B7-063 Stroke Cases Flashcards by Felicia Jones

sudden onset of focal brain deficits from blockage or rupture of cerebral blood vessel

stroke

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3 common causes of ischemic stroke

large vessel artherosclerosis
cardiogenic emboli
small vessel disease

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is hemorrhagic or ischemic stroke more common?

ischemic

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cardiogenic emboli usually consists of […] clot

red

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irregularly irregular rhythm on EKG

a-fib

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diagnostic test for cardiogenic emboli [3]

continous EKG (a-fib)
TTE
TEE

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primary source of cardiogenic embolism

non-valvular a-fib

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mainstay of therapy for patients with a-fib

anticoagulation to prevent ischemic stroke

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direct oral anticoagulants

apixaban
edoxaban
dabigatran
rivaroxaban

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in patients with a-fib and strong contraindication for anti-coagulation, what is an alternate therapy?

watchman device inserted to left atrial appendage

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most common mechanism of ischemia from large vessel artherosclerosis

artery to artery emboli

(like at carotid bifurcation)

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diagnostic tests for artherosclerosis based stroke [2]

angiography (usually CT)
carotid US

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risk factors for artherosclerosis based stroke

hypertension
smoking
hyperlipidemia
diabete mellitus

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prevention of artherosclerosis based stroke [3]

treat risk factors
antiplatelets (no anti-coagulation)
carotid endarterectomy/stenting

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anti-platelet medications [3]

aspirin
clopidogrel
ticagrelor

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is diabetes a modifiable risk factor for stroke?

no, blood sugar control has not been shown to decrease risk

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when is carotid endarterectomy indicated?

symptomatic (stroke) patients with greater than 70% occulsion

(risk of perioperative MI is too high in asymptomatic, or symptomatic patient with only moderate stenosis)

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common mechanisms of penetrating artery occlusion leading to small vessel strokes [2]

lipohyalinosis
microatheroma

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risk factors for lacunar strokes

hypertension
maybe DM

poorly studies

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[…] are assumed to be effective for prevention of lacunar strokes

anti-platelets

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most common cause of ischemic stroke

cryptogenic

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unusual causes of ischemic stroke [2]

aterial dissection
drug abuse (cocaine, meth)

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thrombolytics [2]

TPA (IV alteplase)
tenecteplase

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thombolytics are effective up to […] are onset of ischemic stroke

4.5 hours

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catheter thrombectomy is effective up to [...] after onset of ischemic stroke

catheter thrombectomy is only effective for [...] occlusion

proximal large vessel

are thrombolytics or catheter thrombectomy more effective?

catheter thombectomy (if the patient is a candidate) NNT for TPA=8 NNT for catheter thrombectomy=2

causes of intracerebral intracranial hemorrhage [3]

hypertension amyloid angiopathy coagulopathy

common cause of subarachnoid intracranial hemorrhage

ruptured berry aneurysm

thunderclap headache

subarachnoid intracranial hemorrhage

patients with AD can have amyloid angiopathy, causing

lobar intracerebral intracranial hemorrhage

amyloid angiopathy causes intracerebral intracranial hemorrhage where in the brain?

lobar (cortical)

hypertension causes intracerebral intracranial hemorrhage where in the brain?

deep (subcortical) (thalamus, cerebellum, pons, basal ganglia)

two types of vascular dementia

1. history of clinical strokes correlated with onset of cognitive deficits 2. no history of clinical strokes, but diffuse subcortical disease on imaging (binswanger disease)

no history of clinical strokes, but diffuse subcortical disease on imaging

binswanger disease (subtype of Vascular dementia)

most ischemic strokes are caused by

emboli

red clot

cardiogenic emboli

most common cause of cardiogenic emboli

non-valvular a fib

most effective way to prevent strokes in patients with atrial fibrillation

anticoagulation

biggest modifiable risk factor for strokes

hypertension

occlusion of the lenticulostriate artery supplying the posterior limb of the internal capsule would cause

contralateral hemiplegia

non-cortical infarcts characterized by the absence of cortical signs

lacunar stroke

pure motor stroke indicates [...] artery supplying the [...] is affected

lenticulostriate posterior limb of internal capsule

pure sensory stroke indicates what structure is affected?

thalamus

contralateral hemiparesis and sensory impairment [...] artery supplying the [...] is affected

lenticulostriate posterior limb of internal capsule (can also present with purely motor symptoms)

Infarction of the [...] is the most common type of lacunar stroke and may manifest clinically with pure motor stroke, pure sensory stroke (rare), sensorimotor stroke, dysarthria-clumsy hand syndrome, and/or ataxic hemiparesis.

posterior limb of the internal capsule

a berry aneurysm is also called a [...] aneurysm

saccular

typically occur at bifurcations in the circle of Willis

berry aneurysm

most common location of berry aneurysm

junction of anterior communicating artery and ACA

what two congentital diseases are associated with berry aneurysm?

Ehlers-Danlos autosomal dominant polycyctic kidney disease

berry aneurysm causes [...] hemorrhage

subarachnoid

compression of the [...] due to berry aneurysm causes bitemporal hemianopia, visual acuity deficits, and ischemia in the ACA distribution

anterior communicating artery

rupture of the [...] due to berry aneurysm causes ischemia in the MCA distribution

MCA

compression of the [...] due to berry aneurysm causes ipspilateral CN III palsy (mydriasis, ptosis, down and out eye)

posterior communicating artery

what symptom can differentiate proximal vs distal MCA occlusion?

if leg is spared = distal proximal, leg will be equally affected with face and arm

monotonous but clear speech indicates

loss of parosody (emotional tone) and recognition of parosody (non-dominant hemisphere function)

what type of stroke is characterized by the absence of cortical signs and hemiplegia/hemisensory loss face=arm=leg

lenticulostriate

supplies the basal ganglia structures

lenticulostriate arteries

can't feel number traced on palm

graphesthesia indicates **cortical sensory loss*

superior quadrantanopia/homonymous hemianopia wernickes if dominant left-sided neglect if non-dominant cortical sensory loss

inferior MCA

Broca's gaze preference (FEF involvement) hemiparesis face=arm > leg foot is spared

superior MCA

contralateral weakness/numbness and UMN signs confined to the leg fluent speech no gaze preference no visual defect

unilateral ACA

subfalcine herniation can cause bilateral [...] occlusion

ACA

paraplegia of lower extremity sparing face and hands incontinence abullia

bilateral ACA

dense right visual field defect poor short term memory fluent speech no gaze preferences normal strength, sensation, reflexes

PCA

supplies blood to the thalamus

PCA

contralateral loss of all sensory dense unilateral visual field defect with macular sparing [2]

occlusion of the PCA at thalamus inferior MCA

inferior MCA occlusion can affect which visual radiation?

both

occlusion of [...] can affect the RAS

PCA

occlusion of the ophthalmic artery can cause

amaurosis fugax

episodic unilateral vision loss like a "shade" pulled over the eye

amaurosis fugax (due to occlusion of the ophthalmic artery)

would occlusion of the MCA or PCA cause monocular blindness?

pure hemiplegia without cortical findings

lacunar infarct- lenticulostriate artery

Wernickes aphasia visual field cut

inferior MCA

sudden contralateral leg weakness and sensory loss to all modalities

ACA

Brocas weakness of contralateral face and arm no visual field cut

superior MCA

bilateral visual loss (cortical blindness)

PCA-MCA watershed region with signs of systemic hypoperfusion (e.g., tachycardia, low blood pressure, pallor, sweating)

proximal limb weakness with sparing of the face, hands, and feet (“man-in-the-barrel syndrome”)

ACA-MCA watershed region with signs of systemic hypoperfusion (e.g., tachycardia, low blood pressure, pallor, sweating)

most likely mechanism of stroke with risk factors and non-flow limiting stenosis on the carotid arteries

artery-to-artery emboli

does unilateral carotid stenosis typically cause loss of consciousness?

no, would have to be bilateral to impair the RAS or cortex bilaterally

no risk factors or imaging evidence of atherosclerosis or lacunar disease what's the mechanism of the stroke?

cryptogenic

[...] is not indicated for the secondary prevention of ischemic stroke from atherosclerosis

warfarin