Stroke medicine

Question 1

What are TIAs?

Answer 1

• Focal neurological deficits due to blockage of blood supply to part of the brain
• Lasting less than 24hrs but in practice these are usually much less

Question 2

Risk assessment for TIA to predict short term risk of stroke?

Answer 2

ABCD2 - but NOT a diagnostic tool

Question 3

How is ABCD2 calculated?

Answer 3

Sum of points of 5 different factors inc:
* Age
* BP
* Clinical features
* Duration of symptoms
* Diabetes?

Question 4

Cut off score for ABCD2

Answer 4

Score of 4 or more = higher risk of stroke

Question 5

Management of high risk patients

Answer 5

• Prioritised to be seen in TIA clinic or by a stroke physician ASAP
• Aspirin 300mg daily if suspected TIA started immediatly

Question 6

Investigations for TIA

Answer 6

• Bloods
• Carotid doppler
• CT or MRI

Question 7

Treatment for TIA

Answer 7

• Lifestyle modifcations
• Treatment of high cholesterol and HTN
• Surgical intervention for carotid artery disease
• Antiplatelets if appropriate

Question 8

What is crescendo TIA?

Answer 8

Two or more TIAs in a week - should be treated for high risk stroke

Question 9

Define stroke

Answer 9

• Sudden onset of focal neurological deficit
• Lasting more than 24hrs or with imaging evidence of brain damage (eg infarction shown by emboli, thrombosis or low blood flow or haemorrhage)

Question 10

Initial classification of stroke

Answer 10

• Haemorrhage
• Infarct (ischaemic)

Question 11

How do we identify vascular territory involved - classification?

Answer 11

• Bamford classification and then with brain imaging

Question 12

How to classify underlying cause of infarcts?

Answer 12

TOAST classification

Question 13

Classifying underlying causes of bleeds on brain

Answer 13

• Primary HTN
• Cerebral amyloid angiopathy
• Secondary - eg trauma

Question 14

Emergency treatment of stroke

Answer 14

• Thrombolysis for ischaemic
• Anticoagulation reversal or neurosurgical intervention for bleeds

Question 15

Types of strokes

Answer 15

• TACS
• PACS
• LAC
• POCS

Question 16

What us used to classify the symptoms associated with the types of strokes?

Answer 16

Bamford classification

Question 17

Worse stroke type prognosis

Answer 17

• TACS - often leave pt with significant weakness

Question 18

Assessment tools used for rapid assessment of stroke

Answer 18

FAST:
* Face (facial drooping)
* Arm (weakness)
* Speech (slurred)
* Time (call 999)
ROSIER
* Rosier scale used to distinguish between stroke and stroke mimic. commonly used in A&E

Question 19

What is NIHSS?

Answer 19

• NIH stroke scale - used as clinical stroke assessment tool to evaluate and document neuroligcal status in acute stroke patients
• Measure stroke severity

Question 20

15 items on NIHSS

Answer 20

• Level of conc
• Language
• Neglect
• Visual field loss
• Extraocular movement
• Motor strength
• Ataxia
• Dysarthria
• Sensory loss

Question 21

Pharmaceutical treatment for identified ischaemic stroke

Answer 21

Alteplase - thrombolysis

Question 22

Timeframe to have alteplase

Answer 22

• Within 4.5hrs of onset of stroke
• Increases likelihood of being functionally independent
• Does not increase 90 day risk of mortality

Question 23

Where should stroke pts be cared for and why?

Answer 23

• Organised stroke unit
• Long term reduction in death dependency and need for institutional care

Question 24

What should all people presenting with acute stroke who have had haemorrhage excluded by imaging be given?

Answer 24

• Aspirin 300mg orally if not dysphagic
• 300mg rectally or by enteral tube if they are

Question 25

How long should aspirin 300mg be continued for?

Answer 25

* 2 weeks after the onset of symptoms * Then long term antithrombolytic agent should be commenced

Question 26

Restrictions after stroke and TIA

Answer 26

* Not permitted to drive for 1 month * After this time you can again as long as there is no permanent neurolgical problems * If recurrent TIAs cannot drive for 3 months - must be assessed by doctor prior to driving

Question 27

How is carotid stenosis quantified?

Answer 27

* NASCET - north american symptomatic carotid endarterectomy trial criteria * ECST - european carotdi surgery trialists collaberative group criteria

Question 28

NASCET scoring value to undergo assessment/intervention

Answer 28

50-99% carotid stenosis with stable neurologicla symptoms from stroke or TIA

Question 29

ECST value to undergo assessment/surgery

Answer 29

70-99% carotid stenosis with stable neurological symptoms from stroke or TIA

Question 30

What should those with 50-99% NASCET and 70-99% ECST have?

Answer 30

* Assessed and referred for carotid endarterectomy within 1 weeek of onset of stroke/TIA symptoms * Undergo surgery within a maximum of 2 weeks from onset of stroke/TIA symptoms * Fitness for surgery should be assessed and may be small risk of stroke during surgery

Question 31

What are people with severe middle cerebral artery infarction at risk of?

Answer 31

* Malignant MCA syndrome * Therefore should be considered for decompressive hemicraniectomy if any deterioration in clinical condition eg decrease in conc

Question 32

Timing for decompressive hemicraniectomy for malignant MCA syndrome risk

Answer 32

* Referred within 24hrs of onset of symptoms * Treated within max of 48hrs

Question 33

Criteria for malignant MCA syndrome decompressive hemicraniectomy

Answer 33

* Under 60 * CT infarct of at least 50% MCA territory * NIHSS score above 15

Question 34

Examples of stroke mimics

Answer 34

* Seizures * Space occupying lesions * Hemiplagic migraine * Multiple sclerosis * Sepsis in those with pre-existing neurologicla weakness

Question 35

Risk scoring used to assess if suitable for anticoagulation

Answer 35

CHADS-VASC 2 score

Question 36

When is CHADS-VASC 2 score used?

Answer 36

Determine if someone is suitable for anticoagulants if they are in atrial fibrillation and at risk of stroke

Question 37

What is useful to use alongisde CHADS-VASC 2?

Answer 37

* ORBIT * HAS-BLED score * Both used to assess bleeding risk

Question 38

Anticoagulation for afib stroke risk

Answer 38

* Warfarin * DOAC eg apixaban, rivaroxaban, edoxaban

Question 39

HAS BLED components

Question 40

CHAD VASC 2 components

Question 41

Complex decisions made in stroke examples

Answer 41

* DNACRPS * Commencing enteral feeding eg NG or PEG

Question 42

Indication for enteral feeding

Answer 42

* Poor swallow following large stroke * Without if these patients would aspirate

Question 43

Decision for enteral feeding is baseed on...

Answer 43

* Patient and family preference * Quality of life expected with treatment

Question 44

Risks of NG/PEG tube

Answer 44

Aspiration - still Some patients will never be able to tolerate oral intake again

Question 45

When are NG tubes often inserted?

Answer 45

* Post stroke when swallowing is affected * Decision to proceed with PEG feeding is often complex decision making process involving family and MDT