1. Stroke
Andy Ritson

2. Definition
Focal neurological deficit of cerebrovascular origin lasting >24 hours
<24 hours = TIA
Two types:
Ischaemic
Haemorrhagic

3. Ischaemic stroke

4. Pathophysiology Usually thrombotic embolus Origins:
Heart (AF, MI)
Carotids (atherosclerosis)
Lodges distally occluding blood supply and hence ↓O2 delivery to cerebral tissue

5. Ischaemic Cascade
Failure of ATP dependant Na+/K+ pump – depolarisation
Glutamate toxicity
Ca2+ influx into cells
Initiating wide spread destructive effects
Progressive infarction

6. Risk Factors Atherosclerosis: Cardiac: Thrombosis: Smoking - MI
Diabetes
Hypercholesterolaemia
Age
SE Asian heritage
Thrombosis:
Oral Contraceptive Pill
Polycythaemia
Thrombophilia
Vasculitis
Cardiac:
- MI AF
Valvular heart disease
- Previous Stroke / TIA

7. Clinical Picture
Related to neuroanatomy:

8. Classification Partial Anterior Total Anterior Posterior Lacunar Signs
2 of the following: motor or sensory deficit; higher cortical dysfunction, hemianopia
Motor or sensory deficit, higher cortical dysfunction and hemianopia
Isolated hemianopia, brainstem signs and cerebellar ataxia
Motory or sensory deficit only
Arteries affected
Ant. or middle cerebral
Post. cerebral, basillar or vertebral
Any deep penetrating artery
Higher cortical functions: Speech disturbances and visual-spatial disturbances.
Brainstem signs: Heart rate, blood pressure, breathing, swallowing, digestion, eye movements, speech and body movement.
Cerebellar signs: nystagmus, truncal ataxia, co-ordination problems etc

9. ACUTE MANAGEMENT Airway Breathing Circulation Disablility Exposure
Protected
Swallowing?
Breathing
Adequate on air?
Circulation
Fluid replacement if BP ↓
Do not routinely treat hypertension
Disablility
GCS
Pupils
Exposure
Sustained other injuries with fall?
Concomitant pathologies?
GLUCOSE!

10. Investigations: CT Scan: Bloods – FBC, U+E, Glucose, Coagulation, ESR
Rule out HAEMORRHAGE
Exclude tumour
Evidence of early ischaemic changes
Bloods – FBC, U+E, Glucose, Coagulation, ESR
Cardiac
ECG
Echo
Carotid doppler US
CXR – heart size, lung pathology, tumours

11. Thrombolysis Administered <4.5hrs of symptom onset
Recombinant tissue Plasminogen Activator (rtPA) = “alteplase”
Binds to fibrin and activates plasminogen → cleaves fibrin → degrades thrombus
Also give Aspirin 300mg

12. Contraindications Extremes of age (>80 or <18)
Previous severe disability / terminal illness
Hx ICH / neoplasm or AV malformation
Stroke / prev head trauma (3/12)
Platelets ↓or INR > 1.5
Pregnancy / Recent Childbirth (2 weeks)
Recent MI (1 month)
Active Bleeding / Acute Trauma
Major Surgery (2 weeks)

13. Complications Dysphagia Malnutrition / Medications
Aspiration pneumonia
Immobility
Muscle wasting and contractures
Pressure sores → ulceration → infection
Falls
Osteoporosis
Incontinence
Skin integrity
Retention of Urine
Catheterisation → UTI
Epilepsy
Depression
Death

14. Secondary Prevention Antiplatelet Statin BP (aggressive if DM)
Aspirin 300mg (2/52) then 75mg
Statin
BP (aggressive if DM)
Carotid Endarterectomy
Lifestyle

15. Case 1
An 81 year old woman is found collapsed on her bedroom floor by the sheltered housing warden the day after a trip to her bingo. A CT scan of the brain reveals an area of ischaemia in the left parietal cortex, consistent with a recent cerebral infarct. She is badly bruised and has an obvious weakness on the right side of her body. She is confused and her speech sounds slurred.

16. An 81 year old woman is found collapsed on her bedroom floor by the sheltered housing warden the day after a trip to her bingo. A CT scan of the brain reveals an area of ischaemia in the left parietal cortex, consistent with a recent cerebral infarct. She is badly bruised and has an obvious weakness on the right side of her body. She is confused and her speech sounds slurred.

17. a. What is the definition of a stroke?
A rapidly developing focal neurological deficit of vascular origin lasting over 24 hours or causing death

18. b. Suggest 4 risk factors for stroke?
Hypertension
Atrial fibrillation
Diabetes mellitus
Smoking
Previous TIA/stroke
Increasing Age
Oral contraceptive pill use
Coagulopathy
Sedentary lifestyle
Hypercholesterolaemia
Raised haematocrit
Cocaine use
Male
Asian descent

19. c. The CT scan of the brain showed an area of ischaemia
c. The CT scan of the brain showed an area of ischaemia. Explain the pathogenesis of this cause of stroke.
Narrowing of the supplying blood vessels (thrombus, embolus) causes reduced blood flow (and thus oxygen and glucose) to an area of the brain.
There is a central area of necrosis surrounded by a penumbra that may be salvageable if blood supply is re-established.
There is an initiation of the ischaemic cascade that causes inflammation and oedema that results in tissue damage.
This leads to glutamate toxicity and cell membrane permeability changes thus activating destructive enzymes.

20. d. Given this lady’s symptoms, which is the most likely artery to have been affected by this stroke?
Left Middle Cerebral Artery

21. e. List 4 significant non-neurological complications of stroke.
Aspiration pneumonia
DVT/PE due to immobility
Communication difficulties due to dysphasia and dysarthria
Depression
Bed sores due to immobility
Urinary incontinence

22. f. This patient shows slow improvement over the next three months
f. This patient shows slow improvement over the next three months. Outline 2 management options that the OT would be able to help with in cases like this.
Home assessment and adaptations where appropriate
Physical and cognitive deficit screen and provision of aids where needed

23. Past paper 2
While working as a FY1 on a medical ward you are asked to assess Mrs FK, a 75 year old woman, who was admitted to hospital one week previously with a sudden onset of weakness in the right arm and leg. On examination you confirm the weakness and also find that the muscle tone in the right arm and leg is increased. Sensation is decreased on the right side. Although she can talk, she sometimes has difficulty finding the words she wants.

24. While working as a FY1 on a medical ward you are asked to assess Mrs FK, a 75 year old woman, who was admitted to hospital one week previously with a sudden onset of weakness in the right arm and leg. On examination you confirm the weakness and also find that the muscle tone in the right arm and leg is increased. Sensation is decreased on the right side. Although she can talk, she sometimes has difficulty finding the words she wants.

25. a. What changes do you expect in the tendon reflexes on the right side
a. What changes do you expect in the tendon reflexes on the right side? Hyper-reflexive (brisk) b. What is the mechanism of this alteration to the reflexes? Loss of descending inhibitory input to the reflex arc resulting in an uninhibited reflex response. c. What do you expect the right plantar reflex to be? Up going d. Which cranial nerve is the one most likely to be affected? Trigeminal (CN 5) e. What visual field abnormality might you expect to find on examination? Homonymous hemianopia

26. Over the next 24 hours the patient’s condition deteriorates
Over the next 24 hours the patient’s condition deteriorates. A CT scan confirms an infarct in the left middle cerebral artery territory. Her husband calls you aside and asks you to write in her notes that she should not be resuscitated if she stops breathing.

27. f. Which 2 articles of the Human Rights Act are most applicable when considering these issues?
Article 2 – right to life
Article 3 – protection from mistreatment
e. Having established the diagnosis, what three issues do you need to take into consideration
before writing a “Do Not Resuscitate” order?
Has the DNR order been discussed with the patient and family
Does the patient have capacity to make the decision
Would resuscitation likely to be successful and beneficial for the patient

28. Haemorrhagic strokes

29. Pathology Aneurysms Arteriovenous formation Trauma
Blood coagulation disorders
Vessel erosion by tumours

30. Types
Extradural
Subdural
Intracerebral
Subarachnoid

31. Case 1
18 year old male presents to ED after being hit on the head with a bottle 3 hours previously
What would you do?

32. Deteriorates after another hour
ABCDE
History: slightly drowsy after injury, but has resolved, no LoC
O/E: GCS 15, no focal neurology, large parietal haematoma
Deteriorates after another hour

34. Extradural Laceration of MMA by fracture of temporal or parietal bones
Features:
Lucid interval followed by GCS
Deterioration is due to ICP
May get UMN signs
Management:
ABCDE  CT  Surgeons

35. Case 2 87 year old demented female has fallen out of bed that morning
What would you do?

36. ABCDE
History: headache, “more confused”, AF, vomited
O/E: GCS 13, drowsy, dysphasic
Therefore:
- Bloods and CT

38. Acute Subdural Shearing of veins crossing the subdural space
Associations:
Trauma, alcohol, anticoagulation
Features:
Progressively GCS
Signs of ICP
Management:
ABCDE  CT  Surgeons

40. Chronic Subdural Similar to ASDH, but insidious
Fluctuating consciousness
Personality change
Sleepiness
Unsteadiness
Features of raised ICP
Almost always very old or very young

41. Case 3 48 year old male presents to the ED after a night out
What would you do?
ABCDE
History: friends says he collapsed, had been using cocaine
O/E: GCS 12, Babinski positive on the right, right hemi-paresis
CT and bloods

43. Intra-cerebral Rupture of small intracerebral vessels: Features:
Spontaneous = “haemorrhagic stroke”
Features:
Neurology dependent on location
ICP (blood + oedema)
Associations:
Hypertension
AVM, bleeding disorders, drugs
Management:
ABCDE  CT  ?Surgeons

44. Case 4 48 year old female presents with “worst headache of my life”
What would you do?
ABCDE
History: instantaneous severe occipital headache, vomited 3 times, has polycystic kidneys
O/E: GCS 12, Kernig’s positive, hypertensive, pyrexial

46. Subarachnoid 80% ruptured aneurysm, 5% AVM Associations: Features:
Smoking, alcohol, hypertension
Polycystic kidney disease, family history, bleeding disorders
Features:
Thunderclap headache, vomiting, GCS, neck stiffness, pyrexia, Kernig’s sign, BP
Management:
ABCDE  CT  Nimodipine  Surgeons