1
Q
What are the crucial steps in investigating a suspected stroke patient?
A
- Is this actually a stroke (mimics/chameleons)
- Cause (haemorrhage or embolus)
- Location (which artery)
- Complications (any ongoing or likely)
- Investigation
- Intervention
- Information and discharge planning
2
Q
What is a stroke mimic and what are the most common examples?
A
Non-Vascular conditions that commonly present as/are mistaken for strokes.
BEHIINDD: Brain (masses, tumours, bleeds), Epilepsy, Hypo(glycaemia, natremia), Intoxication, Infection (meningitis), Neuro (migraines, MS), Disc Prolapse, Disection
3
Q
What features strongly suggest Stroke Syndrome?
A
Always true in SS:
- Sudden onset (due to sudden loss of blood supply causing sudden drop in O2 and glucose, causing sudden loss in membrane polarity)
- Focal (affects one NV territory)
- Predominantly negative (loss of functions)
Generally true in SS:
- Sensory/Motor symptoms do not Migrate (as they might do in migraines or seizures)
- Non-stereotypical (i.e. do not repeat themselves)
Often true:
- CVS risk factors
4
Q
What are the 4 Oxford Community Stroke Project Classifications?
A
- TACS: Total Anterior Circulation Syndrome
- PACS: Partial Anterior Circulation Syndrome
- POCS: Posterior Circulation Syndrome
- LACS: Lacunar Syndrome
5
Q
Describe the cause and features of a TACS Stroke?
A
ICA or Proximal MCA occlusion, causes all 3 of:
- Hemiparesis
- Higher cortical dysfunction (dysarthria, VS neglect)
- Homonymous Hemianopia
6
Q
Describe the cause and features of a PACS Stroke?
A
MCA branch occlusion, causes either:
- Isolated Higher cortical dysfunction
OR
- 2 of HH, Cortical Dysfunction or Hemiparesis
7
Q
Describe the cause and features of a POCS Stroke?
A
Caused by occlusion of the PCA, Vertebral, Basilar or Cerebellar vessels, leading to any of:
- Cranial nerve palsy and a contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (e.g. horizontal gaze palsy)
- Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
- Isolated homonymous hemianopia
8
Q
Describe the cause and features of a LACS Stroke?
A
Occlusion of a small penetrating artery, causing either a:
- Pure motor stroke
- Pure sensory stroke
- Sensorimotor stroke
- Ataxic hemiparesis
- Clumsy hand dysarthria
9
Q
In which condition might you see Migrating stroke symptoms?
A
Capsular Warning Syndrome.
Occurs due to the odd shape of the LS arteries, MCA blood flow reduction causes hypoperfusion of LS arteries causing fluctuating and migrating stroke symptoms.
10
Q
In which condition might you see Stereotyping stroke symptoms?
A
Intracranial Stenosis.
Symptoms can be identical to stroke BUT often paired with symptoms of general, systemic hypoperfusion e.g. palpitations, dizziness, pallor, clamminess. Requires angiography to confirm.
11
Q
What methods should be use to determine Stroke vs Stroke mimic?
A
Some conditions can be recognised through history e.g. BPV, TGA, Bell’s Palsy, Vestibular Neuronitis.
Some are readily apparent on basic neuroimaging e.g. haematomas, MS, brain tumours, abscesses.
Some require more thorough, detailed investigation e.g. migraine with aura, forms of epilepsy, functional syndrome
12
Q
How would you distinguish BPV from Stroke?
A
BPV is…
- Associated with changes in position
- Associated with vomiting
- Dx with positive Dix/Halpike test
- Therapeutic benefit with Epley maneuvre
13
Q
How would you distinguish Vestibular Neuronitis (Labyrinthitis) from Stroke?
A
Present similarly to BPV with dizziness and vomiting.
- Confirm with positive head thrust test.
N.B: Isolated vertigo is unlikely to be stroke but many strokes cause vertigo (+ other symptoms)
14
Q
How would you distinguish TGA from Stroke?
A
Isolated loss of episodic memory (but not biographical or procedural) is likely to be TGA.
15
Q
How would you distinguish Migraine w/ Aura from Stroke?
A
Can present with similar neurological symptoms (e.g. blurring of vision, loss of sensation, difficulty concentrating or speaking). But…
- Will tend to be migrating
- Will tend to be fluctuating
- Will tend to be less sudden in onset (20 mins)
16
Q
What causes Migraine with Aura?
A
Cortical Spreading Depression (CSD), a phenomenon that also explains the differences between MwA and Stroke:
- Altered but not entirely switched off brain activity, causing positive symptoms.
- Moves around the brain, causing migrating/fluctuating symptoms with a gradual onset.
17
Q
What are apparent neurological deficits?
A
Areas of significant Gliosis which can maintain normal function in optimal physiological state, but not when under any form of stress e.g. infection, MI, sepsis, hypoxia, hypoglycaemia, stress, fatigue, dehydration etc, causing stroke symptoms.
18
Q
What are some common causes of Stroke in young people?
A
- Vertebral Artery Dissection (common in some genetic CT disorders such as Marfan’s or Ehlers-Danlos)
- Fibromuscular Dysplasia at Carotids
- Dyslipidaemia
- Thrombophilia
Also cocaine.
19
Q
What sort of targeted assessment tools should be considered if trying to identify the cause of a stroke?
A
- ECG (or 24h tape)
- Echo (TT or TO)
- Carotid US
- Thrombophilia screen
- Angiography
- Plasma viscosity/ TA biopsy
20
Q
What is the most likely cause of a PACS stroke?
A
Almost always embolization into branches of the MCA or ACA, investigations should be focused on finding the source of the embolus e.g. carotid artery, heart.
21
Q
What is the TOAST classification of strokes, give some examples of each.
A
Essentially, strokes can be caused by many things. TOAST groups all strokes into 5 larger groups:
- Large artery atherosclerosis (e.g. artherothrombosis in the carotid arteries).
- Cardiac emboli (e.g. AF, flutter, MI, valve prolapse, endocarditis, pulmonary vein thrombosis).
- Small Vessel Occlusion (e.g. lacunar strokes caused by hypertension or DM).
- Other determined (e.g. arterial dissection, fibromuscular dysplasia, cerebral venous thrombosis
- Cause undetermined
22
Q
What are some common complications of Stroke?
A
- Recurrent stroke
- Complications associated with immobility (e.g. bed sores, VTE, constipation)
- Raised ICP (malignant oedema, hydrocephalus)
- Infections
- Mood and cognitive disorders
- Post stroke fatigue
- Post stroke pain
- Spasticity, Contractures
- Secondary Epilepsy
- SEPSIS
23
Q
What is the difference between a stroke complication and a stroke impairment?
A
Impairments = the result of neuronal damage from stroke
Complications are issues aside of that.
Strokes normally cause impairments but rarely kill people, most risk of death comes from complications.
24
Q
What steps can be taken to reduce the risk of stroke complications?
A
- Anticipation
- Thorough monitoring (Daily review of obs, meds, mood, chest, legs, bowels, urine function, impairment progression)
- Timely and regular bloods (mostly CRP and clotting)
- Mobilise and Exercise the patient ASAP
25
Why is maintaining optimum physiological state vital to the care of a stroke patient?
- Reduces risk of complications inc. infection and mood issues
- + Helps with maintenance of the ischaemic penumbra (area around the lesion which takes part in neuroplasticity), therefore has significant effect on recovery.
Want to avoid: Hypoxia, Hypoglycaemia, Hypotension, Anaemia, Sepsis
26
What is the typical care pathway for a stroke patient?
- Admission to stroke unit
- Revascularisation therapy (?)
- Optimise physiology on the wards, prevent and look for complications
- Nutritional support
- Secondary prevention
- Rehab
27
What are the two revascularisation options and what are their windows?
IV Alteplase:
- 4.5 hour window
- Rapid assessment to confirm stroke, check for contraindications, CT head, give bolus)
Thrombectomy:
- 6 hour window (although can do up to 24 depending on what shows on CT, apparently)
- Only selected patients with large vessel occlusion
- CT angiogram can be used to guide/assess
N.B: You can also quite happily give a patient Alteplase immediately then send them for Thrombectomy.
28
What is the NIH Stroke Scale?
Common diagnostic method for quickly assessing the severity of a stroke experienced by a patient.
Gives a quant value for neurological impairments suffered by stroke patients.
29
What are the main Secondary Prevention measures used in stroke patients?
- Antithrombotic therapy
- BP control (130/80 aim)
- BM control (HbA1c < 7)
- Lipid control
- Carotid endarterectomy (and other aetiology specific options)
- Lifestyle (smoking cessation, drinking, diet, sleep)
30
What is meant by Haemorrhagic Transformation of an Ischaemic Stroke?
Complication of IS where BBB dysfunction causes bleeding (commonly after thrombolytic therapy but can happen independently)
31
What anticoagulation drugs are commonly used in AF to prevent stroke risk (or as secondary prevention)?
DOACS are now more common than Warfarin e.g. Apixoban, Rivaroxiban).
Always work out CHADSVASC and HASBLED first
32
What is the issue with wake up strokes?
Impossible to determine when they occurred, therefore hard to give thrombolysis. Require good collateral history and intervention ASAP otherwise can't justify (bleed risk too high).
33
Why is revascularisation therapy so effective in stroke management?
Preserves at risk neural tissue, allowing for neuroplasticity
34
What is the BEFAST system and what is it's purpose?
Rapid screening tool used by patients/their family/paramedics to ascertain which patients need to go to stroke ED.
Balance, Eyes, Face, Arms, Speech --> Time to call 999
35
What is a RAP team and what steps do they take in acute stroke management?
Rapid Assessment Protocol.
- Clinically confirm diagnosis (stroke), Determine whether thrombolysis is indicated (time window), IV access, bloods, weight, send to CT scan
- Look for contraindications
- Consent
- Imaging
- Bolus
36
What is the indication for IV thrombolysis with Alteplase?
- Ischaemic stroke, 4.5 hours of onset
- 'Disabling Impairments' e.g. vision loss, dysphasia, inability to self care
- Patient has no contra-indications
(DI = a subjective term and need to bear in mind patient when deciding whether to thrombolysis or not e.g. if only symptom is loss of finger dexterity, may not be Disabling for a 96 year old but would for a 36 year old concert pianist).
37
What are the absolute contraindications for IV Alteplase thrombolysis?
- Blood pressure > 185/110 mmHg after 2 attempts to reduce levels
- Surgery or trauma within the last 14 days
- Stroke within the last 14 days
- Active internal bleeding
- Severe haematology abnormalities
INR>1.7 or APTT>40
- On dabigatran with abnormal APTT or thrombin time >100 seconds
- On rivaroxaban / apixaban / edoxaban
- On high-dose LMWH
- Platelet count <50 x 109/L
INR>1.7 or APTT>40
- Arterial puncture at a non-compressible site or LP in last 7 days
- Symptoms suggestive of SAH, even if CT normal
- Infective endocarditis, pericarditis or presence of ventricular aneurysm related to recent MI
- Childbirth within the previous 4 weeks
- Acute pancreatitis
- Severe liver disease, including hepatic failure, cirrhosis, portal hypertension, oesophageal varices and active hepatitis.
38
What are the relative contraindications for IV thrombolysis?
- Pre-treatment scan showing (evidence of infarction >4.5h (e.g. hypo-density on CT), mass effect / oedema,
tumour, AVM, aneurysm, evidence of large infarct core)
- Intra-cranial or intra-spinal surgery within last 2 months
- Any non-neurosurgery (including minor surgery) within last 6 weeks
- Stroke or head injury in last 6 weeks
- History of GI or urinary tract bleed in last 6 weeks
- Previous CNS bleeding, e.g. SDH
- Glucose <2.7 or >22 mmol/L
- Seizure at stroke onset
- Possibility of pregnancy
- Greater than 90-minute delay post scan
- Symptoms that start during sleep
- Severe pre-morbid dependency
39
What needs to be imaged when assessing a stroke patient and what modalities are used for these?
- Blood vessels ('Pipes'): CT Angiogram
- Parenchyma: Non-contrast CT scan
- Penumbra and Perfusion: Both
40
What should be looked for in a stroke patient's CT angiogram?
- Large vessel occlusion (grounds for thrombectomy)
| - Collateral circulation (more CC suggests sizeable penumbra and likely better recovery from stroke)
41
What should be looked for in a stroke patient's non-Contrast CT?
- Main role = to exclude CT changes which act as contraindications for thrombolysis
- Also shows evidence of thrombus in vessels (vessels appear whiter)
- Changes suggestive of ischaemia e.g. swelling (aka effacement) and loss of distinction between white and grey matter (happens due to cell membrane dysfunction).
42
What is the ASPECTS score?
Method for evaluating MCA infarcts for thrombectomy/thrombolysis:
- Two CT slices are used, one at the level of the basal ganglia, the other at the level of the lateral ventricles
- MCA territory is divided into 10 regions
- 10 = 0 damage to these regions, -1 for each area damaged
- Low ASPECT score = low chances of being accepted for thrombectomy and high chances of bleeding from thrombolysis
- Generally do not go for thrombectomy if score is 5 or lower
43
What do CT/MRI perfusion scans show?
Degree of perfusion of tissue across the entire brain, indicating areas of such extreme hypoperfusion that the cells are almost certainly dead (the Core) and areas where the cells could still recover (the Penumbra).
After 24 hours, with reperfusion therapy, the penumbra often returns to normal.
44
What % of patients benefit from IV alteplase vs suffer from it?
32% see benefit
3% experience harm (e.g. ICH, allergic reaction)
65% no change in outcome
45
What monitoring is required during Alteplase administration?
- Regular bloods, obs
- Regular neuro assessments
Looking for: Intra-cranial Haemorrhage + Anaphylaxis
If concern: Stop perfusion, repeat scans
46
Why might a patient undergoing thrombolysis deteriorate?
- COULD be due to alteplase adverse effects
- Could be natural evolution of the stroke (Hydrocephalus, Oedema)
- Seizure
- Infection
- Metabolic disturbance
47
What are the complications of thrombolysis and their signs?
Intracerebral Haemorrhage:
- Neurological decline
- New headache
- Rising BP
- Nausea and Vomiting
Extracerebral Haemorrhage:
- Thin, thready pulse
- Malaena
- Distended abdomen
48
When should mechanical thrombectomy be considered?
- Large vessel occlusion (IV thrombolysis generally can't reach the hidden fibrin loads inside large clots, making it ineffective) + NIHSS of 5+
- Outside time window for IVT
- IVT pharmacologically or medically contra-indicated
49
What are the two main Stoke rehab options?
- Early Supported Discharge (~40% eligible)
| - Stroke Rehabilitation Units
50
What is involved in ESD and what are it's benefits?
Hospital level of therapy at home.
Benefits:
- Reduced length of hospital stay
- For every 100 treated, 5 more live at home and 6 more gain benefit (so 11% pts have notable benefits)
- Significantly increases patient satisfaction
51
What are the criteria for ESD?
- Transfer independently or with one carer
- Suitable home environment
- Willing to participate in rehabilitation
- Identified rehabilitation goals
- Family/carers happy
52
What are the criteria for Stroke Rehab transfer?
- Medically stable
- Needing no more than 24% oxygen
- NG feeding established with no risk of refeeding
- Stroke consultant review twice a week
- Do not need to await echo etc before transfer unless urgent.
- Transfer around day 7 (flexible)
53
What processes are involved in Stroke rehabilitation?
Early phase:
- Reperfusion of hypoxic brain
- Reduction of oedema
Later phase:
- Brain remodelling
54
What are some factors suggesting good chances of stroke recovery?
- Absence of coma
- Early motor recovery
- Continence
55
What are some bad prognostic factors for stroke recovery?
- Severe communication deficit
- Old age
- Incontinence
- Neglect
- No leg movement at 2 weeks
- Severe upper limb weakness at 4 weeks
56
How do you manage aphasia and dysarthria post stroke?
Refer to SALT team, therapy.
57
How do you manage dysphagia post stroke?
- Immediately switch them to alternative fluids
- Comprehensive assessment with specialist team
- Consider for NG tube within 24 hours
- Refer to Dietician
- Consider for gastrotomy feeding if NG tube not tolerated or unable to adequately swallow after 4 weeks.
58
How would you manage balance issues in patients post stroke?
- Assessed
- Provided and trained to use relevant walking aid
- Progressive balance training
- Functional task specific training
- Lower limb strength training
59
How would you manage incontinence post stroke?
- Timed toileting
- Review caffeine intake
- Medication review
- Bladder retraining
- Pelvic floor exercises
- Minimise use of constipating drugs
- Oral laxatives
60
What is spasticity and how can it be treated in a stroke patient?
Spasticity is a condition in which muscles stiffen or tighten, preventing normal fluid movement, thus affecting movement, speech and gait. Affects 1/4 stroke patients.
Cons Mx = Repositioning, Passive movement, Pain control.
Medical Mx: IM Botulin injections for focal cases, Skeletal Muscle Relaxants (e.g. Baclofen) for generalised cases
61
How can you train a patient to manage sensation loss post stroke?
Training is focused around getting them to avoid injury to injured body parts.
62
What are some false positives for hyperatenuating blood vessels on a stroke CT?
- Polycythaemia
- Calcification with age
- Raised haematocrit
63
What are the purposes of an unenhanced CT in a stroke syndrome patient?
- Rule out haemorrhage
- Rule out mimics
- Identify a target vessel for thrombolysis (if possible)
- Rule out infarctions which are too old or too big for thrombolysis
64
What clues might suggest ICH over Infarct stroke?
- Possible underlying causes (e.g. hypertension, venous sinus thrombosis, aneurysm, AVM, vasculitis, coagulopathy, coagulopathy, on anti-coagulant therapy, aspirin, cocaine, alcohol, tumours)
- Reduced level of consciousness on admission)
- History of headache prior
- Seizures
65
How do you diagnose an ICH (haem stroke)?
CT scan (should see acute bleed + complications such as swelling).
MRI can help identify underlying cause.
66
How do you manage an ICH?
- Neurosurgery for clot reduction, decompression craniotomy
- Intraventricular shunting for hydrocephalus
Supportive care: BP, mass effect, seizure, secondary prevention
67
What is Cerebral Amyloid Angiopathy?
Cerebral amyloid angiopathy (CAA) is a condition in which proteins called amyloid build up on the walls of the arteries in the brain. CAA increases the risk for stroke caused by bleeding and dementia
68
What are the primary causes of ICH?
Hypertension and CAA
69
What are some secondary causes of ICH?
- Intra-tumoral Haemorrhage
- Arteriovenous Malformation
- Anticoagulation haemorrhage
70
What are some complications of ICH?
- Mass effect (look for midline shift, displaced ventricles on CT)
- Hydrocephalus
- Cerebral herniation (uncal, tenting, coning)
- Raised ICP
71
How long should you avoid driving if you've had a stroke (according to the DVLA)?
- 4 weeks cars
| - 1 year heavy goods vehicles
72
How should a TIA be managed?
Thorough secondary prevention
- Antithrombotic therapy
- BP control (130/80 aim)
- BM control (HbA1c < 7)
- Lipid control
- Carotid endarterectomy (and other aetiology specific options)
- Lifestyle (smoking cessation, drinking, diet, sleep)
73
Broadly, how can you distinguish between an Infarction and a Haemorrhage on an MRI
Infarctions are dark
Bleeds are white
74
What is Fibrynolitic Necrosis?
Process by which HTN + Diabetes can cause LACS
75
What is the most likely cause of stroke in a pregnant patient?
Thrombophilia.
Also look for VTE, active cancer or multiple miscarriages
76
How are ICHs typically divided, and what causes each category?
Central/Deep Haemorrhages (normally caused by hypertension)
Lobar Haemorrhages (tend to be secondary to some underlying pathology e.g. tumour bleeds, cerebral amyloid angiopathy, vascular anomalies
77
What are the most common complications of stroke?
- Recurrence of stroke (due to unaddressed aetiological factors)
- Raised ICP (due to malignant oedema, haemorrhagic transformation...)
- Infections (RTI from aspiration, UTI from incomplete emptying)
- VTE, Constipation, Bed sores (all complications of immobility)
- Mood, pain, fatigue
- Spasticity, contractures
- Secondary epilepsy
78
When is a patient considered suitable for IV alteplase thrombectomy?
Non-contraindicated patients, with disabling stroke, presenting within 4.5 hours.
79
When is a patient considered suitable for mechanical thrombectomy?
Patients with LVO, presenting within 6 hours on onset.
80
How is malignant oedema managed?
Decompressive Hemicraniectomy (DHC)- indicated for biologically fit (normally younger than 60 years old) individuals.
81
Briefly, what are the management options for ICH?
Main management strategies are focused on preventing raised ICP:
Cons: Blood pressure control, Correction of any clotting abnormalities.
Surg: Haematoma evacuation, ventricular drains
82
What conditions should DOAC therapy be considered for?
- AF (Chadvasc and Hasbled permiting)
- Severe LV dysfunction
- Thrombophilioa
- Venous sinus thrombosis
- TIA
- Stroke upon confirmation of infarct, or 24 hours after thrombolysis
83
How is Carotid artery occlusion managed?
Normally initiate management pathway once symptomatic (after TIA, or stroke with good recovery)
If Occlusion less than 50% = Plaque stabilisation therapy:
- BP control (less than 130/80)
- High dose statin therapy
- Dual antiplatelet therapy
If Occlusion greater than 50% = Carotid Endarterectomy
84
What secondary stroke prevention measures should be considered in an AF patient for whom anticoagulation is contra-indicated?
Left Atrial Appendage Closure
85
How can post-stroke swallowing difficulties be assessed and then managed?
Assessment:
- Bedside assessment, e.g. with SALT team
- Video fluoroscopy
- Flexible endoscopic evaluation of swallowing (FEES)
Management = parenteral feeding
- NG feeding
- PEG if not tolerated
N.B: Avoid PE feeding for EoL patients, little reward for massive discomfort and risk
86
What is the NIHSS?
Systemic assessment tool that provides a quant measure of stroke related neurological deficit. Used for:
- patient selection for various acute therapies
- estimating prognosis
- charting stroke recovery
87
What is the ASPECT?
Alberta Stroke Programme Early CT score.
10 point qunt topographic CT scan score used in patients with MCA stroke. Assesses the MCA vascular territory segmentally and provides a scale of severity (1 = worse, 10 = best)
88
What is the modified Ranking score?
Measure of global disability used to assess baseline function and evaluate outcomes.
0 - No symptoms.
1 - No significant disability. Able to carry out all usual activities, despite some symptoms.
2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.
3 - Moderate disability. Requires some help, but able to walk unassisted.
4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk without assistance.
5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent.
6 – Dead.
89
What do the CHADSVASC and HASBLED scores represent?
CV = Risk of stroke in patients with AF, indicating DOAC therapy
HB = Risk of bleed, contraindicating DOAC therapy
90
What is the ABCD2 scoring system?
Gives stroke risk for patients who've just had a TIA
Age (60+) = 1
BP (140+ or 90+) = 1
Clinical features (2 if unilateral weakness, 1 if speech impairment)
Duration (up to 60 minutes = 1, more = 2)
Diabetes = 1
Score /7, 4+ requires urgent review (as does more than 2 in last 7 days, or patients in AF).
91
What does a RAP team do?
- confirm diagnosis
- confirm ONSET TIME
- can thrombolysis be used
- what is the patients premorbid status like (and are they are they at risk of complications)
- take bloods, get venous access etc...
92
At what blood pressure is thrombolysis contra-indicated?
185/110
If above this, can give medication (IV beta blocker) to rapidly reduce the blood pressure then perform thrombolysis, but need sufficient time.
93
What are some adverse effects of thrombolysis
- Evolution of the stroke causing raised ICP: oedema, hydrocephalus
- Seizure
- Infection
- Metabolic disturbance
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