Stroke

• What is the frontal lobe responsible for?

  Planning

  Problem solving

  Motor

  Emotions

  Smell

  Broca's area (speech production)
• What is the parietal lobe responsible for?

  Sensation (pain, touch)

  Wernicke's (speech understanding)

  Spatial thinking (depth perception)
• What is the temporal lobe responsible for?

  Auditory

  Memory

  Smell
• What is the occipital lobe responsible for?

  Vision
• What is the thalamus responsible for?

  Body temp

  Sleep

  Hunger

  Memory

  Emotion
• What are the 2 types of stroke?

  Ischaemic (due to disrupted blood supply) -> 80-90% of strokes

  Haemorrhagic (due to intracranial haemorrhage) -> 10-20% of strokes
• Give some examples of how blood supply to the brain may be disrupted.

  Thrombus/embolus

  Atherosclerosis

  Shock

  Vasculitis
• What are the RFs for haemorrhagic stroke?

  Older age

  Male

  HTN

  FHx of haemorrhagic stroke

  Haemophilia & other bleeding disorders

  Anticoagulation

  Cerebral aneurysms

  Smoking

  Hyperlipidaemia

  Diabetes

  COC
• What are the anterior cerebral artery symptoms of stroke?

  Hemiplegia (often upper limb)

  Slurred speech (can become aphasia)

  Personality changes

  Change in smell
• What are the middle cerebral artery symptoms of stroke?

  Sensory loss

  Hemiparesis (often lower limb)

  Facial asymmetry

  Speech deficits

  Homonymous hemianopia
• What are the posterior cerebral artery symptoms of stroke?

  Visual changes (blurred, diplopia, homonymous hemianopia w/macular sparing)

  Imbalance (gait ataxia)

  Confusion
• What are the signs & symptoms of haemorrhagic stroke?

  Severe headache

  Altered consciousness

  Vomiting

  Nuchal rigidity (impaired neck flexion)

  Focal neurological signs (e.g. weakness, visual loss, sensory changes)

  Aphasia

  Seizures

  HTN
• What are the DDx of stroke?

  Space-occupying lesion

  Hypoglycaemia

  Trauma

  Brain abscess

  MS

  Migraine with aura

  Non-epileptic seizure

  Meningitis
• What are the immediate Inx for suspected stroke?

  Obs

  Full Hx & examination

  Screening tools (ROSIER/NIHSS)

  ECG (check for AF)

  Blood glucose

  Bloods (FBC, CRP, U&Es)

  CT head (non-contrast)

  CT angio
• What are the non-immediate Inx for stroke?

  Long-term ECG (if no AF on initial ECG)

  Carotid artery USS (for carotid artery stenosis)

  Coag (esp in younger pts)

  Lipid profile

  HbA1c

  MRI (if CT not helpful)

  Echo (? source of emboli, could be valvular issue)

  Younger pts...

  • thrombophilia screen
  • vasculitis screen
  • HIV & syphilis
• What is the management of haemorrhagic strokes?

  Keep BP down to at least 130-140 (with IV labetalol or GTN infusion)

  Ring neurosurgery (for evacuation of haematoma formation)

  Reverse any anticoagulation
• What is the management of ischaemic strokes?

  Thrombolysis (alteplase) within 4.5 hrs of symptom onset

  Thrombectomy - can be up to 24 hrs after symptom onset

  Aspirin 300mg -> DO NOT give if going to give thrombolysis
• What is the long-term management of strokes?

  SALT

  Physio

  OT

  Dietician

  Rehab

  Prevention/manage underlying cause

  • stop smoking
  • stop drinking
  • exercise
  • statins
  • control HTN
  • control diabetes
  • long-term antiplatelet
  • carotid endarterectomy
• What are the possible complications of stroke?

  Death

  Recurrence

  Long-lasting neurological damage

  Delirium

  Seizures

  Coning

  Cerebral oedema

  Aspiration pneumonia (can be up to 70% mortality)

  Haemorrhagic transformation (when ischaemic stroke becomes haemorrhagic)
• What are the RFs for ischaemic stroke?

  Male

  Older age

  FHx

  Previous stroke/TIA

  HTN

  Hypercoagulable state

  Coronary artery stenosis

  AF

  Smoking

  Hyperlipidaemia

  Diabetes

  Vasculitis

  Thrombophilia

  COC
• What is used to classify strokes (esp ischaemic)?

  Bamford classification
• What will be seen in a lumbar puncture of a patient who had a haemorrhagic stroke 12 hrs ago?

  Xanthochromia (yellowing of CSF)

  -> due to RBC breakdown
• Types of stroke based on Bamford classification

  Total anterior circulation stroke (TACS)

  Partial anterior circulation stroke (PACS)

  Posterior circulation stroke (POCS)

  Lacunar stroke (LACS)
• What is TACS?

  Total anterior circulation stroke

  Stroke affects anterior & middle cerebral arteries

  Features:

  • unilateral motor or sensory deficit (or both) affecting at least 2 of the face, arm & leg
  • homonymous hemianopia
  • higher cerebral dysfunction (e.g. dysphasia, neglect, dyscalculia)
• What is PACS?

  Partial anterior circulation stroke

  Affects anterior OR middle cerebral artery

  Features:

  EITHER

  • unilateral motor/sensory deficit (or both) affecting at least 2 of the face, arm & leg AND
  • homonymous hemianopia

  OR

  • higher cerebral dysfunction alone
• What is POCS?

  Posterior circulation stroke

  Affects posterior cerebral artery

  Features (any):

  • cerebellar dysfunction
  • conjugate eye movement disorder
  • bilateral motor and/or sensory deficit
  • ipsilateral cranial nerve palsy WITH contralateral motor and/or sensory deficit
  • isolated homonymous visual field defect
• What is a lacunar stroke?

  Occlusion of small arteries that provide brain's deep structures

  Features (any):

  • pure motor stroke
  • pure sensory stroke
  • sensorimotor stroke
  • ataxic hemiparesis
  • dysarthria-clumsy hand syndrome
• What is ROSIER?

  Screening tool for stroke

  Stroke is possible in pts scoring 1 or more
• 3 absolute contraindications to thrombolysis

  Major trauma/surgery in past 3 weeks

  Prior haemorrhagic stroke

  GI bleeding within last month
• What is Weber's syndrome?

  Medial midbrain stroke syndrome

  Features:

  • ipsilateral oculomotor nerve palsy
  • contralateral hemiparesis
• How does basilar artery occlusion present?

  Locked in syndrome

  Features:

  • quadriparesis with preserved consciousness & ocular movements
  • loss of consciousness
  • can present with sudden death
• What is Wallenberg's syndrome?

  Lateral medullary stroke syndrome

  Features:

  • ipsilateral Horner's syndrome
  • ipsilateral loss of pain & temp sensation on face
  • contralateral loss of pain & temp sensation on body
• What is lateral pontine syndrome?

  Similar to lateral medullary syndrome

  Features:

  • cerebellar ataxia
  • vertigo
  • hearing loss
  • ipsilateral facial weakness