Stroke - WB

Question 1

What is ABCD2 tool?

Answer 1

• Estimates the risk of stroke after a suspected transient ischemic attack (TIA)
• Includes factors such as age, BP, clinical features of TIA, duration and history of diabetes

Question 2

CHAD2DS2VASc score

Answer 2

• Score for AF stroke risk
• Score of 2 or more = anticoagulate

Question 3

HASBLED score

Answer 3

• Estimates major risk of bleeding for patients on anticoagulants for AF within 1yr
• Weighs up risk vs benefit

Question 4

NIHSS score

Answer 4

Severity of stroke. Includes:
* Alertness
* Ability to answer age and current month
* Can blink eyes and squeeze hands
* Visual field defect?
* Facial palsy?
* Motor of arms and legs
* Ataxia
* Sensation changes

Question 5

Key questions to answer when assessing ?stroke patient

Answer 5

• Is it a stroke?
• What caused it?
• Complications? Any likely?
• Treatment needed and when?
• How well is outcome likely to be?
• When can they safely leave acute care?

Question 6

What causes stroke symptoms?

Answer 6

• Dysfunction of neurovascular unit - relationship between neurones, glial cells and endothelial lumens
• Hypoperfusion –> reduced ATP –> no energy for cell for membrane transport –> no AP’s

Question 7

Stroke syndrome features

Answer 7

• Sudden onset
• Focal
• Predominantly negative - loss of function
• Fit into vascular territory

Question 8

What suggests stroke is NOT the cause?

Answer 8

• Isolated presentation feature (eg vertigo)
• Migration - of symptoms, slow
• Sterotyping - repeated episodes previously of same thing over weeks (could be intracranial stenosis or capsular warning syndrome though)

Question 9

Unknown cause of stroke name

Answer 9

Cryptogenic

Question 10

Typical cause of PACS presentation

Answer 10

Embolisation from cardiac emboli (eg in AF, valvular heart disease, HF, endocarditis)

Question 11

Large vessel emboli typical cause

Answer 11

Carotid atheroma emboli
Peripheral vascular disease

Question 12

LACS typical cause

Answer 12

Fibrinolytic necrosis if hypertensive/diabetic (endothelial damage and blockage)

Question 13

TOAST criteria

Answer 13

Classification of ischaemic stroke causes

Question 14

Classification of haemorrhagic strokes

Answer 14

• Central/deep vs lobar
• Central/deep are typically primary due to HTN
• Lobar tend to be secondary - inc vascular anomalies, mass, cerebral amyloid angiopathy

Question 15

Complications/likely complications of stroke

Answer 15

• Premature death - often due to post stroke complications
• Recurrent stroke and extension of stroke - extension due to loss of ischaemic penumbra (still viable but then dies), recurrent due to not addressing cause/RF
• Raised ICP - haematoma expansion, malignant oedema, haemorrhagic transformation, hydrocephalus
• Infections - aspiration pneumonia, UTI
• Immbolity complications - VTE, constipation, pressure sores
• Mood and cognitive function - affect rehab
• Post stroke pain/fatigue - spasticity, neuropathic pain, poor sleep, brain damage
• Spasticity, contractures, secondary epilepsy

Question 16

Preventing post-stroke complications

Answer 16

• Routine NEWS
• Observations
• Mood
• Bowel and urine function
• Reviewing stroke impairments
• Sleep
• Legs/calves review ?DVT
• Monitoring bloods

Question 17

Contents of stroke bundle

Answer 17

• Admit to stroke unit
• Revascularisation
• Optimise physiology (surveillance, prevention, early intervention of complications and nutrition support)
• Secondary prevention
• Rehab and reablement

Question 18

How well will a patient recover?

Answer 18

• Prognosis can be derived from NIHSS and OCSP class
• Functional prognosis best informed by recovery trajectory - will continue until a patient reaches functional plateau

Question 19

Functional plateau groups

Answer 19

• Early, high functioning plateau - extreme version of this is TIA/minor stroke, excellent functional prognosis
• Early, low functioning plateau - TACS with no meaningful improvement as time passes, poor proognisis
• Delayed and medium functioning plateau - define recovery in most moderate strokes, benefit from change at sustained rehab efforts until plateau occurs

Question 20

driving post stroke

Answer 20

• 4 week restriction for cars
• 1 year for HGV licenses
• Residual VF defects are seperate requierments
• If persistent/residual disbaility - refer to regional driving assessment centres to allow car modifcation and allow resumption

Question 21

When is decompresisve hemicraniectomy done?

Answer 21

• Malignant oedema in under 60s
• Can be considered if biologically fit and older than this
• Neurosurgical units manage

Question 22

IC haemorrhage main concern

Answer 22

• Raised ICP
• Can be from haematoma expansion or hydrocephalus
• Blood pressure control and correct clotting abnormalities necessary
• Evac haematoma and ventricular drains can be used

Question 23

Investigations prior to anticoagulation for AF, thrombophilis, venous sinus thrombosis

Answer 23

• ECG
• MRV/CTV
• 24hr BP
• Echo
• Thrombophilia screen

Question 24

Carotid endarterectomy - when?

*

Answer 24

• Management of symptomatic carotid disease - after TIA with good recovery of more than 50% lumen reduction (NASCET) on carotid USS
• Need good BP control <130/80, high dose statin, DAPT before surgery
• = plaque stabilisation

Question 25

Left atrial appendage closure - when?

Answer 25

* Option for secondary prevention of stroke in those with AF who cannot have anticoagulation

Question 26

NG/PEG feeding for stroke patients - when?

Answer 26

* Temporary measure for when unsafe swallow currently * Assess swallow with flexible endoscopic evaluation of swallowing (FEES) and video fluroscopy * Not to be used to prolong suffering at end of life

Question 27

Palliation options post stroke

Answer 27

* Address pain * Mouth care * Tube and IV feeding not appropriate - feed orally for pleasure (feed at risk)

Question 28

ASPECT score

Answer 28

* Alberta stroke program early CT score * 10 point CT scan score used in patients with MCA stroke * Segmental assessment of MCA territory is made, 1 point deducted from initial score of 10 for every region involved - 0 = diffuse involvement * Used in revasculiration for patient selection and outcome prediction

Question 29

Modified rankin scale

Answer 29

* Global disability used to assess baseline function, evaluate outcomes and treatment impact after interventions * 0-6 * 0 = no symptoms * 6 = dead

Question 30

ROSIER scale

Answer 30

Differentiate between stroke and stroke mimic in hopsital

Question 31

Stroke mimic - 3 types

Answer 31

* Visible on brain imaging (MS, subdural haematoma, SOL etc) * Distinct non-stroke syndrome features - BPPV, vestibular neuronitis, syncope syndrome, transient global amnesia (sudden temp loss of short term memory) * Specialist assessment often needed - migraine with aura, focal seizures, functional syndrome (EEG and MRI needed)

Question 32

What is stroke recrudescence of symptoms?

Answer 32

* Neurological dysfunction in patients with chronic stroke but good recovery * Residual areas of scar tissue at site of previous damage * Symptoms can return due to underperfomance of glial tissue in scenarios (eg in infections, low BP, low glucose, fatigue) * Correction of underlying stressor --> return to baseline

Question 33

Features of early stroke on CT scan

Answer 33

* Effacement of ventricles * Loss of grey/white matter differentiation * Increased density of relevent BV - clotted blood

Question 34

Hypertensive ICH location

Answer 34

* DEEP * Eg in basal ganglia/cerebellum