilisation, hydration, enoxaparin
17. Rehabilitate early
18. With-hold BP lowering medication for 5 ays unless ++high
19. Etiological investigation->further imaging, ECHO, holter

Question 14

Prevention of second stroke

Answer 14

1. Identify underlying cause
2. Aspirin 70-150mg PO daily
3. Warfarin if AF
4. ACEi
5. Statin therapy
6. Exercise, diet, weight loss, smoking cessation
7. Diabetes management

Question 15

CHADS

Answer 15

CHADS2
Stroke risk stratification for patients with
atrial fibrillation
Congestive heart failure (1 point)
Hypertension sBP >160 mmHg/treated
hypertension (1 point)
Age >75 yr (1 point)
Diabetes (1 point)
Prior Stroke or TIA (2 points)

Question 16

Contraindications to thrombolysis

Answer 16

Hx: improving sx, minor sx, seizure
at stroke onset, recent major surgery
(within 14 d) or trauma, recent GI or
urinary hemorrhage (within 21 d),
recent LP or arterial puncture at
noncompressible site, PMHx ICH, sx of
SAH/pericarditis/MI, pregnancy.
P/E: sBP ≥185, dBP ≥110, aggressive
Rx to decrease BP, uncontrolled serum
glucose, thrombocytopenia.
Ix: hemorrhage or mass on CT, high INR
or aPTT.

Question 17

Indications for thrombolysis

Answer 17

Onset w/i 4.5 hours
Clinically significant deficit on NIH stroke scale examination
CT does not show hemorrhage/non vascular cause
>18 yo

Question 18

NIH stroke scale examination

Answer 18

The scale uses 11 items that evaluate:
• Level of consciousness
• Visual system
• Motor system
• Sensory system
• Language abilities