11 Jan 24 Flashcards by Zoia Akram

Lateral medullary syndrome lesions
And tracts with s/S

Vestibular nucleus - diplopia dizziness
Trigeminal nucleus - i/L pain sensation of face

Inf Cerebellar peduncle - ataxia
Nucleus ambiguous- dysphonia, dysphagia hoarseness loss of gag.

Lateral ST tract. - C/L pain and temp
Sympathetic fibres- Horners syndrome

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Arterial supply of lateral medulla

PICA

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Common causes of lateral medullary stroke ?

Posterior circulation stroke ;

Vertebral artery dissection
Spontaneous
Trauma (sports , neck manipulation)

Atherosclerosis
Embolism

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C/F of retinitis pigmentosa

Night blindness
Progressive vision loss esp in midperiphery (highest density of rods)
Dec visual acuity (late)

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Retinitis pigmentosa fundoscopy ?

Retinal vessel attenuation
Optic disc pallor
Abnormal retinal pig

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RF for TIA and ischemic stroke

HTN Most imp
Smoking 2nd
DM
Hypercholesterolemia
Alcohol /lifestyle/ obesity(small effect)

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Pt with central vertigo evaluate for cerebellar hemm/stroke if;

Prominent stroke features ;

      Hyperlipidemia 
      HTN
      DM

New onset headache
Neurologic S/S. Weakness/numbness/dysarthria

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Central Vertigo ?

▶️nystagmus has Any trajectory
▶️Not inhibited by fixation of gaze
▶️Not fatiguable (>1min duration)
▶️No latency period

Vs peripheral
Never purely vertical nystagmus
Inhibted by fixed gaze
Fatiguable <1min
Latency period (2-40sec)

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Stroke instant management

Do ABCs

Non contrast CT (rapidly diff between ischemic and hemm stroke)

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Non contrast CT stroke

Hemorrhagic: Hyperdense white area in brain parenchyma
Ischemic :
CT normal in early<6hr ischemic str
Loss of grey white matter diff
Hypoattenuation of deep nuclei

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Intracerebral hemorrhage S/S

Inc ICP
Headache
N/V
AMS
Focal deficits

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Time course of strokes by etiology

Embolic; Max at onset
Thrombotic: Fluctuating
Hemm. ; Progressively worsening

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Hemorrhagic stroke mech

Generally involve small penetrating arteries resp for lacunar infarcts but result in rupture of charcot bouchard aneurysms

Common location
BG (putamen)
Cerebellum
Thakamus
Pons

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Putaminal hemorrhage C/P

S/S due to involvement of adj internal capsule (compression from hemorrhage)
C/L hemiparesis
Hemianesthesia

             👹Corticospinal and somatosensory fibers in posterior limb

Conjugate gaze deviation toward side of lesion (frontal eye field fibres pass thru anterior limb of capsule )
(See conjugate gaze palsy exhibit from INO of MS)

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Broca aphasia C/P and supply

Slow speech poor pronounciation cannot repeat (dysarthria and expressive aphasia)

Supply MCA ➡️ dominant frontal lobe

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Wernicke aphasia

Non sensical speech with lack of comprehension

Supplye dominat tempora cortex

Pt with ischemic stroke comes 7 hours later ,,,,,?

Do CTA head n neck

If large vessel occlusion ➡️mech thrombectony

If LVO absent ➡️ standard ttt antiplatelets etc

Indications for mechanical thrombectomy criteria;

➡️. Diabling neurological S/s
➡️. Symptom onset < 24hrs
➡️. CT scan showing no evidence of hemmorhage
➡️Large vessel occlusion on CTA

BP control in ischemic stroke

THROMBOTICS INDICATED
Control BP < 185/110 prior to thrombolytics
After thrombolytic maintain 180/105 for 24hr

THROMBOTICS NOT INDICATED
Permissive HTN 169/90 to maintain perfusion to ischemic penumbra

Lower BP acutely only if > 220/120
By only 15% in 24hr

Hemorrhagic stroke ttt

ABC

BP control (IV nicardipine or labetalol with SBP goal 140-160

Reversal of anticoagulation
Vit K Protamine sulfate

Regulate ICP

Malignant hemispheric infarction
Cause

Massive ischemic stroke causes cerebral edema (inc ICP) leading to brain herniation
and
hemmorrhagic transformation

Mostly follows large vessels ischemia

Dx repeat CT non contrast

Ttt decompressive hemicraniectomy

Anterior cerebral artery stroke

Motor and sensory deficits of lower limb
More in LL than UL
Face not involved
See homunculus

Urinary incontinence ( medial frontal lobe)

Lacunar infarcts S/S

Supplies deep brain structures

Can cause
Pure motor hemiparesis
Pure sensory
Dysarthria Clumsy hand syndrome
Ataxic hemiparesis
Sensorimotor syndrome

MCA stroke

C/L motor and somatosensory deficits
More pronounced in upper limb than lower

Homonymous hemianopia or quadrantanopia

If dominat lobe LT. Aphasia
Non dominant RT. Hemineglect / anosognosia

SAH C/P

Ruptured berry aneurysm (imp) Thunderclap headache N/V Brief LOC Focal deficits Meningismus

SAH. Dx

😵‍💫Non contrast CT 😵‍💫 if Ct negative LP Elevated opening pressure Xanthochromia High RBC that doesnt decline from first collection tube to last 😵‍💫Confirm dx with cerebral Angio 📞. CT is done in first 6hr. Minor bleeding and degradation of blood reduce efficacy of CT over time . Hence we do LP

SAH ttt

🚜Aneurysm clipping 🚜Endovascular procedure ( coiling /stenting) 🚜Nimodipine and euvolemia to reduce delayed cerebral ischemia

Isolated cranial nerve neuropathies from compressing aneurysm SAH

3rd nerve ; Pcom aneurysm Pupillary dilation (outward parasym fibres). ptosis , down and out gaze (motor fibres inwards) 2nd nerve : Internal carotid or Acom U/L visionloss or bitemporal hemianopisa 4th and 6th ; SCA or AICA aneurysm

Complication of SAH

1. Rebleeding : rapid neurologic deterioration at first day Management; urgent aneurysm repair reduces risk 2: Vasospasm ( vasogenic metabolites from degraded blood ) Presents with stroke like symptoms again Occurs at 3-14 days after SAH Ttt; Nimodipine reduces risk by vasodilating small vessels and improves outcomes

3rd nerve ischemic neuropathy

3rd nerve Inner somatic fibers : Levatir muscle (ptosis) , 4 EOMs Down n outgaze Outr parasympathetic fibers ; Supple iris and ciliary muscles (Dilated pupils) Farther from blood supply Ischemic neuropathy (DM) Causes ptosis and down and out gaze Sparing pupil

3rd nerve compressive neuropathy

Aneurysm Outer fibers involved first. Later somatic So dilated pupils with ptosis and down n out gaze Managemnet: CT or MRA

Cavernous sinus thrombosis features

Skin infection/ sinus/oribit Severe headache Intracranial HTN Vomiting Papilledema Low grade fever B/L periorbital edema Hypoesthesia Hyperesthesia in V1/V2 dist Cranial nerve 3,4,5,6 deficits Dx : MRV Ttt : Antibiotics Prevent/reverse cerebral herniation

Why we dont use anticoagulants for ischemic stroke

Increase risk for hemmorrgic conversion

Strokes localization Cerebral cortex

VANS Hemiparesis Hemianopia gaze preference Vision Aphasia A (Dominant) Neglect N (Non dominant) Sensory deficits S

Internal capsule (lacunar infarct ) deficit

Pure motor Lower half of face

ACA occlusion

Lower extremity motor and sensory deficit Abulia (lack of will) Dyspraxia , emotional disturbance , urinary incontinence

Vertebrobasilar system lesion(brainstem)

C/L hemiplegia I/L cranial nerve involvement Ataxia