NEUROLOGICAL MEDICINE

What is a stroke?

A sudden focal neurological deficit due to cerebral ischaemia or haemorrhage lasting >24 hours or causing death.

Which circulation is involved in a posterior circulation TIA?

Vertebrobasilar circulation

What are Charcot–Bouchard microaneurysms?

Small aneurysms of penetrating cerebral arteries caused by chronic hypertension

What are the common sites of hypertensive intracerebral haemorrhage?

• Basal ganglia

• Thalamus

• Pons

• Cerebellum

What are the Bamford clinical classifications of stroke?

Total anterior circulation stroke (TACS)
Partial anterior circulation stroke (PACS)
Lacunar circulation stroke (LACS)
Posterior circulation stroke (POCS)

What defines posterior circulation stroke (POCS)?

• Cranial nerve dysfunction with contralateral motor or sensory deficit

• Bilateral motor or sensory deficits

• Cerebellar dysfunction

• Isolated homonymous visual field defect

What lifestyle advice should be given after a stroke?

• Stop smoking

• Regular physical activity

• Healthy balanced diet

  Achieve and maintain a healthy weight

Reduce salt intake

Avoid excessive alcohol

Manage stress

What are the classic clinical syndromes of lacunar stroke?

• Pure motor stroke

• Pure sensory stroke

• Sensorimotor stroke

• Ataxic hemiparesis

• Dysarthria–clumsy hand syndrome

What is amaurosis fugax?

Transient monocular visual loss due to retinal ischaemia

What are the 3 features required for total anterior circulation stroke (TACS)?

• Contralateral hemiparesis and/or hemisensory loss

• Contralateral homonymous hemianopia

• Higher cortical dysfunction (dysphasia, visuospatial neglect or impaired cognition)

What is amaurosis fugax?

Transient monocular visual loss due to retinal ischaemia

What are the features of a posterior circulation TIA?

• Diplopia

• Vertigo and vomiting

• Choking and dysarthria

• Ataxia

• Hemisensory loss

• Hemianopic visual loss

• Bilateral visual loss

• Tetraparesis

• Rare loss of consciousness

• Possibly transient global amnesia

Which circulation is involved in an anterior circulation TIA?

Carotid circulation

What are the features of an anterior circulation TIA?

• Amaurosis fugax

• Aphasia

• Hemiparesis

• Hemisensory loss

• Hemianopic visual loss

What is a transient ischaemic attack (TIA)?

Brief neurological dysfunction from temporary cerebral ischaemia without infarction, with complete recovery.

What are the main mechanisms of ischaemic stroke?

• Thrombosis

• Large-artery stenosis

• Small-vessel disease

• Cardioembolism

• Hypoperfusion

What are other vascular causes of stroke?

• Arterial dissection

• Cerebral venous sinus thrombosis

• Vasculitis

What are the main types of stroke?

• Ischaemic stroke

• Haemorrhage stroke

• Other vascular causes

What are the main causes of haemorrhagic stroke?

• Intracerebral haemorrhage

• Subarachnoid haemorrhage

What defines partial anterior circulation stroke (PACS)?

2 features of TACS

OR

Isolated higher cortical dysfunction

OR

Isolated homonymous visual field defect

How is blood pressure managed in acute intracerebral haemorrhage?

• For SBP 150–220 mmHg, lower early toward 140 mmHg, maintaining about 130–150 mmHg

• If SBP >220 mmHg, aggressive intravenous treatment may be considered

What is the blood pressure approach in acute ischemic stroke without thrombolysis?

• Usually do not lower BP unless >220/120 mmHg

• If >220/120, lower gradually by about 15% in the first 24 hours

What blood pressure should be maintained after thrombolysis?

Keep BP <180/105 mmHg for the first 24 hours

What blood pressure is required before thrombolysis in ischemic stroke?

BP must be <185/110 mmHg before thrombolysis

What antiplatelet is used early after acute ischemic stroke?

Aspirin, started as soon as possible after intracranial haemorrhage has been excluded

What is the long-term aspirin dose after ischemic stroke?

75–150 mg once daily for secondary prevention

Why is aspirin given early after ischemic stroke?

It reduces the risk of early recurrent ischemic stroke

How can venous thromboembolism be prevented after stroke?

• Early mobilisation

• Intermittent pneumatic compression

• Anticoagulant prophylaxis when appropriate

What should be avoided to prevent urinary tract infection after stroke?

Unnecessary indwelling urinary catheters

What is the TOAST classification?

An aetiological classification of ischaemic stroke based on the underlying cause

What are the 5 TOAST subtypes?

• Large-artery atherosclerosis

• Small-vessel occlusion

• Cardioembolism

• Stroke of other determined aetiology

• Stroke of undetermined aetiology

What are important risk factors for small-vessel occlusion?

• Hypertension

• PDiabetes mellitus

What is the main difference between TOAST and Oxfordshire classification?

TOAST classifies stroke by aetiology while Oxfordshire classifies stroke by clinical syndrome and anatomical circulation

What are examples of other determined causes of ischaemic stroke?

• Arterial dissection

• Vasculitis

• Sickle cell disease

• Hypercoagulable states

What are important causes of cardioembolic stroke?

• 
  

• Atrial fibrillation

• Left ventricular thrombus

• Valvular heart disease

List common stroke mimics.

• Seizure

• Hypoglycaemia

• Migraine with aura

• Brain tumour

• Functional neurological disorder

• Bell’s palsy

• Vestibular neuritis

• Encephalopathy

• Multiple sclerosis

• Syncope

What features suggest a seizure with Todd’s paresis rather than stroke?

• Recent seizure of convulsion

• Post-ictal confusion

• Tongue biting

• Weakness that resolves over hours

What features suggest functional neurological weakness?

• Inconsistent examination findings

• Non-anatomical pattern

• Give-way weakness

What features suggest Bell’s palsy rather than stroke?

• Isolated peripheral facial weakness

• Forehead involvement

• No limb neurological deficits

What features suggest migraine with aura rather than stroke?

What features suggest functional neurological weakness?
Inconsistent examination findings
Non-anatomical pattern
Give-way weakness

• What features suggest Bell’s palsy rather than stroke?
  Isolated peripheral facial weakness
  Forehead involvement
  No limb neurological deficits

• Positive neurological symptoms

• Gradual symptom progression

• Visual phenomena such as flashing lights

• Headache

What features suggest hypoglycaemia rather than stroke?

• Low blood glucose

• Neurological symptoms improve after glucose correction

What features suggest vestibular neuritis rather than posterior circulation stroke?

• Vertigo with no other focal neurological deficits

• Unidirectional nystagmus

• Positive head impulse test

What features suggest syncope rather than stroke?

• Transient loss of consciousness

• Pallor

• No persistent focal neurological deficit afterwards

What features suggest encephalopathy rather than stroke?

• Global confusion

• Bilateral neurological abnormalities

• Evidence of a metabolic or systemic cause

What features suggest multiple sclerosis rather than stroke?

• Young patient

• Previous neurological episodes

• Symptoms evolving over days rather than suddenly

What features suggest syncope rather than stroke?
Transient loss of consciousness
Pallor
No persistent focal neurological deficit afterwards

• How is the ROSIER score interpreted?
  
  

• Score ≥1: stroke more likely

• Score <1: stroke mimic more likely

What features suggest a brain tumour rather than stroke?

• Subacute or progressive symptoms

• Headache

• Seizures

• Lack of sudden onset

What are the components of the ROSIER score?

• Loss of consciousness or syncope: −1

• Seizure activity: −1

• Facial weakness: +1

• Arm weakness: +1

• Leg weakness: +1

• Speech disturbance: +1

• Visual field defect: +1

What is the ROSIER score?

Recognition of Stroke in the Emergency Room score used to help distinguish stroke from stroke mimics

What is the preferred mechanical method for venous thromboembolism prevention after stroke?

Intermittent pneumatic compression devices

What is the acute aspirin dose after ischemic stroke?

• About 160–325 mg once daily

• A commonly used dose is 300 mg