Stroke |X

Question 1

What is the WHO definition of stroke?

Answer 1

A clinical syndrome, of presumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral functions lasting more than 24 hours or leading to death

Question 2

What are 2 causes of stroke? What % are they?

Answer 2

1. Cerebral infarction - 80%

2. Cerebral haemorrage - 20%

Question 3

What are 2 causes of cerebral bleeds?

Answer 3

1. Intracranial haemorrhage

2. Sub-arachnoid haemorrhage

Question 4

What are common risk factors for a cerebral infarction (5)?

What are 4 less common risk factors for a cerebral infarction?

Answer 4

Common

1. Hypertension
2. Atrial fibrillation
3. Smoking
4. Hypercholesterolaemia
5. Diabetes

Less common

1. Pro-thrombotic conditions
2. Infective endocarditis
3. Alcohol
4. Intravenous drug use

Question 5

What 4 lifestyle changes can you make to reduce the incidence of stroke?

Answer 5

1. Good bp control
2. Diabetes
3. Hyperlipidaemia
4. Stopping smoking

Question 6

What are the ddx of a stroke?

Answer 6

1. Subdural haematoma
2. Epilepsy
3. Hypoglycaemia
4. Brain tumours
5. Migraine
6. Encephalitis
7. Cerebral abscess

Question 7

How do you differentiate between a subdural haematoma from a stroke (3)?

Answer 7

1. Subdural haematoma usually more gradual onset with fluctuating s+s, drowsiness
2. Often preceded by hx of trauma or blood thinning agents
3. CT scan will make diagnosis

Question 8

How do you differentiate epilepsy from a stroke (2)?

Answer 8

1. Collateral history - Todd’s paresis can develop in those who have had a fit
2. More rapid recovery (24 hours)

Question 9

How do you differentiate hypoglycaemia from a stroke (1)?

Answer 9

Check BM

Question 10

How do you differentiate brain tumours from a stroke (2)?

Answer 10

1. Usually more insidious (days-weeks) with a stuttering or slowly progressive course
2. CT scan shows tumour

Question 11

How do you differentiate migraines from a stroke (2)?

Answer 11

1. Migraine can occasionally cause transient weakness which rapidly improves
2. Headache usually prominent feature

Question 12

How do you differentiate encephalitis from a stroke (3)?

Answer 12

1. May be an antecedent feature of infection
2. Fitting and fluctuation are more common with encephalitis
3. Electroencephalogram most useful

Question 13

How do you differentiate cerebral abscess from a stroke (2)?

Answer 13

1. Think cerebral abscess if infective features, longer prodrome, headache and reduced consciousness
2. CT

Question 14

What are the classic symptoms of stroke (6)?

Answer 14

1. Speech disturbance
   - Expressive/receptive dysphasia
   - dysarthria
2. Other higher cortical dysfunction
   - dysphagia
   - parietal lobe signs
3. Limb weakness
4. Sensory disturbance
5. Visual impairment
6. Brainstem symptoms

Question 15

How fast is the onset of symptoms of stroke?

Answer 15

Abruptly, usually without warning

Question 16

What is a transient ischaemic attack (TIA)?

Answer 16

A clinical syndrome characterised by an acute loss of focal cerebral or ocular function with symptoms lasting less than 24 hours (often only a few hours)

Question 17

What is expressive dysphasia?

Answer 17

Understanding is preserved and the patient tries to convey meaningful responses to the questions asked. Reading and writing may be impaired, but understanding is intact.

Question 18

What is receptive dysphasia?

Answer 18

Receptive dysphasia is due to a lesion in Wernicke’s area of the brain and results in the inability to understand language correctly.

Question 19

What is dysarthria?

Answer 19

Dysarthria is motor disturbance of speech individuals know what they want to say, but cannot get the words out correctly, because of weakness to the tongue or facial muscles.

Question 20

What are parietal lobe signs?

Answer 20

Sensory neglect - the patient has intact sensation when tested unilaterally but when confronted by bilateral stimuli, ignores the affected side

Question 21

What are features of brainstem signs (3)?

Answer 21

1. Cranial nerve palsies
2. Cerebellar signs (ataxia)
3. Locked-in syndrome

Question 22

What are cerebellar signs (5)?

Answer 22

1. Dysarthria
2. Nystagmus
3. Intention tremor
4. Past pointing
5. Broad based staggering gait

Question 23

What is a commonly accepted method of classifying a stroke?

Answer 23

Oxford Stroke Classification

Question 24

What are the classifications in the Oxford Stroke Classification?

*****8

Answer 24

1. Lacunar (LACS)
   - Motor or sensory deficit only
2. Partial anterior circulation (PACS)
   - 2 of following: motor or sensory deficit; higher cortical dysfunction; hemianopia
3. Total anterior circulation (TACS)
   All of: motor or sensory; cortical; hemianopia
4. Posterior circulation (POCS)
   Isolated hemianopia; brain stem signs; cerebellar ataxia

Question 25

Which type of stroke has the worst prognosis?

Answer 25

TACS

Question 26

Roughly what % of people become dependent after a stroke?

Answer 26

30%

Question 27

What is the mortality of stroke? 1. TACS 2. Others

Answer 27

1. 60% | 2. 10-20%

Question 28

What is the acute investigation of a stroke? 1. Checking stability of patient 2. Diagnostic testing

Answer 28

Checking stability of patient 1. BP, pulse 2. BM 3. O2 sats 4. Temp Diagnostic testing 1. CT/MRI of brain 2. ECG - AF 3. Carotid US - detects stenosis 4. Echocardiogram - detect thrombus in heart 5. Bloods - FBC, INR, lipid profile, U+E glucose, TFT/TSH, cholesterol 6. CXR 7. Urine dip/MSU

Question 29

What is the acute treatment of an ischaemic stroke?

Answer 29

Thrombolysis: tPA (tissue plasminogen activator) - dissolves blood clots

Question 30

What is the timeframe in which you need to start treating a stroke patient?

Answer 30

3 hours -but to be evaluated and receive treatment, they need to be in hospital within 60 mins

Question 31

In the medium term management of stroke, what medications do they need to be on?

Answer 31

1. Aspirin 300mg for 2 weeks, then 75mg PO 2. Paracetemol iv prn 3. Metoclopromide iv prn

Question 32

What is the non-pharmacological management of stroke in the medium term?

Answer 32

1. IV fluids 2. O2 3. Dietician 4. Physiotherapy 5. OT 6. Speech therapy and swallowing assessment 7. Rehabilitation - consultant determines what type of therapy is best for patient: a. rehab unit b. subacute rehab c. extended care facility d. home care with PT/OT

Question 33

What does rehab following a stroke involve?

Answer 33

Planned programmes of specialist rehabilitation support and enable individuals to maximise their independence following an illness, accident or after hospital or care home admission.

Question 34

What do care plans following discharge in a stroke patient involve (9)?

Answer 34

1. Treatment and advice on pain control. 2. Exercises to improve balance or muscle strength or joint movement - walking indoors, outdoors and 3. Medication management. 4. Promotion of a healthy lifestyle. 5. Wound management 6. Support to improve meal preparation, washing, dressing, doing housework and getting out and about. 7. Ways to increase confidence in abilities. 8. Continence management. 9. Address any changes that are needed in the home environment.

Question 35

What is the mneumonic to recognise stroke in the community?

Answer 35

F - acial weakness A - rm weakness S - peech problems T - ime to call 999