Introduction to Stroke

Question 1

What is a stroke?

Answer 1

• a sudden loss of focal (meaning a specific location) cerebral function
• symptoms last >24 hours or death

Question 2

In a stroke how long do the symptoms generally present for?

1 - 1-2 hours
2 - 6-8 hours
3 - 12-16 hours
4 - >24 hours or death

Answer 2

4 - >24 hours or death

Question 3

What are the 2 most common causes of a stroke?

Answer 3

1 - spontaneous haemorrhage (blood vessel bursts)
2 - Ischemia (inadequate blood flow(

Question 4

The 2 most common causes of a stroke are

1 - spontaneous haemorrhage
2 - Ischemia (inadequate blood flow)

What are the 2 main causes of an ischemia stroke?

Answer 4

• thrombosis = blood clot, or thrombus, grows in blood vessels of the brain
• embolus (referred to as an embolism) = blood clot develops elsewhere in the body and travels to the brain, blocking blood vessels

Question 5

A transient Ischemia attack (TIA) differs to a stroke, how is this different?

Answer 5

• acute with symptoms for <24 hours
• loss of function can be focal (specific part of brain) cerebral for ocular (eye) and then relieve itself

Question 6

A transient Ischemia attack (TIA) is an acute attack with symptoms lasting for <24 hours. It causes a loss of function that can be focal (specific part of brain) cerebral or ocular (eye). This is thought to be caused by an acute loss of blood flow. What are the 2 most common causes?

Answer 6

1 - thrombosis (growing blood clot)
2 - embolism (clot broken off in body and gets trapped in blood vessels in the brain)
- both could cause reduced blood flow on and off until blood vessels become completely blocked

Question 7

Does a transient ischaemic attack (TIA) occur in isolation with no risks?

1 - yes just a mini stroke with no consequences
2 - increases the risk of a stroke
3 - increases risk of dementia
4 - increases the risk of vasculitis

Answer 7

2 - increases the risk of a stroke
- highest risk within days of TIA
- risk reduces only 3 months following subsidence of the symptoms

Question 8

What does acute stroke syndrome refer to?

Answer 8

• period where it is not possible to distinguish between TIA and stroke

Question 9

How many people a year are affected by strokes?

1 - 10,000
2 - 100,000
3 - 150,000
4 - 200,000

Answer 9

3 - 150,000

Question 10

What % of people who have a stroke is fatal within the year of the stroke?

1 - 10%
2 - 25%
3 - 45%
4 - 75%

Answer 10

2 - 25%

Question 11

What % of people who have a stroke then live with severe disability?

1 - 10%
2 - 25%
3 - 33%
4 - 75%

Answer 11

3 - 33.3%

Question 12

What % of people who have a stroke are <65 years of age?

1 - 10%
2 - 25%
3 - 50%
4 - 75%

Answer 12

2 - 25%

Question 13

What % of people who have a stroke has previously been preceded by a transient ischemic attack?

1 - 10%
2 - 20%
3 - 50%
4 - 75%

Answer 13

2 - 20%

Question 14

What are the costs of stroke to the UK per year?

Answer 14

• £9 billion

Question 15

What % of <65 year old survivors of a stroke are unable to return to work?

Answer 15

• nearly 70%

Question 16

Are ischemic or haemorrhage strokes more common?

Answer 16

• ischemic accounts for aprox 85%
• far and above leading cause

Question 17

What % of strokes are intracranial haemorrhage?

1 - 10%
2 - 20%
3 - 50%
4 - 75%

Answer 17

1 - 10%

Question 18

What % of strokes are subarachnoid (bleeding in space around the brain) haemorrhage?

1 - 10%
2 - 5%
3 - 50%
4 - 75%

Answer 18

2 - 5%
- sub = below
- between subarachnoid and pia mater

Question 19

What are the 3 most common causes of an ischemic attack?

Answer 19

1 - Large vessel-vessel thromboembolism (50%)
2 - Cardioembolic events (20%) (AF, endocarditis)
3 - Small vessel disease (25%) (diabetes, hypertension)

Question 20

What is an Intracranial hemorrhage (ICH), also known as a intracranial bleed?

Answer 20

• bleeding within the skull
• not within the brain though

Question 21

An intracranial hemorrhage (ICH), also known as a intracranial bleed is bleeding within the skill and not the brain specifically. What group of patients is most at risk to an ICH?

1 - diabetics
2 - hypertensives
3 - obese
4 - previous cancer

Answer 21

2 - hypertensives
- vessels under high pressure are more likely to rupture

Question 22

What is an subarachnoid hemorrhage (ICH), which comes under the umbrella term of intracranial bleed?

Answer 22

• bleeding between subarachnoid and pia mater
• not in the brain though

Question 23

What is a septic emboli?

Answer 23

• an infected blood clot
• such as sinusitis (swollen and inflamed sinuses)

Question 24

Subarachnoid haemorrhage is bleeding into the space between the arachnoid and pia mater meninges. What is one of the most common causes of this?

1 - intracranial aneurysm
2 - head trauma
3 - infection
4 - medication

Answer 24

1 - intracranial aneurysm
- rupture of an intracranial aneurysm (weak blood vessel that bursts) or vascular malformation

Question 25

Subarachnoid haemorrhage is bleeding into the space between the brain and the skull. The most common causes are a rupture of an intracranial aneurysm (weak blood vessel that bursts) or vascular malformation. What is the most common symptom of a subarachnoid haemorrhage? 1 - muscle weakness on one side of the body 2 - paralysis 3 - fever 4 - intense headache

Answer 25

4 - intense headache

Question 26

Subarachnoid haemorrhage is bleeding into the space between the arachnoid and pia mater ;ayers of the meninges. One of the most common causes is a rupture of an intracranial aneurysm (weak blood vessel that bursts) or vascular malformation. The most common symptom of a subarachnoid haemorrhage is a severe acute headache. What can happen if this is missed?

Answer 26

- increased blood in brain increases intracranial pressure (ICP) - increased ICP can damage and kill brain cells - permanent brain damage

Question 27

Why is addressing hypertension an important modification of risk stroke?

Answer 27

- patients with hypertension are at increased risk of intracranial haemorrhage

Question 28

How can being aware and treating atrial fibrillation reduce the risk of a stroke?

Answer 28

- AF = a common heart rhythm disorder and increases the risk of virchow's triad - blood can pool in the atria forming blood clots - if blood clot breaks away, forming an embolism it could travel to your brain and block it

Question 29

Why is addressing carotid artery disease (CAD) (stenosis) an important modification of risk stroke?

Answer 29

- stenosis due to CAD can reduced blood flow - internal coronary artery supplies the brain, so this would reduce blood flow

Question 30

Why is addressing diabetes an important modification of risk stroke?

Answer 30

- increased sugar in your blood damages the blood vessels - blood vessels can become stiff causing atherosclerosis - this can then lead to blockage of blood vessels

Question 31

Why is addressing obesity an important modification of risk stroke?

Answer 31

- increased risk of CVD, diabetes and hypertension - all increase the risk of stroke

Question 32

Why is addressing obesity an important modification of risk stroke?

Answer 32

- can lead to atrial fibrillation (AF) and virchow's triad - AF = a common heart rhythm disorder - blood can pool in the atria forming blood clots - if blood clot breaks away, forming an embolism it could travel to your brain and block it - causing ischaemic stroke (most common 85%)

Question 33

Why is addressing smoking an important modification of risk stroke?

Answer 33

- hypertension, CVD, atherosclerosis - all increase risk of strokes

Question 34

When you suspect a stroke, what imaging modality must be used and what are we imaging? 1 - 1st CT and/or MRI imaging 2 - ultrasound 3 - PET scan

Answer 34

1 - 1st CT and/or MRI imaging

Question 35

When you suspect a stroke, what imaging modality must be used when we would want to investigate vascular pathology? 1 - CT 2 - MRI imaging 3 - MRI angiogram 4 - ultrasound

Answer 35

3 - MRI angiogram - MRI that focusses on blood vessels

Question 36

When you suspect a stroke, what imaging modality must be used if we suspect carotid stenosis due to a potential thrombosis? 1 - CT 2 - MRI imaging 3 - MRI angiogram 4 - carotid doppler

Answer 36

4 - carotid doppler - doppler would identify a blockage of an blood vessel

Question 37

When you suspect a stroke, what modality must be used if we suspect atrial fibrillation? 1 - ECG 2 - MRI imaging 3 - MRI angiogram 4 - carotid doppler

Answer 37

1 - ECG and cardiac monitoring - blood pressure monitoring - full blood counts

Question 38

What is the Oxfordshire Community Stroke Project (OCSP) Classification for strokes?

Answer 38

- practical method for assessing management options for patients who have had a stroke - understanding the pathophysiology of a stroke will drive treatment options

Question 39

The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). What does total anterior circulation syndrome mean?

Answer 39

- a type of cerebral infarction - entire anterior circulation supplying one side of the brain affected - very serious affect on carotid artery

Question 40

The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). A total anterior circulation syndrome (TACS) mean is a type of cerebral infarction. It affects the entire anterior circulation supplying one side of the brain. It is very serious and is affected by the carotid artery. What 3 presentations must be present for a diagnosis of TACS? 1 - unilateral motor weakness, higher cortical deficit, systemic visual field defects 2 - bilateral motor weakness, higher cortical deficit, homonymous visual field defect 3 - unilateral motor weakness, higher cortical deficit, homonymous visual field defect 4 - unilateral motor weakness, lower cortical deficit, homonymous visual field defect homonymous visual = vision lost in one eye

Answer 40

3 - unilateral motor weakness, higher cortical deficit, homonymous visual field defect

Question 41

The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). In order for a patient to be diagnosed with partial circulation syndrome (PACS) mean, how many of the following criteria must be met? - unilateral motor weakness - higher cortical deficit - homonymous (one side of eye cannot see) visual field defect

Answer 41

- 2 of these features

Question 42

The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). What does a lacunar stroke (LACS) mean? 1 - stroke affecting tissue, resembling a lacuna 2 - stroke affecting the lacunae blood vessels 3 - occlusion of blood vessels in the penetrating arteries in deep brain structures

Answer 42

3 - occlusion of blood vessels in the penetrating arteries in deep brain structures - common type of ischaemic stroke - can affect the basal ganglia

Question 43

The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). What does posterior circulation stroke syndrome (POCS) mean?

Answer 43

- damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem)

Question 44

There are some salient points in Acute Stroke Management, which essentially means the faster a stroke is treated the better the clinical outcome. Plasminogen activators (tPA) are one key treatment that should be used acutely. What are tPAa? 1 - serine protease catalysing the activation of plasmin 2 - degrading embolisms 3 - degrading fibrinogen directly 4 - inhibiting coagulation of blood

Answer 44

1 - serine protease catalysing the activation of plasmin - plasmin is important fibrinolysis, breakdown of fibrin, component of blood clots - essentially stops blood embolism forming

Question 45

There are some salient points in Acute Stroke Management, which essentially means the faster a stroke is treated the better the clinical outcome. Plasminogen activators (tPA) are one key treatment that should be used acutely. tPAa's are serine proteases that catalyze the activation of plasmin, which is important fibrinolysis, breakdown of fibrin, component of blood clots, reducing the risk of an embolism. In acute ischaemic stoke presentation, how soon does this need to be given to reduce disability? 1 - <1 hour from stroke 2 - <2 hours from stroke 3 - <3 hours from stroke 4 - <4.5 hours from stroke

Answer 45

4 - <4.5 hours from stroke

Question 46

Where should all patients with a suspected stroke be admitted to? 1 - GP 2 - emergency department 3 - ICU 4 - stroke ward

Answer 46

4 - stroke ward

Question 47

In a subset (10%) of acute ischaemic stroke patients who demonstrate radiographic evidence of a proximal anterior circulation large vessel occlusion (proximal middle cerebral or distal internal carotid) within 6 hours of symptom onset, what treatment can offer distinct benefit? 1 - Plasminogen activators (tPA 2 - aspirin 3 - MRI angiogram 4 - mechanical thrombectomy

Answer 47

4 - mechanical thrombectomy - minimally invasive technique to remove the blood clot

Question 48

What are the 4 most common differentials that could present as a stroke, but are not a stroke?

Answer 48

1 - Space occupying lesion 2 - Seizure 3 - Migraine (e.g. hemiplegic) 4 - Functional neurological disorder

Question 49

What is bells palsy?

Answer 49

- an unexplained episode of facial muscle weakness or paralysis - sudden onset affecting whole side of the face - damage or infection to the CN VII (7) the facial nerve

Question 50

In addition to addressing the physical aspects of a stroke, what else must be taken into account in a patient who has had a stroke?

Answer 50

- post-stroke psychiatric co-morbidities - associated with decreased likelihood of returning to work, poorer quality of life and long term disability

Question 51

Patients who have suffered a stroke are more likely to suffer from phobic anxiety disorders. What are these?

Answer 51

- specific phobic disorders involve persistent, unrealistic, intense anxiety about and fear of specific situations, circumstances, or objects

Question 52

Management of Neuropsychiatric Manifestations is important. Why is rehabilitation important?

Answer 52

- to return people back to previous level - reduce atrophy, neural degeneration

Question 53

Management of Neuropsychiatric Manifestations is important. Why are multidisciplinary collaborations important?

Answer 53

- it is a comorbidity affecting multiple parts of the body

Question 54

What is homonymous hemianopia?

Answer 54

- hemi = greek for half - an = greek for without - opsia = greek for seeing - loss of visual field side of the vertical midline

Question 55

Homonymous hemianopia has greek origins in its name: hemi = greek for half, an = greek for without, opsia = greek for seeing. So loss of visual field side of the vertical midline. If the right or left side of the hemisphere is affected, which side will the loss of sight be on?

Answer 55

1 - right hemisphere damaged left side of left eye and left side of right eye loss 2 - left hemisphere damaged right side of left and right side of right eye loss

Question 56

What does dysphasia mean? - dys = greek for difficult - phaots = spoken

Answer 56

- language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage

Question 57

Dysphasia means difficulty speaking. Which 2 parts of the brain is crucial for speech? 1 - brodmann areas 22, 44 and 45 2 - brodmann areas 1, 2 and 3 3 - brodmann areas 4 and 17 4 - brodmann area 6

Answer 57

1 - brodmann areas 22, 44 and 45 - Wernicke's area = brodmann area 22 - Brocas area = brodmann areas 44 and 45

Question 58

A patient presents with sudden onset right sided weakness and dysphasia, dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous. Out of the following, which diagnosis would she have? - Total anterior circulation syndrome (TACS) - Partial anterior circulation stroke (PACS) - Lacunar strokes (LACS) - Posterior Circulation Stroke Syndromes (POCS)

Answer 58

- TACS because she has all 3 clinical presentations 1 = unilateral motor weakness 2 = higher cortical deficit 3 = homonymous visual field defect

Question 59

A patient presents with sudden onset right sided weakness and dysphasia, dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous and is diagnosed with Total anterior circulation syndrome (TACS). She attends A&E within an hour of the symptoms starting, from the following treatments, which would be most appropriate? 1 - Aspirin and IV fluids and admit to stroke ward 2 - Thrombolysis only (plasminogen activator (tPA)) 3 - Thrombectomy only 4 - Thrombolysis and thrombectomy

Answer 59

2 - Thrombolysis only with plasminogen activator (tPA) - only good if within the first 4.5 hours of symptoms starting

Question 60

Does the image below show an ischaemic or haemorrhagic stroke?

Answer 60

- haemorrhagic stroke - white area is a bleed

Question 61

Does the image below show an ischaemic or haemorrhagic stroke?

Answer 61

- blood clot so ischaemic

Question 62

A patient presents with a left temporoparietal haemorrhage, and presents with speech disturbance, loss of balance on the right side and right homonymous hemianopia. She also has a history of hypertension, atrial fibrillation and is on warfarin. What is likely to be causing the haemorrhage? 1 - trauma from a fall 2 - hypertension 3 - obesity 4 - infection

Answer 62

2 - hypertension - increased pressure in brain due to hypertension - bleed made worse by blood thinning (warfarin)

Question 63

A patient presents with a left temporoparietal haemorrhage, and presents with speech disturbance, loss of balance on the right side and right homonymous hemianopia. She also has a history of hypertension, atrial fibrillation and is on warfarin. Increased pressure in brain due to hypertension has likely made the blood vessels weak, hence the haemorrhage, and the bleed is made worse by blood thinning (warfarin). What are 2 important treatment options must be used on this patient? 1 - Aspirin and IV fluids and admit to stroke ward 2 - Thrombolysis only (plasminogen activator (tPA)) 3 - prothrombin complex, vitamin K and surgery 4 - Thrombectomy

Answer 63

3 - prothrombin complex, vitamin K and surgery - surgery to relieve the pressure

Question 64

In the image below, we can see an embolism. Which of the following would this be based on the image below? 1 - Total anterior circulation syndrome (TACS) 2 - Partial anterior circulation stroke (PACS) 3 - Lacunar strokes (LACS) 4 - Posterior Circulation Stroke Syndromes (POCS)

Answer 64

3 - LACS as its small in deep brain tissue - pure motor function would be affected - deep brain tissue affected

Question 65

In the image below, we can see an embolism due to a Lacunar strokes (LACS). We know this because the presenting patient only had motor function affected and we can see it is in the deep brain tissue that is affected. The patient was fine the night before but found collapsed the next day, what would be his initial treatment option? 1 - Aspirin and IV fluids and admit to stroke ward 2 - Thrombolysis only (plasminogen activator (tPA)) 3 - prothrombin complex, vitamin K and surgery 4 - Thrombectomy

Answer 65

1 - Aspirin and IV fluids and admit to stroke ward - beyond the 4.5 hours for Thrombolysis plasminogen activator (tPA) - not proximal anterior circulation large vessel occlusion and beyond 6 hours for thrombectomy

Question 66

What does photophobic mean?

Answer 66

- photo = light - phobia = fear of - sensitivity to light

Question 67

What can we see on the head CT-scan below?

Answer 67

- migraine

Question 68

What is a collateral history?

Answer 68

- information about the patient from the patient's known contacts

Question 69

If a patient presents with dysphasia (speech difficulty) and sensitivity to light, and has been off work previously due to severe headaches, is this likely to be a stroke or migraine?

Answer 69

- migraine - can mimic a stroke - can be triggered by stress, change of diet, hormonal changes, weather, alcohol etc

Question 70

A 45 year old patient presents with left facial weakness involving the whole of left side of face, including the forehead and with incomplete closure of left eye. Has had a recent infection of sinuses and symptoms have been present for a few days. Is the diagnosis likely to be some form of a stroke or bells palsy?

Answer 70

- bells palsy - affects CN VII (7) the facial nerve - damage to or in infection of CN VII can cause bells palsy - we can distinguish because bells palsy is a lower motor neuron problem

Question 71

A 45 year old patient presents with eft facial weakness involving the whole of left side of face, including the forehead and with incomplete closure of left eye. Has had a recent infection of sinuses and symptoms have been present for a few days. The diagnosis is bells palsy. What is bells palsy?

Answer 71

- unexplained episode of facial muscle weakness or paralysis - acute onset and worsens over 48 hours - due to damage to CN VII the facial nerve - key feature is that the lower motor neuron is affected

Question 72

Although the cause of bells palsy is unknown, what is the most common precipitating factor that it has been linked with it? 1 - viral infection of sinuses 2 - trauma 3 - stroke 4 - hypertension

Answer 72

1 - viral infection of the sinuses

Question 73

What does the image below show? 1 - TACS 2 - PACs 3 - left occipital tumour 4 - haemorrhage

Answer 73

3 - left occipital tumour - can see different structure in occipital region

Question 74

What are some of the most common things that can mimic a stroke that we need to be aware of?

Answer 74

- Seizures - Tumour - Migraine - Bells palsy - Hypoglycaemia - Infection (and cerebral hypoperfusion) - Subdural haemorrhage - Functional disorder