Stroke

• What is an ischaemic stroke?


  A medical emergency characterised by a sudden onset of focal neurological deficit secondary to ischaemia
• What symptoms can occur due to an ischaemic stroke?


  Symptoms can include contralateral motor and sensory deficits, homonymous hemianopia, and higher cerebral dysfunction
• What is the initial management step for suspected stroke?


  Urgent neuroimaging, primarily via non-contrast CT scan
• Why is neuroimaging important in stroke management?


  To differentiate between ischaemic and haemorrhagic types of stroke
• What further investigations are conducted after initial neuroimaging?

  Carotid ultrasound, CT/MR angiography, echocardiogram, and various blood tests
• What is the purpose of further investigations in stroke management?


  To define the cause of stroke and quantify vascular risk factors
• What is the acute management for ischaemic stroke?


  Thrombolysis in selected patients or mechanical thrombectomy for eligible patients
• What is the time frame for thrombolysis in ischaemic stroke?


  Usually within 4.5 hours of symptom onset
• What is the long-term management for ischaemic stroke?


  Antiplatelet therapy, risk factor optimisation, and multidisciplinary rehabilitation
• How is an ischaemic stroke defined?


  A sudden onset focal neurological deficit secondary to focal brain ischaemia, lasting >24 hours or with evidence of infarction on imaging
• What percentage of strokes are ischaemic?


  85%
• What causes ischaemic stroke?


  Reduced blood supply in a cerebral vascular territory due to stenosis or complete occlusion of a cerebral artery
• What is the ischaemic penumbra?


  The cerebral area surrounding the ischaemic event where there is ischaemia without necrosis, amenable to recovery with thrombolysis
• What are the underlying aetiologies of ischaemic stroke?


  • 25% caused by intracranial small vessel atherosclerosis
  • 50% caused by large vessel atherosclerosis (e.g., carotid artery stenosis)
  • 20% are cardio-embolic (e.g., atrial fibrillation)
  • Rare causes include primary vascular causes (vasculitis, arterial dissection) and haematological causes (prothrombotic states)
• What are the common stroke risk factors?


  • Age
  • Male Sex
  • Family History
  • Hypertension
  • Smoking
  • Diabetes
  • Atrial fibrillation
  • High cholesterol
  • Obesity
  • Migraine
• What is the Bamford/Oxford Stroke Classification System?


  • A classification system for ischaemic stroke
  • Helps remember the localisation of common stroke syndromes
  • Includes TACI, PACI, LACI, and POCI definitions

  
• What defines a total anterior circulation infarct (TACI)?


  Contralateral hemiplegia or hemiparesis, contralateral homonymous hemianopia, and higher cerebral dysfunction
• What defines a partial anterior circulation infarct (PACI)?


  Two of the TACI symptoms or higher cerebral dysfunction alone
• What defines a lacunar infarct (LACI)?


  A pure motor stroke, pure sensory stroke, sensorimotor stroke, ataxic hemiparesis, or dysarthria-clumsy hand syndrome
• What defines a posterior circulation infarct (POCI)?


  Cerebellar dysfunction, conjugate eye movement disorder, bilateral motor/sensory deficit, or ipsilateral cranial nerve palsy with contralateral motor/sensory deficit
• What are the different posterior stroke syndromes to be aware of?

  • Basilar artery occlusion: locked-in syndrome, loss of consciousness, sudden death
  • Anterior inferior cerebellar artery: lateral pontine syndrome with cerebellar ataxia, vertigo, hearing loss, ipsilateral facial weakness
  • Wallenberg's syndrome: ipsilateral Horner's syndrome, loss of pain and temperature sensation on the face, contralateral loss over the body
  • Weber's syndrome: ipsilateral oculomotor nerve palsy and contralateral hemiparesis
• What is the DR ABCDE approach in acute management of ischaemic stroke?


  • D: Danger (ensure safety)
  • R: Response (check responsiveness)
  • A: Airway (ensure airway is clear)
  • B: Breathing (check breathing)
  • C: Circulation (check circulation)
  • D: Disability (assess neurological status)
  • E: Exposure (expose and examine)
• What imaging should be performed on arrival to the emergency department for suspected stroke?

  CT Head to distinguish ischaemic from haemorrhagic stroke
• What should be done if no evidence of ischaemic stroke is found on CT Head?


  A CT Angiogram and CT perfusion should be performed to assess for large vessel occlusion
• What are the contraindications for thrombolysis?


  Recent head trauma, recent surgery, systolic blood pressure above 185, current oral anticoagulation, raised INR
• What is the time frame for mechanical thrombectomy in ischaemic stroke?


  Usually within 6 hours, up to 24 hours in select patients
• What should be started if hyper-acute treatments are not offered?


  An antiplatelet agent such as Aspirin or Clopidogrel
• When should antiplatelet therapy be started if hyper-acute treatments are offered?


  24 hours after treatment following a repeat CT Head
• What is the gold standard test to confirm the presence of an acute ischaemic stroke?


  MRI Head with Diffusion Weighted Imaging (DWI)
• What is the purpose of post-hyperacute investigations?


  To further define the cause of the stroke and quantify vascular risk factors
• What are the post-acute investigations for stroke management?


  • Carotid ultrasound to identify critical carotid artery stenosis
  • 24 to 72 hour cardiac monitoring for atrial fibrillation
  • CT/MR angiography for intracranial and extracranial stenosis
  • Echocardiogram if cardio-embolic source is suspected
  • Further investigation in young patients (vasculitis screen, thrombophilia screen)
  • HbA1c and Serum Lipids to optimise cardiovascular risk factors
• What is the role of rehabilitation in chronic stroke management?


  • Involves a multidisciplinary team (MDT)
  • Includes physiotherapy, occupational therapy, speech and language therapy, and neurorehabilitation
• What is the mnemonic for secondary stroke prevention?

  • HALTSS:
  • Hypertension
  • Antiplatelet therapy
• What is the purpose of CT/MR angiography in stroke management?


  To identify intracranial and extracranial stenosis
• When is an echocardiogram indicated in stroke management?


  If a cardio-embolic source is suspected
• Why might further investigation be necessary in young stroke patients?

  To conduct a vasculitis screen or thrombophilia screen
• What tests are used to optimize cardiovascular risk factors?

  HbA1c and Serum Lipids
• What does chronic stroke management involve?

  • Rehabilitation and supportive management
  • MDT approach including:
  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
  • Neurorehabilitation
• What mnemonic can help remember the key steps in secondary stroke prevention?

  HALTSS
• What does the 'H' in the mnemonic HALTSS stand for?


  Hypertension