Stroke (N)

Question 1

Define stroke.

Answer 1

A clinical syndrome consisting of rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin

Question 2

What are the two types of stroke?

Answer 2

• ischaemic stroke (85%) - cerebral infarction due to insufficient blood flow due to a thrombus or embolus
• haemorrhagic stroke (15%) - cerebral infarction due to haemorrhage (rupture of blood vessel causing leakage of blood into brain)

Question 3

What is a central venous sinus thrombosis (stroke)?

Answer 3

Rare form of stroke that occurs due to thrombosis of the dural venous sinuses

Question 4

What are some risk factors for stroke? (7)

Answer 4

• age >65
• hypertension
• diabetes
• AF
• obesity
• smoking
• high cholesterol

Question 5

What is the main feature of stroke, regardless of its location?

Answer 5

Acute onset

Question 6

What are the five key functions affected by stroke?

Answer 6

• motor
• sensation
• speech
• balance
• vision

Question 7

What are some general clinical features of a stroke? (7)

Answer 7

• unilateral weakness / paralysis
• sensory, visual or cognitive impairment
• dysphasia
• ataxia
• impaired coordination
• impaired consciousness
• head/neck pain (if carotid or vertebral artery dissection)

Question 8

What are the types of stroke according to the Bramford stroke classification? (4)

Answer 8

• total anterior circulation stroke (TACS)
• partial anterior circulation stroke (PACS)
• lacunar syndrome (LACS)
• posterior circulation syndrome (POCS)

Question 9

What are the criteria for a total anterior circulation stroke (TACS)?

Answer 9

Affects middle and anterior cerebral arteries

All three of the following:

• unilateral weakness (and/or sensory deficit) of the face, arm and leg
• homonymous hemianopia
• higher cerebral dysfunction (dysphasia, visuospatial disorder)

Question 10

What are the criteria for a partial anterior circulation stroke (PACS)?

Answer 10

Involves smaller arteries of anterior circulation e.g. upper/lower division of MCA

Two of the following:

• unilateral weakness (and/or sensory deficit) of the face, arm and leg
• homonymous hemianopia
• higher cerebral dysfunction (dysphasia, visuospatial disorder)

Question 11

What are the criteria for lacunar syndrome (LACS)?

Answer 11

One of the following:

• pure sensory stroke
• pure motor stroke (unilateral weakness of face and arm, arm and leg or all three)
• sensori-motor stroke
• ataxic hemiparesis

Question 12

What are the criteria for posterior circulation syndrome (POCS)?

Answer 12

One of the following:

• cranial nerve palsy and a contralateral motor/sensory deficit
• bilateral motor/sensory deficit
• conjugate eye movement disorder (e.g. gaze palsy)
• isolated homonymous hemianopia or cortical blindness
• (cerebellar/brainstem syndromes, LoC)

Question 13

What is a ‘classic’ stroke?

Answer 13

Middle cerebral artery stroke

Question 14

What features would you see in a middle cerebral artery stroke? (4)

Answer 14

• contralateral weakness and sensory loss in upper limbs and lower half of face
  
  • contralateral facial weakness
  • contralateral hemiparesis (motor cortex) - upper limb weakness
  • contralateral hemisensory loss (sensory cortex)
• contralateral homonymous hemianopia
• aphasia
  
  • damage to Broca’s area (left frontal lobe) –> expressive aphasia (speech production)
  • damage to Wernicke’s area (left temporal lobe) –> receptive aphasia (speech comprehension)
• dysarthria, dysphagia, apraxia

Question 15

What would damage to Broca’s area (left frontal lobe) cause in MCA stroke?

Answer 15

Expressive aphasia (speech production)

Question 16

What would damage to Wernicke’s area (left temporal lobe) cause in MCA stroke?

Answer 16

Receptive aphasia (speech comprehension)

Question 17

What features would you see in an anterior cerebral artery stroke? (4)

Answer 17

• contralateral weakness and sensory loss in lower limb (hemiparesis)
• abulia (behaviour changes, intellect, executive function etc)
• urinary incontinence
• confusion

Question 18

What features would you see in a posterior cerebral artery stroke? (6)

Answer 18

• contralateral homonymous hemianopia with macular sparing
• visual agnosia (difficulty recognising familiar objects/faces)
• contralateral sensory loss (or motor loss, in all 4 limbs)
• memory deficits
• vertigo
• nausea

Question 19

What do you see on stroke of midbrain branches of posterior cerebral artery?

Answer 19

Ipsilateral oculomotor (CN III) palsy (down and out eye) and contralateral weakness of the upper and lower extremity

(Weber’s syndrome)

Question 20

What features would you see in a posterior circulation stroke? (3+6)

Answer 20

• damage to the brainstem
• ipsilateral symptoms
• DANISH (cerebellar signs):
  
  • Dysdiadochokinesia
  • Ataxia
  • Nystagmus
  • Intention tremor
  • Slurred speech
  • Hypotonia

Question 21

What would you see in a posterior inferior cerebellar artery (PICA) stroke AKA lateral medullary syndrome? (Posterior circulation stroke)

Answer 21

Lateral medullary syndrome:

• cerebellar signs (DANISH)
• nystagmus
• vertigo and vomiting
• ipsilateral facial pain and temperature loss
• contralateral upper and lower limb pain and temperature (sensory) loss
• ipsilateral Horner’s syndrome

Question 22

What would you see in an anterior inferior cerebellar artery (AICA) stroke? (Posterior circulation stroke)

Answer 22

• sudden onset vertigo and vomiting
• ipsilateral facial paralysis
• deafness

Question 23

What is Weber’s syndrome and what are its features? (2)

Answer 23

A form of midbrain stroke characterised by:

• ipsilateral CN III palsy (down and out eye)
• contralateral hemiparesis

Question 24

What features would you see in a pontine haemorrhage? (3)

Answer 24

• reduced GCS
• paralysis
• bilateral pin-point pupils

Question 25

What feature would you see in a basilar artery stroke?

Answer 25

Locked in syndrome - decreased GCS and motor symptoms

Question 26

What features would you see in a posterior communicating artery aneurysm? (2)

Answer 26

- CN III palsy (eye down and out, dilated pupil) - eye pain

Question 27

What are the four types of aphasia and their symptoms?

Answer 27

- Broca's aphasia - speech non-fluent, comprehension normal, repetition impaired - Wernicke's aphasia - speech fluent, comprehension abnormal, repetition impaired - conduction aphasia (arcuate fasciculus) - speech fluent, comprehension normal, repetition impaired (aware of errors) - global aphasia - speech non-fluent, comprehension abnormal, repetition impaired

Question 28

What acronym can we use to diagnose stroke in the community?

Answer 28

BE FAST: - Balance - Eyes - Face (one side drooping) - Arms or legs (weakness) - Speech - Time

Question 29

What score can we use to tell the difference between stroke and stroke mimic?

Answer 29

ROSIER (Recognition Of Stroke In Emergency Room) Stroke likely if score >0

Question 30

What are the first-line investigations for stroke? (4)

Answer 30

- non-contrast CT head (1st line radiological investigation) - serum glucose - rule out hypo/hyperglycaemia - serum electrolytes - rule out metabolic disturbances - serum urea and creatinine - rule out AKI/renal failure

Question 31

What scans do we do in suspected stroke? (2)

Answer 31

- non-contrast CT head - to exclude haemorrhage and confirm ischaemic stroke (NB CT does not rule out ischaemic stroke) - CT angiogram - look for which vessel is occluded

Question 32

What might non-contrast CT head show in ischaemic stroke?

Answer 32

- may show areas of low density in the grey and white matter of the territory (may take time to develop) - other signs include the 'hyperdense artery' sign corresponding with the responsible arterial clot (visible immediately)

Question 33

What might non-contrast CT head show in haemorrhagic stroke?

Answer 33

Typically show areas of hyperdense material (blood) surrounded by low density (oedema)

Question 34

How do we investigate stroke after the patient has been treated?

Answer 34

Look for cause of stroke through e.g. - echocardiogram (structural heart disease) - ambulatory ECG (AF) - carotid doppler (carotid atherosclerosis) - if >70% occlusion do carotid endarterectomy (surgery to remove plaque from carotid)

Question 35

What do we do if carotid doppler shows >70% occlusion (stroke)?

Answer 35

Carotid endarterectomy - surgery to remove plaque from carotid

Question 36

What score can we use to measure disability of someone after a stroke?

Answer 36

Barthel index

Question 37

What are some differential diagnoses for stroke? (10)

Answer 37

- hypertensive encephalopathy - hypoglycaemia - complicated migraine - seizure and postictal deficits (Todd's paresis) - conversion and somatisation disorders - Wernicke's encephalopathy - brain tumour - sepsis - intracranial venous thrombosis (non-contrast CT shows hyperdensity in affected sinus) - cavernous sinus thrombosis (chemosis, exophthalmos and periorbital sweating)

Question 38

What is the first step to stroke management?

Answer 38

CT head before thrombolysis to rule out haemorrhage (especially if on warfarin/DOAC/bleeding disorder)

Question 39

What do we do for ischaemic stroke management after head CT ruled out haemorrhage, if <4.5h from onset?

Answer 39

**Thrombolysis - IV alteplase** (recombinant tissue plasminogen activator)

Question 40

How do we manage ischaemic stroke - anterior circulation stroke (ACA or MCA) within 6h?

Answer 40

Mechanical thrombectomy + thrombolysis (IV alteplase)

Question 41

How do we manage ischaemic stroke - 6-24h and limited infarct core in anterior circulation?

Answer 41

Mechanical thrombectomy

Question 42

How do we manage ischaemic stroke - within 24h and limited infarct core in posterior circulation?

Answer 42

Mechanical thrombectomy + thrombolysis

Question 43

What should BP be lowered to before thrombolysis (stroke)?

Answer 43

185/110 mmHg

Question 44

When is thrombolysis contraindicated in stroke?

Answer 44

- previous intracranial haemorrhage - seizure - intracranial neoplasm - suspected subarachnoid haemorrhage - stroke/brain injury in preceding 3m - lumbar puncture in preceding 7d - GI haemorrhage in last 3wk - active bleeding - pregnancy - oesophageal varices - uncontrolled hypertension >200/120mmHg - concurrent anticoagulation (INR>1.7) - major surgery/trauma in last 2wk

Question 45

How do we manage ischaemic stroke if >4.5h from onset?

Answer 45

Conservative management (aspirin PO 300mg daily) + swallow assessment

Question 46

What do we do 2 weeks after ischaemic stroke? (2)

Answer 46

Secondary prevention: - stop aspirin 300mg daily - start clopidogrel 75mg daily for life (if not tolerated, aspirin + modified release dipyridamole)

Question 47

What do we give patients with stroke risk due to AF?

Answer 47

Anticoagulation (DOAC) initiated 2 weeks after stroke

Question 48

When do we do surgery for ischaemic stroke?

Answer 48

If ipsilateral carotid artery stenosis >50-70% (carotid doppler) --> carotid endarterectomy Hypoglossal nerve at risk of damage

Question 49

How do we manage haemorrhagic stroke?

Answer 49

Stop anticoagulants (if warfarin, consider vitamin K and prothrombin concentrate) and control BP if acute

Question 50

When do we start anticoagulation following a stroke vs TIA?

Answer 50

- ischaemic stroke - after 2 weeks - TIA - immediately once haemorrhage ruled out

Question 51

What are some complications of stroke? (7)

Answer 51

- aspiration pneumonia - cerebral oedema - immobility - pressure sores, constipation, depression - infections - DVT - cardiovascular events - death