Cerebrovascular Flashcards
0
Q
stroke involving perforating branches of ACA causes what
A
head of caudate / corpus callosum / fornix: abulia, agitation, dysarthria, hemiparesis
1
Q
stroke involving anterior choroidal artery causes what sx?
A
contralat hemianopia / hemiparesis
optic tract and posterior limb of internal capsule
2
Q
lateral aspect of cerebral hemisphere from cortical MCA branches cause what sx?/
A
face/arm motor/sensory
Aphasia / Gerstmann
Cortical sensory loss/neglect
3
Q
dominant anterior MCA stroke gives what
A
Broca’s and hemiparesis
4
Q
dominant MCA posterior division stroke gives what
A
hemisensory loss, Wernicke’s aphasia, Gerstmann
5
Q
borderline MCA/ACA watershed gives what sx
A
transcortical motor aphasia (repetition intact)
6
Q
Posterior disconnection syndrome (posterior cc)
A
left unilateral ideomotor apraxia: can’t produce left hand movement on verbal command OR left constructional apraxia (can’t copy drawing w/ left hand)
7
Q
anterior disconnection CC syndrome causes what sx
A
alien hand syndrome (left hand movement dissociated from conscious volition)
8
Q
What syndrome / vessel?
contralat hemiparesis, ipsilat CN 3 palsy
A
PcA perforators: Webers midbrain stroke (motor in ears)
9
Q
What syndrome / vessel? contralat hemiparesis, ipsilat CN 3 palsy AND contralat hemiathetosis/chorea/tremor
A
Midbrain lesion involving Red nucleus / STN
Benedikt
PCA perforators
10
Q
ipsilat lower motor neuron VII palsy, contralat hemiparesis
what syndrome /vessel
A
millard gubler, pontine syndrome from basilar perforators
11
Q
syndrome / vessels
ipsilat LMN CN VII palsy, contralat hemiparesis AND ipsilat horizontal gaze palsy, and MLF w/ INO
A
Foville gets the MLF and abducens nerve and facial nerve/nucleus
12
Q
ipsilat face, contralat body loss of pain/temp
dysarthria
ipsilat ataxia, vertigo, Horners
What syndrome / vessel
A
PICA Wallenberg syndrome (lateral medullary): not involving motor
13
Q
Contralat hemiparesis and sensory loss to vibration and proprioception, ipsilat XII tongue palsy
Syndrome /vessel
A
Dejerine’s from VA and anterior spinal artery perforators (medullary syndrome)
14
Q
most vulnerable area of spinal cord for infarct
what artery
A
T4-6
Artery of adamkiewicz at T12-L2
15
Q
lacunar stroke location with hemiataxia and hemiparesis on same side of body?
A
basis pontis, corona radiata, thalamocapsular
16
Q
treatment for pt w/ TIA and afib
A
coumadin w/ INR goal 2-3
17
Q
ASA + Plavix for stroke prevention in afib
A
superior to asa to prevent stroke in afib, but same risk of hemorrhage as coumadin
18
Q
Dabigatran
A
reversible direct thrombin inhibitor, no INR monitoring or food interactions for stroke prevention in afib, but still P450 interactions
19
Q
What is rivaroxaban?
A
reversible factor Xa inhibitor for stroke prevention in afib
20
Q
only drug shown to decrease mortality compared to warfarin for stroke prevention in afib, what type of med?
A
apixaban reversible factor Xa inhibitor
21
Q
valvular heart dz and stroke prevention when to use antiplatelet vs anticoag 1. rheumatic mitral valve 2. nonrheumatic mv 3. mvp and recurrent stroke 4. prosthetic valves
A
- coumadin
- antiplatelet
- antiplatelet
- coumadin 2.5-3.5 unless bioprosthetic
22
Q
management for symptomatic carotid artery disease when
- occluded
- 70-99% stenotic
- 50-69% stenotic
- <49%
A
- medical
- CAE < 2 wks
- +/- CAE
- medical
23
Q
asx carotid artery disease tx?
A
CAE if occlusion >80%
24
intracranial vs extracranial dissection presentations
intracranial: SAH
extracranial: ischemia
25
pain and lower>upper cranial neuropathy concerning for what?
carotid dissection
26
labs to consider for arterial thrombosis
anticardiolipin, anti B2 glycoprotein, lupus anticoagulant factor
27
labs for venous thrombus
factor V leiden, anti-thrombin III, protein C/S, MTHFR, prothrombin gene mutation
28
mgmt of stroke and antiphospholipid Ab vs APL syndrome: tx?
antiplatelet if just the antibody
| anticoagulation if the syndrome
29
Classic anticoagulation options and their monitoring (3)
heparin / PTT tx
LMWH factor Xa
Coumadin w/ INR
30
young female w/ large vessel (aorta, carotid, vertebral, subclavian) narrowing, asymmetric pulses and BP, granulomatous arteritis
Dx and tx
Takayasu's arteritis
| Immunosuppression and vascular reconstruction
31
older female >50y, mediuma nd large vessel extracranial branches of aortic arch with jaw claudication , wt loss, HA, high ESR
Dx, Tx steps, Pathology?
Giant Cell / Temporal Arteritis
Pathology: intimal thickening, media inflammation, skip lesions (fragmented)
Steroids immediately, and bx large chunk b/c skips
Immunosuppression
32
Granulomatous inflammation of small arteries and beading of vessels
isolated CNS angiitis / vasculitis
33
where does the right common carotid arise from?
the brachiocephalic artery
34
three branches of aorta
1. brachiocephalic artery which goes to right common carotid and right subclavian
2. left common carotid
3. left subclavian
35
vertebrals arise from what
right and left subclavian
36
What are the main branches of the ICA?
```
Ophthalmic (1st)
Posterior communicating artery (connects anterior/posterior circ
Anterior choroidal
ACA/MCA
(OPAAM)
```
37
What supplies: hypothal, optic tract, anterior/medial thalamus?
posterior communicating
38
major branch of the ACA that supplies the head of the caudate, anterior limb of IC, anterior putamen?
Causes what sx?
recurrent artery of Huebner (causes contral face/arm wkness)
39
What separates the A1 and A2 segment of the ACA?
the anterior communicating artery
40
What are the branches of the vertebral artery?
PICA
Anterior spinal
posterior spinal
41
vessel involved in lateral medullary syndrome
PICA
42
Main branches of the basilar artery
```
perforators (paramedian/circumferential)
AICA
SCA (Superior cerebellar)
Internal auditory (if not AICA branch)
PCA
```
43
AICA (AI can cause what)
auditory impairment
44
vessel involved in nystagmus, ipsilat ataxia, contralat loss of p/t, ipsilat Horner's
Superior cerebellar (involves spinothalamic, sympathetic tract, cerebellum/superior cerebellar peduncle
45
5 syndromes you can get w/ PCA infarcts
1. Alexia w/o Agraphia (occipital/splenium cc)
2. Anton (b/l occipital)
3. Balint (b/l parieto/occipital)
4. Korsakoff (paramedian thalamic branches)
5. Prosopagnosia (b/l mesio-temporal/occipital)
46
4 Thalamic regions / lesions w/ arterial supply and sx
1. anterior region causes abulia/apathy: polar or tuberothalamic artery (branch of post comm a): think biPOLAR/Affective d/o
The rest are branches of PCA:
2. dorsal: visual field defect: posterior choroidal
3. paramedian: altered mental status / amnesia/ vertical gaze palsy: posterior thalamoperforators/paramedian thalamic
4. posteriolateral: pure sensory, sensorimotor, or Dejerine Roussy: thalamogeniculate artery
47
what syndrome, what cause?
| contralat hemianesthesia/hemiataxia, dysesthesia, transient hemiparesis, choreoathetosis
Dejerine Roussy from posterolateral thalamic lesion / occlusion of thalamogeniculate artery
48
regions of medial brainstem involved based on CN:
midbrain
pons
medulla
MEDIAL Only:
MB: CN3 nucleus/nerve in rostral MB, CNIV nerve and nucleus in caudal MB, CNV/mesencephalic trigeminal tract
Pons: CNVI nucleus and nerve and CN VII wraps around CNVI nucleus
Med: CNXII nerve/ nucleus
49
lateral brainstem regions involved in stroke?
LATERAL MEDULLA only: spinal trigeminal nucleus, vestibular nucleus, nucleus ambiguus, nucleus tractus solitarius, nucleus/nerve of CNX
50
midbrain blood supply?
PCA
51
what syndrome:
ipsilat CNIII palsy contralat weakness
What area?
Weber's syndrome
ventral midbrain
(WEbers, WEakness)
52
Ipsilat CN III palsy and contralat ataxia/tremor
| syndrome and area?
Claude's, midbrain tegmentum involves red nucleus, CN III
| Santa CLAUSE in RED suit, and CLaude is CLumsy
53
syndrome and area:
| CN III palsy, contralat weakness, AND ataxia/tremor
Benedikt: Weak like Weber and Clumsy like Claude so deserves Benediction.
Involves MB tegmentum and brachium
54
Blood supply of pons
basilar / lateral caudal areas also some AICA
55
Ipsilat lateral rectus palsy, CN7 palsy, contralat facial sparing hemiparesis
Syndrome / area
Millard-Gubler: ventral pons
CN 7-6 (7 and 6 letters)
(And Mallard ducks live in Ponds)
56
Lesion where causes locked in syndrome?
bilateral ventral pons
57
what happens to eyes in pontine strokes?
they look toward weakness, and ponder the paresis instead of typical eyes toward lesion (wrong way eyes)
58
CN involvement with lateral vs medial medullary lesions
CN XII is involved with the tongue / MEDIAL
| CN X and all the other nuclei are involved in LATERAL
59
Wallenberg syndrome involves what sx?
Think Wahlberg in Boogie NIGHTS and ataxia/vertigo with boogie-ing and therefore no motor weakness
N: n/v (vestibular nucleus)
I: impaired pain/temp (trigeminal nucleus and spinothalamic tract)
G: Gag decreased (CNX) ipsil
H: Horner's: sympathetic fibers
T: taste impaired (Nucleus solitarius)
S: soft speech (hoarse: CNX)
60
dysarthria clumsy hand syndrome : 3 possible locations?
lacunar strokes in:
basis pontis
internal capsule
cerebral peduncle
61
strongest risk factor for stroke
incr age
62
most common modifiable risk fx for stroke
htn
63
what causes man in the barrel syndrome? (proximal leg and arm weakness)
ischemia between ACA/MCA watershed b/l
64
most common site of intracerebral hemorrhage
putamen (htn hemorrhage)/ Basal Ganglia
65
coma, quadriparesis, pinpoint pupils w/o doll's eye movement
pontine hemorrhage
66
Classification for SAH grading?
Hunt/Hess: 0-V
0: Asx
1: mild sx HA/nuchal rigidity
2. more severe sx but neuro intact except +/- CN
3. drowsy, neuro deficit
4. stupor/hemiparesis
5. coma, decerebrate
67
how many days after SAH does vasospasm occur and what can prevent it?
nimodipine day 5-14
68
most common site of aneurysm?
anterior communicating
69
5 genetic conditions assoc w/ aneurysms
1. AD Polycystic kidney dz
2. Ehlers Danlos type IV
3. Marfans
4. NF1
5. Pompe
70
most common causes of hemorrhage:
SAH
Subdural
Epidural
SAH: berry/sacular aneurysm
SDH: torn bridging veins
epidural: middle meningeal artery
71
what causes CN VI palsy with facial pain due to CN V involvement
caution?
Gradenigo syndrome. Transverse sinus thrombosis due to otitis / mastoiditis
72
most common sinus venous thrombosis?
| Radiographic sign
sagittal sinus - empty delta sign
73
best place to see cavernous malformation?
T2 MRI (better than arteriogram)
74
pulsatile proptosis, limited eye movement, vision loss, bruit, +/- trigeminal involvement
Dx?
carotid-cavernous fistula
75
string of beads in young woman w/ stroke presentation
cervicocephalic fibromuscular dysplasia
76
alpha galactosidase deficiency
Fabry
77
periumbilical hyperkeratotic papules
Fabry's
78
recurrent posterior fossa strokes in young woman should make you think of what
Fabry's (X-inactivation of certain organs can lead to female disease, even in X-linked disorder)
79
dolichoectatic arteries: what are they and when do you see them?
dilation / tortuosity of vessels
| -Fabry's
80
ischemia vs hemorrhage in moyomoya
ischemic initially, but then can get hemorrhages due to fragile small abnormal collateral vessels
81
moya moya can be assoc with what mutation or what other genetic disorders/causes (5)
1. chr 17 or chr 3 in familial form
2. Sickle cell
3. NF1
4. TS
5. acquired in radiation
82
Notch 3, chromosome 19
CADASIL
83
pathology seen on EM and in arterioles in skin biopsy in CADASIL
eosinophilic inclusions in arterioles
| EM: granular osmophilic material in media
84
possible preventative treatments in moya moya early on
CCBs and antiplatelets
85
CADASIL vs CARASIL?
CARASIL: also alopecia, spondylosis, mutation in HTRA1 (recessive not dominant like CADASIL)
86
A to G mutation in mtDNA nucleotide 3243 (tRNA: Leucine)
MELAS
87
mitochondria with parking lot like inclusions on EM?
MELAS
88
succinate dehydrogenase stain, think of what disease and finding
MELAS, parking lot inclusions
89
4 possible treatment for MELAS
Coenzyme Q
Dichloroacetate
Carnitine
Arginine
90
30-40 yo pt w/ vision, memory loss, seizures, hemiparesis and dysarthria
Dx, mutation, MRI finding
```
HERNS: Hereditary Endotheliopathy, Retinopathy, Nephropathy, and Stroke (cerebroretinal vasculopathy syndrome)
TREX1 gene (Trex can't see or think)
MRI shows tumefactive contrast enhancing white matter lesion
```
91
arachnodactyly, hyperextensible digits, long limbs, joint laxity, aortic root dilation, thromboembolisms, carotid dissections, intracranial aneurysms; dx and what is defected
Marfan, fibrillin dz
92
hypermobile joints and skin elasticity, dissections, aneurysms, AV fistulae, ccardiac defects, what is defective / what dx
Ehlers-Danlos, collagen tissue d/o
93
What is Call Fleming syndrome
reversible drug-related ischemic syndrome
| usu w/ sympathomimetic meds (cocaine, stimulants, nasal congestants)
94
marfinoid, ID, ectopia lentis, and stroke risk
Homocystinuria
95
cystathionine beta synthase def causes what
homocystinuria
96
Osler Weber Rendu can cause what issues in neuro? (2)
ischemic stroke
| SAH from brain AVMs
97
pulseless disease
Takayasu
98
Aggrenox: what is it and what is major s/e?
aspirin + dipyridamole (plt phosphodiesterase inhibitor)
| causes Aggravating HA
99
microangiopathy w/ perivascular lymphocytes, retino-cochlear-cerebral vasculopathy
-what brain area usually involved and what does it look like
Susac syndrome
| snow-ball microinfarct in corpus callosum
100
interstitial keratitis, uveitis, scleritis, vestibular dysfunction
Dx?
Cogan's syndrome
101
Thrombotic vasculopathy + stroke, livedo reticularis, +/- antiphospholipid syndrome
Dx and Tx?
Sneddon syndrome, anticoagulation or antiplatelet
102
risk of symptomatic bleed w/ tpA
3-6%
103
Improvement in mortality / morbidity with tPA?
no effect on mortality
| 30% pts w/ minimal / no disability at 3 mos after TPA
104
Differences in 3.5-4 hour window compared to first 3 hours for tPA
relative exclusion for
1. age >80
2. severe stroke
3. hx of DM or prior stroke
4. taking oral anticoagulant
105
risk of mortality with tpa ICH bleed?
50%
106
overall mortality with tpa
3%
107
BP goal post tpa?
<180/105
108
special screening in sickle cell patients and what is the appropriate management?
starting at age 2y: TCDs to look at peak systolic velocity of MCA, if >200cm, get exchange transfusions (risk of stroke 10-30 --> < 30-50% and hydroxyurea or bypass surgery
109
drug to consider for low HDL and high lipoprotein A?
Niacin tx for primary stroke prevention
110
Timing of hemorrhage in T1 and T2 (I: iso, B: bright, D: Dark)
- Hyperacute
- Acute
Hyperacute: <24h
T1: iso or dark
T2: Bright
(I Bleed, I Die)
111
Timing of hemorrhage in T1 and T2 (I: iso, B: bright, D: Dark)
Subacute: early and late
Chronic
early: 3-7: Bright, Dark
late:7-14: Bright, Bright
>14: Dark, Dark
(Bleed Die, Bleed Bleed, Die Die)
112
what is Terson's syndrome?
vitreal hemorrhage in setting of sudden incr ICP
113
Types of associated hemorrhages seen in SAH? (3)
1. subhyaloid hemorrhages
2. Retinal hemorrhage
3. Vitreal hemorrhage w/ sudden incr in ICP (Terson's)
114
when should you do LP to look for xanthochromia in suspected SAH
after 6 hrs
115
risk of rebleeding after SAH in firs 24 hrs vs next 2 wks
4% first 24h
| 1% daily x 2 wks
116
diffusion imaging findings acute stroke
bright DWI
| dark ADC
117
popcorn appearance on MRI?
cavernous malformation
118
familial cavernous malformation is what gene and what chromosome
CCM1 on chr 7
119
DWI vs ADC, beware of what on DWI
DWI bright, but beware of T2 shine through and look for ADC dark correlate
120
encephalopathy, branch retinal artery occlusions, hearing loss
Dz
Cause
MRI
Susac
autoimmune
snowball MRI
