MRCP NEUROLOGY NOTES
Stroke
Stroke by anatomy
The Oxford Stroke Classification (also known as the Bamford Classification) classifies strokes based on the initial symptoms.
The following criteria should be assessed:
1. Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg.
2. Homonymous hemianopia
3. Higher cognitive dysfunction e.g. dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
• Involves middle & anterior cerebral arteries.
• All 3 of the above criteria are present.
Partial anterior circulation infarcts (PACI, c. 25%)
• Involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery.
• 2 of the above criteria are present
Lacunar infarcts (LACI, c. 25%)
• Involves perforating arteries around the internal capsule, thalamus & basal ganglia.
• Presents with 1 of the following:
. Unilateral weakness (and/or sensory deficit) of face & arm, arm & leg or all three
i. Pure sensory stroke
ii. Ataxic hemiparesis
Posterior circulation infarcts (POCI, c. 25%)
• Involves vertebrobasilar arteries
• Presents with 1 of the following:
. Cerebellar or brainstem syndromes
i. Loss of consciousness
, ii. Isolated homonymous hemianopia
Other recognised patterns of stroke:
a. Lateral medullary syndrome (PICA)
• Aka Wallenberg's syndrome
• Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's
• Contralateral: limb sensory loss
b. Weber's syndrome
• Ipsilateral III palsy
• Contralateral weakness
Lateral medullary syndrome
Also known as Wallenberg's syndrome, occurs following occlusion of the posterior inferior cerebellar artery.
Cerebellar features
• Ataxia
• Nystagmus
Brainstem features
• Ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. Horner's
• Contralateral: limb sensory loss
, Stroke: assessment
The FAST screening tool (Face/Arms/Speech/Time) is widely known by the general public following a publicity campaign. It has a positive predictive value of
78%.
A variant of FAST called the ROSIER score is useful for medical professionals. It is validated tool recommended by the Royal College of Physicians.
Investigations: A non-contrast CT head scan is the 1st line for suspected stroke.
, Stroke management
Nice guidelines (2019)
Selected points relating to the management of acute stroke include:
• Blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits.
• BP should not be lowered in the acute phase unless there are complications e.g. Hypertensive encephalopathy.
• Aspirin 300 mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded.
• With regards to AF, the Royal College of Physician (RCP) state: anticoagulant should not be started until brain imaging has excluded haemorrhage,
and usually not until 14 days have passed from the onset of an ischaemic stroke.
• If the cholesterol is > 3.5 mmol/l pt should be commenced on a statin. Many physicians will delay treatment until after at least 48 hrs d/t risk of
haemorrhagic transformation.
Stroke
Stroke by anatomy
The Oxford Stroke Classification (also known as the Bamford Classification) classifies strokes based on the initial symptoms.
The following criteria should be assessed:
1. Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg.
2. Homonymous hemianopia
3. Higher cognitive dysfunction e.g. dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
• Involves middle & anterior cerebral arteries.
• All 3 of the above criteria are present.
Partial anterior circulation infarcts (PACI, c. 25%)
• Involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery.
• 2 of the above criteria are present
Lacunar infarcts (LACI, c. 25%)
• Involves perforating arteries around the internal capsule, thalamus & basal ganglia.
• Presents with 1 of the following:
. Unilateral weakness (and/or sensory deficit) of face & arm, arm & leg or all three
i. Pure sensory stroke
ii. Ataxic hemiparesis
Posterior circulation infarcts (POCI, c. 25%)
• Involves vertebrobasilar arteries
• Presents with 1 of the following:
. Cerebellar or brainstem syndromes
i. Loss of consciousness
, ii. Isolated homonymous hemianopia
Other recognised patterns of stroke:
a. Lateral medullary syndrome (PICA)
• Aka Wallenberg's syndrome
• Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's
• Contralateral: limb sensory loss
b. Weber's syndrome
• Ipsilateral III palsy
• Contralateral weakness
Lateral medullary syndrome
Also known as Wallenberg's syndrome, occurs following occlusion of the posterior inferior cerebellar artery.
Cerebellar features
• Ataxia
• Nystagmus
Brainstem features
• Ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. Horner's
• Contralateral: limb sensory loss
, Stroke: assessment
The FAST screening tool (Face/Arms/Speech/Time) is widely known by the general public following a publicity campaign. It has a positive predictive value of
78%.
A variant of FAST called the ROSIER score is useful for medical professionals. It is validated tool recommended by the Royal College of Physicians.
Investigations: A non-contrast CT head scan is the 1st line for suspected stroke.
, Stroke management
Nice guidelines (2019)
Selected points relating to the management of acute stroke include:
• Blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits.
• BP should not be lowered in the acute phase unless there are complications e.g. Hypertensive encephalopathy.
• Aspirin 300 mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded.
• With regards to AF, the Royal College of Physician (RCP) state: anticoagulant should not be started until brain imaging has excluded haemorrhage,
and usually not until 14 days have passed from the onset of an ischaemic stroke.
• If the cholesterol is > 3.5 mmol/l pt should be commenced on a statin. Many physicians will delay treatment until after at least 48 hrs d/t risk of
haemorrhagic transformation.
