Stroke and its Consequences

Question 1

What is a stroke?

Answer 1

rapid onset of neurological deficit caused by focused cerebral, spinal or retinal infarcation or haemorrhage with symptoms lasting over 24 hours

Question 2

Stroke is a syndrome:

Answer 2

• placeholders to guide investigation
• not a diagnosis

Question 3

Transient Ischaemic Accident (TIA):

Answer 3

rapid onset of neurological deficit caused by focused cerebral, spinal or retinal infarcation or haemorrhage with symptoms lasting less than 24 hours

may herald a stroke

Question 4

What are the types of stroke?
Which type is more common?

Answer 4

• Ischaemic = 80-85% = blocked
  blood vessels
• Haemorrhagic = 15-20%

Question 5

What are the three main causes of ischaemic stroke?

Answer 5

• small vessel disease (20%)
• atherosclerosis (30%)
• cardio-embolic (30%)

Question 6

Ischaemic Stroke: Small Vessel Disease:

Answer 6

• high up on surface of brain,
  smaller vessels
• hypertension and diabetes
• hyalinisation = deposition
  proteinaceous material
• thickened, concentric smooth
  muscle cell layer, duplicated
  basement membrane
• lumen gradually narrows until
  occlusion
• commonly affecting perforating
  arteries from the middle cerebral
  artery

Question 7

Ischaemic Stroke: Atherosclerosis:

Answer 7

• medium to large vessels brain,
  neck, aorta
• accumulation and migration of
  monocytes and lymphocytes and
  foam cells
• plaque is formed with a necrotic
  core and fibrous cap
• narrows the artery

Question 8

Atherosclerosis:

Answer 8

insert diagram

Question 9

Arterial dissection causes what % of strokes in people under 60?

Answer 9

• 25%
• pain localised to side
• carotid/back of neck for vertebral

Question 10

Ischaemic Stroke: Cardio-embolic:

Answer 10

• atrial fibrillation is the most
  common cause
• multiple vascular territories are
  affected
• disrupted contraction of atrium,
  often dilation, blood pools and
  naturally clots when static

Question 11

Risk Factors for ischaemic stroke:

Answer 11

• age/gender/genetics
• hypertension
• hyperlipidaemia
• smoking
• diabetes mellitus
• obesity

Question 12

Rarer Risk Factors for Ischaemic Stroke:

Answer 12

• drugs
• cancer
• thrombophilia
• obstructive sleep apnoea

Question 13

Haemorrhagic Stroke: Pathophysiology:

Answer 13

1) Weakening of blood vessel wall:
small vessel disease/ amyloid
angiopathy

2) Abnormal vascular anatomy: high
pressure arterial blood in veins,
veins burst

3) Erosion into blood vessels: cancer

4) Abnormal Blood Clotting:
congenital haemophilia, acquired

Question 14

how does haemorrhage cause brain injury?

Answer 14

insert slide

Question 15

How does haemorrhagic stroke kill?

Answer 15

• herniation of the temporal lobe
  uncus
• herniation of cerebellar tonsils
• hydrocephalus
• compression of brainstem

Question 16

Intracerebral Haemorrhage that isn’t stroke:

Answer 16

• hematomas
• extra-axial
• not a stroke
• pressure upon the brain

Question 17

Intracerebral Haemorrhage on CT:

Answer 17

insert slide

Question 18

What important stroke risk factor is an important part of pathophysiology of both ischaemic and haemorrhagic stroke?

Answer 18

hypertension

Question 19

Circle of Willis:

Answer 19

insert diagram

Question 20

Anterior and Posterior Circulation:

Answer 20

insert diagram

Question 21

Anterior, Middle, and Posterior Cerebral Artery Supply:

Answer 21

insert diagrams

Question 22

Anterior, Middle and Posterior Cerebral Artery Supply (Axial):

Answer 22

insert diagram

Question 23

Stroke Symptoms:

Answer 23

• FAST
• facial weakness
• arm weakness
• speech problems
• time to call 999
• hemiparesis/hemianaesthesis/
  speech problems
• diplopia, ataxia, hemianopia
  (double vision, impaired
  coordination, loss of half the visual
  field)

Question 24

Stroke: Anterior Cerebral Artery: Symptoms:

Answer 24

• circulation syndromes
• hemiparesis/anaesthesia,
• leg>arm weakness
  (partial weakness on one side)
• frontal lobe signs: disinhibition,
  apathy

Question 25

Stroke: Middle Cerebral Artery: Symptoms:

Answer 25

- circulation syndrome - hemiparesis/anaesthesis - arm>leg weakness - dysphasia, inattention/neglect - higher cortical functions and mathematical ability affected

Question 26

Stroke: Posterior Cerebral Artery: Symptoms:

Answer 26

- circulation syndrome - homonymous hemaniopia (loss of half the visual field)

Question 27

Stroke: Basilar/Cerebellar Artery: Symptoms:

Answer 27

- hemiparesis (partial weakness one side) - hemianaethesia + diplopia - ataxia, crossed signs can mimic anterior cerebral artery stroke symptoms

Question 28

Middle Cerebral Artery Strokes and Hemispheric Dominance:

Answer 28

- most people are left handed - most people are left hemisphere dominant - Broca's and wernicke's on left - dominant hemisphere MCA strokes can cause language problems (dysphasia) - non-dominant hemisphere MCA strokes affects the attentional centers resulting in inattention/neglect/sensory extinction

Question 29

Patient has left sided weakness and inattention. Location of stroke?

Answer 29

Right middle cerebral artery stroke

Question 30

Patient has right sided weakness and dysphasia, Location of stroke?

Answer 30

Left middle cerebral artery

Question 31

Acute Treatment of Stroke:

Answer 31

- ABCDE (+ glucose!!) - exclude mimincs like hypoglycaemaia - is it ischaemic/haemorrhagic? - hyperacute = recanalisation therapy - acute = reduce complication/ preventative - long term = rehab, secondary prevention

Question 32

Acute Treatment of Ischaemic Stroke:

Answer 32

- can we clear the blockage? - recanalisation therapy: 1) IV thrombolysis: tissue plasminogen activator 2) Mechanical Thrombectomy: arterial puncture, wire passed into cerebral circulation, thrombus removed by stent retriever - antiplatelets as prevention - BP control if thrombolysis given - therapy input: physio, OT, speech and language therapy - surgery is rare; decompressive hemicraniectomy

Question 33

Contraindications of IV thrombolysis as part of recanalisation therapy:

Answer 33

- haemorrhage - abnormal clotting - high BP - head injury

Question 34

Acute Haemorrhagic Stroke Treatment:

Answer 34

- no equivalent to thrombolysis/thrombectomy - bp control to reduce risk of rebleed - clotting (correct any abnormalities) - therapy: physio, OT, speech and language - surgery: selected case cause decompression/drain insertion

Question 35

Secondary Prevention of Ischaemic Stroke:

Answer 35

- antiplatelets - anticoagulants if atrial fibrillation is cause - antihypertensives (ACE inhibitors, CCB, diuretics) - statins - insulin or metformin for diabetic causes of stroke

Question 36

Secondary Prevention of Haemorrhagic Stroke:

Answer 36

- avoidance of antithrombotic treatment - antihypertensive treatment

Question 37

56 year old man brought in by ambulance crew. Right sided weakness and dysphasia one hour ago Symptoms ‘back to normal’ worse for 20 mins On examination he walks in from ambulance BP 156/88 mmHg PR 60 /min BM 5.5 mmol/L He has mild expressive speech problems Slight drift of his right arm He tells you the symptoms are continuing to get better What is the diagnosis? - ischaemic stroke affecting left hemisphere territory - stroke affecting left hemisphere territory - transient ischaemic attack

Answer 37

Symptoms still present = stroke Left sided middle cerebral artery stroke??? probably ischaemic but without imaging can not say

Question 38

85 year old right handed woman. Background hypertension. Usually independent. Witnessed sudden onset right sided weakness and dysphasia at 16.30 Arrival to A&E at 17.30 On examination dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous hemianopia. ECG shows sinus rhythm, BP 210/106 mmHg, Blood sugar 6.3 mmol/L What is the best next course of action?

Answer 38

- aspirin not given until haemorrhage excluded - contact local stroke team - urgent head CT

Question 39

What is often seen in CT brain during acute stroke?

Answer 39

- dense middle cerebral artery; showing in situ thrombosis - early ischaemic changes

Question 40

85 year old right handed woman. Background hypertension. Usually independent. Witnessed sudden onset right sided weakness and dysphasia at 16.30 Arrival to A&E at 17.30 On examination dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous hemianopia. ECG shows sinus rhythm, BP 210/106 mmHg, Blood sugar 6.3 mmol/L. What is shown/the cause? - acute haemorrhage in the left hemisphere - calcification in flax cerebri - subarachnoid haemorrhage - thrombus in the left middle cerebral artery

Answer 40

Thrombus in the left middle cerebral artery could be subarachnoid normally presents with severe headache could be haemorrhage but is small so not proportional to symptoms

Question 41

85 year old right handed woman. Background hypertension. Usually independent. Witnessed sudden onset right sided weakness and dysphasia at 16.30 Arrival to A&E at 17.30 On examination dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous hemianopia. ECG shows sinus rhythm, BP 210/106 mmHg, Blood sugar 6.3 mmol/L. thrombus in left cerebral artery What treatments is she eligible for? - aspirin - decompressive hemicraniectomy - IV thrombolysis - mechanical thrombectomy

Answer 41

- Aspirin largely preventative - Decompressive hemicraniectomy only needed in malignant MCA syndrome - IV thrombolysis effective but many patients don’t benefit - Mechanical thrombectomy only in large vessel occlusion but very effective treatment Eligible for all but most likely IV thrombolysis

Question 42

87 year old right handed woman. Background hypertension, AF (on warfarin), OA. Lives alone, independent. Onset of speech disturbance and started bumping into things on her right according to husband, from around midday. On examination receptive dysphasia and right homonymous hemianopia. BP 179/87 mmHg BM 7.5 What can you see on the CT? - left cerebellar haemorrhage - left occipital haemorrhage - left frontal haemorrhage - left tempero-parietal haemorrhage

Answer 42

left tempero-parietal haemorrhage

Question 43

87 year old right handed woman. Background hypertension, AF (on warfarin), OA. Lives alone, independent. Onset of speech disturbance and started bumping into things on her right according to husband, from around midday. On examination receptive dysphasia and right homonymous hemianopia. BP 179/87 mmHg BM 7.5 CT = left tempero-parietal haemorrhage What is the most likely cause of this haemorrhage? - anticoagulation with warfarin - hypertensive small vessel disease - underlying arteriovenous malformation - malignant tumour

Answer 43

anticoagulation with warfarin otherwise hypertension, arteriovenous

Question 44

87 year old right handed woman. Background hypertension, AF (on warfarin), OA. Lives alone, independent. Onset of speech disturbance and started bumping into things on her right according to husband, from around midday. On examination receptive dysphasia and right homonymous hemianopia. BP 179/87 mmHg BM 7.5 CT = left tempero-parietal haemorrhage What treatment is most likely to help? - ICP bolt insertion for intercranial pressure management - left temporal craniectomy - hypertension treatment - reversal of INR

Answer 44

reversal of INR

Question 45

63 year old man Presents to stroke team with right leg weakness Woke up with symptoms Unable to walk Mild drift in right arm only Which arterial territory affected? - anterior cerebral artery - middle cerebral artery - posterior cerebral artery - cerebellar artery - basilar artery

Answer 45

- anterior cerebral artery infarct (left) - cause more weakness in arm>leg

Question 46

Biggest risk of haemorrhagic stroke is

Answer 46

rebleeds reversal of anticoagulation is most helpful (vitamin K)

Question 47

Penumbra:

Answer 47

- part of brain threatened by ischaemic stroke but not yet dead

Question 48

76 year old man, with history of hypertension, type one diabetes, previous stroke and ischaemic heart disease Elective admission for a coronary angiogram Nil by mouth from midnight the day prior to procedure On morning of angiogram, the nurse in charge notices that he has become very pale, clammy and slumped to the left hand side What test to be done? - blood sugar - CT

Answer 48

blood sugar

Question 49

72 year old woman Bumping into things for one month on her right A week ago developed gradual onset headache Yesterday could not read properly ‘I can’t see the end of the word when I look at it…’ On examination - right homonymous hemianopia. Past medical history of breast cancer. - left occipital haemorrhagic stroke - left occipital metastatic cancer - left posterior territory ischaemic stroke - subarachnoid haemarrhage

Answer 49

progressive symptoms suggests a space occupying lesion can be seen in subdural haematoma red flag for cancer subarachnoid haematoma causes sudden onset of very severe headaache with focal neurology later Answer: space occupying lesion in left occipital lobe

Question 50

Stroke mimics:

Answer 50

- sugar (low or high) - seizures - syncope - sepsis (ppl with history of stroke) - psychogenic - migraines (6 S)