Stroke

Question 1

Stroke

Answer 1

Examine this patient’s limbs neurologically and then proceed to examine anything else that you feel is important.

Question 2

Clinical signs of Stroke

Answer 2

1. Inspection: walking aids, nasogastric tube or PEG tube, posture (flexed upper limbs and extended lower limbs), wasted or oedematous on affected side.
2. Tone: spastic rigidity, ‘clasp knife’ (resistance to movement, then sudden release). Ankles may demonstrate clonus (>4 beats).
3. Power: reduced. –> MRC grade
4. Coordination: sometimes reduced. Usually impaired due to weakness but may reflect cerebellar involvement in posterior circulation stroke.
5. Reflexes: brisk with extensor plantars
Offer to
6. Walk the patient if they are able to, to demonstrate the flexed posture of the upper limb and ‘tip toeing’ of the lower limb.
7. Test sensation (this is tricky and should be avoided if possible!). Proprioception is important for rehabilitation.

Question 3

Other signs of Stroke

Answer 3

1. Upper motor neurone unilateral facial weakness (spares frontalis due to its dual innervation).
2. Gag reflex and swallow to minimize aspiration.
3. Visual fields and higher cortical functions, e.g. neglect helps determine a Bamford classification.
4. Signs of the Cause: irregular pulse (AF), blood pressure, cardiac murmurs or carotid bruits (anterior circulation stroke).

Question 4

Medical Research Counsil (MRC) graded muscle power

Answer 4

0, none
1, flicker (Fasiculation)
2, moves with gravity neutralized (not against gravity)
3, moves against gravity
4, reduced power against resistance
5, normal
Extensors are usually weaker than flexors in the upper limbs and vice versa in the lower limbs.

Question 5

Definitions of Stroke

Answer 5

• Stroke: rapid onset, focal neurological deficit due to a vascular lesion lasting > 24 hours.

Question 6

Definition of Transient ischaemic attack (TIA)

Answer 6

• TIA: focal neurological deficit lasting < 24 hours.

Question 7

Investigation of Stroke

Answer 7

1. Bloods: FBC, CRP/ESR (young CVA may be due to arteritis), glucose and renal function
2. ECG: AF or previous infarction
3. CXR: cardiomegaly or aspiration
4. CT head: infarct or bleed, territory
5. Consider
* Echocardiogram,
* Carotid Doppler,
* MRI/A/V (dissection or venous sinus thrombosis in young patient),
* Clotting screen (thrombophilia),
* Vasulitis screen in young CVA

Question 8

Acute Management of Stroke

Answer 8

1. Thrombolysis with tPA (within 4.5 hours of acute ischaemic stroke)
2. Clopidogrel (or aspirin + dipyridamole)
3. Referral to a specialist stroke unit: multidisciplinary approach: physiotherapy, occupational therapy, speech and language therapy and specialist stroke rehabilitation nurses
4. DVT prophylaxis

Question 9

Chronic Management of Stroke

Answer 9

1. Carotid endarterectomy in patients who have made a good recovery, e.g. in PACS (if >70% stenosis of the ipsilateral internal carotid artery)
2. Anticoagulation for cardiac thromboembolism
3. Address cardiovascular risk factors
4. Nursing +/− social care.

Question 10

complications of stroke

Answer 10

Aspiration pneumonia
Seizure
hemorrhagic transformation
VTE
Hospital acquired infection eg pneumonia, line sepsis, catheter associated sepsis
pressure sores
contracture
depression

Question 11

Bamford classification of stroke (Lancet 1991)

Answer 11

1. Total anterior circulation stroke (TACS)
   * Hemiplegia (contra‐lateral to the lesion)
   * Homonomous hemianopia (contra‐lateral to the lesion)
   * Higher cortical dysfunction, e.g. dysphasia, dyspraxia and neglect
2. Partial anterior circulation (PACS) * 2/3 of the above
3. Lacunar (LACS) * Pure hemi‐motor or sensory loss
4. Posterior Circulation syndrome (POCS): at least one of these need to be present
   * CN palsy and contralat motor/sensory deficit
   * bilateral motor/sensory deficit
   * conjugate eye movement disorder
   * Cerebellar dysfunction
   * isolated homonymous hemianopia

Question 12

Prognosis at 1 year (%) for TACS

Answer 12

• Dead 60%
• Dependent 35%
• Independent 5%

Question 13

Prognosis at 1 year (%) for PACS

Answer 13

• Dead 15%
• Dependent 30%
• Independent 55%

Question 14

Prognosis at 1 year (%) for LACS

Answer 14

• Dead 10%
• Dependent 30%
• Independent 60%

Question 15

Dominant parietal‐lobe cortical signs (Stroke)

Answer 15

1. Dysphasia: receptive, expressive or global
2. Gerstmann’s syndrome
   * ⚬⚬ Dysgraphia, dyslexia and dyscalculia
   * ⚬⚬ L‐R disorientation
   * ⚬⚬ Finger agnosia

Question 16

Non‐dominant parietal‐lobe signs (Stroke)

Answer 16

1. Dressing and constructional apraxia
2. Spatial neglect

Question 17

Either parietal‐lobe signs

Answer 17

1. Sensory and visual inattention
2. Astereognosis
3. Graphaesthesia

Question 18

The lesion == What is the Visual field defects?

1. Optic Nerve
2. Optic Chiasm
3. Optic Tract
4. Optic Radiation (Parietal lobe)
5. Optic Radiation (Temporal lobe)

Answer 18

Visual field defects

1. Optic Nerve => Unilateral field defect
2. Optic Chiasm => Bitemporal Hemianopia
3. Optic Tract => Homonymous Hemianopia
4. Parietal lobe => Inferior Homonymous Quadrantinopia
5. Temporal lobe => Superior Homonymous Quadrantinopia

Question 19

Lateral medullary (Wallenberg) syndrome

Answer 19

• Most common brainstem vascular syndrome
• Due to occlusion of posterior inferior cerebellar artery (PICA)
• Often variable in its presentation

Question 20

Brainstem structures affected by Unilateral lesion of Lateral medullary (Wallenberg) syndrome

Answer 20

1. Vestibular Nucleus
2. Inferior Cerebellar Peduncle
3. Descending Sympathetic Tract
4. CN 5 Descending Spinal Tract
5. CN 5 Spinal Nucleus
6. Spinothalamic Tract
7. Nucleus Tractus Solitarius (CN 7, 9, 10)
8. Nucleus Ambiguus (CN 9, 10)==> Specific to PICA

Question 21

Clinical consequences of Lateral medullary (Wallenberg) syndrome (PICA) Ipsilateral to lesion (e.g. on right with right‐sided infarction)

Answer 21

1. Nystagmus (Present with vertigo and vomiting) => Vestibular nucleus
2. Cerebellar signs => Inferior cerebellar peduncle
3. Horner syndrome => Descending sympathetic tract
4. Loss of trigeminal pain and temperature sensation => Trigeminal nerve (CN V) spinal nucleus and tract
5. Palatal paralysis and decreased gag reflex => Nucleus ambiguus (CN IX and X)

Question 22

Clinical consequences of Lateral medullary (Wallenberg) syndrome (PICA) Contralateral to lesion (e.g. on left with right‐sided lesion)

Answer 22

Loss of pain and temperature sensation => Spinothalamic tract