Stroke - passmed

Question 1

Management of stroke - general points

Answer 1

• Manage blood glucose, hydration, O2 and temperature
• Blood pressure - do not lower in acute phase unless complications (hypertensive encephalopathy or considered for thrombolysis)
• BP control should be considered if present within 6 hrs and systolic BP >150

Question 2

AF rules in stroke

Answer 2

• Anticoags not started until brain imaging excludes haemorrhage
• Usually not until 14 days have passed from onset of ischaemic stroke

Question 3

Cholesterol rules stroke

Answer 3

• If more than 3.5mmol/L commence on statin
• Many delay treatment until after at least 48hrs due to risk of haemorrhagic transformation

Question 4

Thrombolysis rules stroke

Answer 4

• Alteplase or tenecteplase
• Administer 4.5hrs of symptoms
• Exclude haemorrhage first

Question 5

Broadened criteria for thrombolysis

Answer 5

Consider if:
* Treatment can be started between 4.5 and 9hours of known onset or within 9hrs from midpoint of sleep AND
* They have evidence from CT/MR perfusion or MRI (DWI-FLAIR) of salvagable brain tissue
* Irrespective of large artery and require mechanical thrombectomy

Question 6

Blood pressure rules prior to thrombolysis

Answer 6

Lower to 185/110 before thrombolysis

Question 7

Contraindications of thrombolysis

Answer 7

Question 8

Thrombectomy functionl status requirment

Answer 8

• Pre-stroke functional status of less than 3 on modified Rankin scale (2 or less)
• Score more than 5 on NIHSS (6 or more)

Question 9

Timeline for thrombectomy

Answer 9

• Within 6 hours of onset
• With IV thrombolysis if within 4.5hrs
• To people who have acute ischaemic stroke and confirmed proximal anterior circulation on CTA or MRA

Question 10

Extended criteria for thrombectomy

Answer 10

• Last known to be well within 6-24hrs (inc wake up strokes)
• If have confirmed occlusion of PAC demonstrted by CTA or MRA AND
• potential to salvage brain tissue as shown by CT perfusion of DWI MRI (showing limited infarct core volume)

Question 11

When to CONSIDER thrombectomy

Answer 11

• Well up to 24hrs before (inc wake up strokes)
• Ischaemic stroke confirmed of proximal posterior circulation (basilar or PCA) demonstrated by CTA or MRA AND
• Potential to salvage brain tissue as shown by CT perfusion or diffusion weighted MRI (showing limited infarct core volume)

Question 12

Secondary prevention post stroke

Answer 12

• Clopidogrel
• Aspirin only if clopidogrel contraindicated/not tolerated

Question 13

When is carotid endarterectomy offered?

Answer 13

• Stroke/TIA in carotid territory and not severely disabled
• Should be considered if stenosis is >50% on affected side (according to NASCET)
• Perform ASAP within 7 days

Question 14

Oxford stroke classification - types

Answer 14

• TACI
• PACI
• LACI
• POCI

Question 15

TACI/PACI

Answer 15

Total:
* Unilateral hemiparesis and/or hemisensory loss of face, arm and leg
* Homonymous hemianopia
* Higher cognitive dysfunction - eg dysphasia
* Involves middle and anterior cerebral arteries

PACI:
* Only 2 of the above
* Usuallly upper/lower division of middle cerebral artery

Question 16

LACI

Answer 16

• Involves perforator arteries of internal capsule, thalamus and basal ganglia

Presents with one of:
* Unilateral weakness (and/or sensory deficit) of face and arm or arm and leg or all three
* Pure sensory stroke
* Ataxic hemiparesis

Question 17

POCI

Answer 17

• Involves vertebrobasilar arteries

Presents with one of:
* Cerebellar/brainstem syndromes
* Loss of consciousness
* Isolated homonymous hemianopia

Question 18

What is lateral medullary syndrome?

Answer 18

• Posterior inferior cerebellar artery affected
• AKA Wallenbergs
• Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, CN palsy/Horners
• Contralateral limb sensory loss

Question 19

Webers syndrome

Answer 19

• Midbrain stroke
• Ipsilateral CN III palsy
• Contralateral weakness

Question 20

Patients who have suffered haemorrhagic stroke are more likely to have:

Answer 20

• Decreased level of consciousness
• Headache
• Nausea and vomitting
• Seizures

Question 21

Imaging for stroke - initial and then future

Answer 21

• CT head - no contrast - check for haemorrhage
• MRI (DWI) can be considered if CT inconclusive - better at detecting acute ischaemia
• CTA/MRA if considering thrombectomy

Question 22

Bloods for ?stroke

Answer 22

• FBC
• Coagulation profile
• U&E
• LFT
• Fasting lipids
• Glucose

Rule out mimics - hypoglycaemia, electrolyte disturbances
Assess risk factors - dyslipidaemia, diabetes
Evaluate contraindications for thrombolysis eg coagulopathy

Question 23

Further investigations to identify underlying cause of stroke

Answer 23

• Echo - TTE ot TOE - identify AF, patent foramen ovale, valvular heart disease, LV thrombus
• Carotid dopper US - carotid stenosis/occlusion if anterior circulation stroke
• 24hrs ECG - detect paroxysmal AF
• Cerebral angiography - if?cerebral vasculitis, arterial dissection or venous sinus thrombosis and non-invasive imaging modalities are inconclusive

Question 24

Stroke mimics

Answer 24

• Migraine + aura - gradual, escalate over mins-hours, +photophobia/phonophobia or nausea, history of migraine
• Bells palsy - does not spare forehead, can also have hyperacusis or altered taste ant 2/3 tongue
• Hypoglycaemia - rapid onset, resolve once glucose corrected, can have sweating, palps, tremor (adrenaline release)

Question 25

Neurological complications of stroke

Answer 25

* Hemiparesis/hemiplegia * Aphasia * Dysphagia --> aspiration pneumonia * Cognitive impairment - dementia, memory, attention, spatial awareness, executive function

Question 26

Physical complications of stroke

Answer 26

* Falls - muscle weakness, balance problems, altered spatial awareness * Pain - thalamic lesions * Incontinence - urinary and faecal, bladder training programmes and continence promotion stategies can benefit

Question 27

Vascular complications of stroke

Answer 27

* VTE - immbolity * CV - MI, HF, arrhythmias

Question 28

Psychological complications of stroke

Answer 28

* Depression/anxiety * Emotional lability - rapid, exaggerated changes in mood --> distress

Question 29

Infection complications stroke

Answer 29

* Pneumonia - aspiration due to dysphagia * UTI - catheter/retention

Question 30

Driving rules post stroke/TIA

Answer 30

* Stroke/TIA = one month off driving, may not need to inform DVLA if no residual neurological deficit * If drive lorry/bus - must not drive for 1 year, notify DVLA * Multiple TIAs over short period of time - 3 months off driving, inform DVLA