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Cerebrovascular Flashcards

0
Q

stroke involving perforating branches of ACA causes what

A

head of caudate / corpus callosum / fornix: abulia, agitation, dysarthria, hemiparesis

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1
Q

stroke involving anterior choroidal artery causes what sx?

A

contralat hemianopia / hemiparesis

optic tract and posterior limb of internal capsule

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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

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3
Q

dominant anterior MCA stroke gives what

A

Broca’s and hemiparesis

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4
Q

dominant MCA posterior division stroke gives what

A

hemisensory loss, Wernicke’s aphasia, Gerstmann

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5
Q

borderline MCA/ACA watershed gives what sx

A

transcortical motor aphasia (repetition intact)

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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)

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7
Q

anterior disconnection CC syndrome causes what sx

A

alien hand syndrome (left hand movement dissociated from conscious volition)

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8
Q

What syndrome / vessel?

contralat hemiparesis, ipsilat CN 3 palsy

A

PcA perforators: Webers midbrain stroke (motor in ears)

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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

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10
Q

ipsilat lower motor neuron VII palsy, contralat hemiparesis

what syndrome /vessel

A

millard gubler, pontine syndrome from basilar perforators

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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

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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

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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)

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14
Q

most vulnerable area of spinal cord for infarct

what artery

A

T4-6

Artery of adamkiewicz at T12-L2

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15
Q

lacunar stroke location with hemiataxia and hemiparesis on same side of body?

A

basis pontis, corona radiata, thalamocapsular

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16
Q

treatment for pt w/ TIA and afib

A

coumadin w/ INR goal 2-3

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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

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18
Q

Dabigatran

A

reversible direct thrombin inhibitor, no INR monitoring or food interactions for stroke prevention in afib, but still P450 interactions

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19
Q

What is rivaroxaban?

A

reversible factor Xa inhibitor for stroke prevention in afib

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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

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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
  1. coumadin
  2. antiplatelet
  3. antiplatelet
  4. coumadin 2.5-3.5 unless bioprosthetic
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22
Q

management for symptomatic carotid artery disease when

  1. occluded
  2. 70-99% stenotic
  3. 50-69% stenotic
  4. <49%
A
  1. medical
  2. CAE < 2 wks
  3. +/- CAE
  4. medical
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23
Q

asx carotid artery disease tx?

A

CAE if occlusion >80%

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24
Q

intracranial vs extracranial dissection presentations

A

intracranial: SAH
extracranial: ischemia

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25
Q

pain and lower>upper cranial neuropathy concerning for what?

A

carotid dissection

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26
Q

labs to consider for arterial thrombosis

A

anticardiolipin, anti B2 glycoprotein, lupus anticoagulant factor

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27
Q

labs for venous thrombus

A

factor V leiden, anti-thrombin III, protein C/S, MTHFR, prothrombin gene mutation

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28
Q

mgmt of stroke and antiphospholipid Ab vs APL syndrome: tx?

A

antiplatelet if just the antibody

anticoagulation if the syndrome

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29
Q

Classic anticoagulation options and their monitoring (3)

A

heparin / PTT tx
LMWH factor Xa
Coumadin w/ INR

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30
Q

young female w/ large vessel (aorta, carotid, vertebral, subclavian) narrowing, asymmetric pulses and BP, granulomatous arteritis
Dx and tx

A

Takayasu’s arteritis

Immunosuppression and vascular reconstruction

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31
Q

older female >50y, mediuma nd large vessel extracranial branches of aortic arch with jaw claudication , wt loss, HA, high ESR
Dx, Tx steps, Pathology?

A

Giant Cell / Temporal Arteritis
Pathology: intimal thickening, media inflammation, skip lesions (fragmented)
Steroids immediately, and bx large chunk b/c skips
Immunosuppression

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32
Q

Granulomatous inflammation of small arteries and beading of vessels

A

isolated CNS angiitis / vasculitis

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33
Q

where does the right common carotid arise from?

A

the brachiocephalic artery

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34
Q

three branches of aorta

A
  1. brachiocephalic artery which goes to right common carotid and right subclavian
  2. left common carotid
  3. left subclavian
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35
Q

vertebrals arise from what

A

right and left subclavian

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36
Q

What are the main branches of the ICA?

A 
Ophthalmic (1st)
Posterior communicating artery (connects anterior/posterior circ
Anterior choroidal
ACA/MCA
(OPAAM)
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37
Q

What supplies: hypothal, optic tract, anterior/medial thalamus?

A

posterior communicating

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38
Q

major branch of the ACA that supplies the head of the caudate, anterior limb of IC, anterior putamen?
Causes what sx?

A

recurrent artery of Huebner (causes contral face/arm wkness)

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39
Q

What separates the A1 and A2 segment of the ACA?

A

the anterior communicating artery

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40
Q

What are the branches of the vertebral artery?

A

PICA
Anterior spinal
posterior spinal

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41
Q

vessel involved in lateral medullary syndrome

A

PICA

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42
Q

Main branches of the basilar artery

A 
perforators (paramedian/circumferential)
AICA
SCA (Superior cerebellar)
Internal auditory (if not AICA branch)
PCA
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43
Q

AICA (AI can cause what)

A

auditory impairment

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44
Q

vessel involved in nystagmus, ipsilat ataxia, contralat loss of p/t, ipsilat Horner’s

A

Superior cerebellar (involves spinothalamic, sympathetic tract, cerebellum/superior cerebellar peduncle

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45
Q

5 syndromes you can get w/ PCA infarcts

A
  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)
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46
Q

4 Thalamic regions / lesions w/ arterial supply and sx

A
  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:

  1. dorsal: visual field defect: posterior choroidal
  2. paramedian: altered mental status / amnesia/ vertical gaze palsy: posterior thalamoperforators/paramedian thalamic
  3. posteriolateral: pure sensory, sensorimotor, or Dejerine Roussy: thalamogeniculate artery
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47
Q

what syndrome, what cause?

contralat hemianesthesia/hemiataxia, dysesthesia, transient hemiparesis, choreoathetosis

A

Dejerine Roussy from posterolateral thalamic lesion / occlusion of thalamogeniculate artery

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48
Q

regions of medial brainstem involved based on CN:
midbrain
pons
medulla

A

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
Q

lateral brainstem regions involved in stroke?

A

LATERAL MEDULLA only: spinal trigeminal nucleus, vestibular nucleus, nucleus ambiguus, nucleus tractus solitarius, nucleus/nerve of CNX

50
Q

midbrain blood supply?

51
Q

what syndrome:
ipsilat CNIII palsy contralat weakness
What area?

A

Weber’s syndrome
ventral midbrain
(WEbers, WEakness)

52
Q

Ipsilat CN III palsy and contralat ataxia/tremor

syndrome and area?

A

Claude’s, midbrain tegmentum involves red nucleus, CN III

Santa CLAUSE in RED suit, and CLaude is CLumsy

53
Q

syndrome and area:

CN III palsy, contralat weakness, AND ataxia/tremor

A

Benedikt: Weak like Weber and Clumsy like Claude so deserves Benediction.
Involves MB tegmentum and brachium

54
Q

Blood supply of pons

A

basilar / lateral caudal areas also some AICA

55
Q

Ipsilat lateral rectus palsy, CN7 palsy, contralat facial sparing hemiparesis
Syndrome / area

A

Millard-Gubler: ventral pons
CN 7-6 (7 and 6 letters)
(And Mallard ducks live in Ponds)

56
Q

Lesion where causes locked in syndrome?

A

bilateral ventral pons

57
Q

what happens to eyes in pontine strokes?

A

they look toward weakness, and ponder the paresis instead of typical eyes toward lesion (wrong way eyes)

58
Q

CN involvement with lateral vs medial medullary lesions

A

CN XII is involved with the tongue / MEDIAL

CN X and all the other nuclei are involved in LATERAL

59
Q

Wallenberg syndrome involves what sx?

A

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
Q

dysarthria clumsy hand syndrome : 3 possible locations?

A

lacunar strokes in:
basis pontis
internal capsule
cerebral peduncle

61
Q

strongest risk factor for stroke

62
Q

most common modifiable risk fx for stroke

63
Q

what causes man in the barrel syndrome? (proximal leg and arm weakness)

A

ischemia between ACA/MCA watershed b/l

64
Q

most common site of intracerebral hemorrhage

A

putamen (htn hemorrhage)/ Basal Ganglia

65
Q

coma, quadriparesis, pinpoint pupils w/o doll’s eye movement

A

pontine hemorrhage

66
Q

Classification for SAH grading?

A

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
Q

how many days after SAH does vasospasm occur and what can prevent it?

A

nimodipine day 5-14

68
Q

most common site of aneurysm?

A

anterior communicating

69
Q

5 genetic conditions assoc w/ aneurysms

A
  1. AD Polycystic kidney dz
  2. Ehlers Danlos type IV
  3. Marfans
  4. NF1
  5. Pompe
70
Q

most common causes of hemorrhage:
SAH
Subdural
Epidural

A

SAH: berry/sacular aneurysm
SDH: torn bridging veins
epidural: middle meningeal artery

71
Q

what causes CN VI palsy with facial pain due to CN V involvement
caution?

A

Gradenigo syndrome. Transverse sinus thrombosis due to otitis / mastoiditis

72
Q

most common sinus venous thrombosis?

Radiographic sign

A

sagittal sinus - empty delta sign

73
Q

best place to see cavernous malformation?

A

T2 MRI (better than arteriogram)

74
Q

pulsatile proptosis, limited eye movement, vision loss, bruit, +/- trigeminal involvement
Dx?

A

carotid-cavernous fistula

75
Q

string of beads in young woman w/ stroke presentation

A

cervicocephalic fibromuscular dysplasia

76
Q

alpha galactosidase deficiency

77
Q

periumbilical hyperkeratotic papules

78
Q

recurrent posterior fossa strokes in young woman should make you think of what

A

Fabry’s (X-inactivation of certain organs can lead to female disease, even in X-linked disorder)

79
Q

dolichoectatic arteries: what are they and when do you see them?

A

dilation / tortuosity of vessels

-Fabry’s

80
Q

ischemia vs hemorrhage in moyomoya

A

ischemic initially, but then can get hemorrhages due to fragile small abnormal collateral vessels

81
Q

moya moya can be assoc with what mutation or what other genetic disorders/causes (5)

A
  1. chr 17 or chr 3 in familial form
  2. Sickle cell
  3. NF1
  4. TS
  5. acquired in radiation
82
Q

Notch 3, chromosome 19

83
Q

pathology seen on EM and in arterioles in skin biopsy in CADASIL

A

eosinophilic inclusions in arterioles

EM: granular osmophilic material in media

84
Q

possible preventative treatments in moya moya early on

A

CCBs and antiplatelets

85
Q

CADASIL vs CARASIL?

A

CARASIL: also alopecia, spondylosis, mutation in HTRA1 (recessive not dominant like CADASIL)

86
Q

A to G mutation in mtDNA nucleotide 3243 (tRNA: Leucine)

87
Q

mitochondria with parking lot like inclusions on EM?

88
Q

succinate dehydrogenase stain, think of what disease and finding

A

MELAS, parking lot inclusions

89
Q

4 possible treatment for MELAS

A

Coenzyme Q
Dichloroacetate
Carnitine
Arginine

90
Q

30-40 yo pt w/ vision, memory loss, seizures, hemiparesis and dysarthria
Dx, mutation, MRI finding

A 
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
Q

arachnodactyly, hyperextensible digits, long limbs, joint laxity, aortic root dilation, thromboembolisms, carotid dissections, intracranial aneurysms; dx and what is defected

A

Marfan, fibrillin dz

92
Q

hypermobile joints and skin elasticity, dissections, aneurysms, AV fistulae, ccardiac defects, what is defective / what dx

A

Ehlers-Danlos, collagen tissue d/o

93
Q

What is Call Fleming syndrome

A

reversible drug-related ischemic syndrome

usu w/ sympathomimetic meds (cocaine, stimulants, nasal congestants)

94
Q

marfinoid, ID, ectopia lentis, and stroke risk

A

Homocystinuria

95
Q

cystathionine beta synthase def causes what

A

homocystinuria

96
Q

Osler Weber Rendu can cause what issues in neuro? (2)

A

ischemic stroke

SAH from brain AVMs

97
Q

pulseless disease

98
Q

Aggrenox: what is it and what is major s/e?

A

aspirin + dipyridamole (plt phosphodiesterase inhibitor)

causes Aggravating HA

99
Q

microangiopathy w/ perivascular lymphocytes, retino-cochlear-cerebral vasculopathy
-what brain area usually involved and what does it look like

A

Susac syndrome

snow-ball microinfarct in corpus callosum

100
Q

interstitial keratitis, uveitis, scleritis, vestibular dysfunction
Dx?

A

Cogan’s syndrome

101
Q

Thrombotic vasculopathy + stroke, livedo reticularis, +/- antiphospholipid syndrome
Dx and Tx?

A

Sneddon syndrome, anticoagulation or antiplatelet

102
Q

risk of symptomatic bleed w/ tpA

103
Q

Improvement in mortality / morbidity with tPA?

A

no effect on mortality

30% pts w/ minimal / no disability at 3 mos after TPA

104
Q

Differences in 3.5-4 hour window compared to first 3 hours for tPA

A

relative exclusion for

  1. age >80
  2. severe stroke
  3. hx of DM or prior stroke
  4. taking oral anticoagulant
105
Q

risk of mortality with tpa ICH bleed?

106
Q

overall mortality with tpa

107
Q

BP goal post tpa?

108
Q

special screening in sickle cell patients and what is the appropriate management?

A

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
Q

drug to consider for low HDL and high lipoprotein A?

A

Niacin tx for primary stroke prevention

110
Q

Timing of hemorrhage in T1 and T2 (I: iso, B: bright, D: Dark)

  • Hyperacute
  • Acute
A

Hyperacute: <24h
T1: iso or dark
T2: Bright
(I Bleed, I Die)

111
Q

Timing of hemorrhage in T1 and T2 (I: iso, B: bright, D: Dark)
Subacute: early and late
Chronic

A

early: 3-7: Bright, Dark
late:7-14: Bright, Bright
>14: Dark, Dark
(Bleed Die, Bleed Bleed, Die Die)

112
Q

what is Terson’s syndrome?

A

vitreal hemorrhage in setting of sudden incr ICP

113
Q

Types of associated hemorrhages seen in SAH? (3)

A
  1. subhyaloid hemorrhages
  2. Retinal hemorrhage
  3. Vitreal hemorrhage w/ sudden incr in ICP (Terson’s)
114
Q

when should you do LP to look for xanthochromia in suspected SAH

A

after 6 hrs

115
Q

risk of rebleeding after SAH in firs 24 hrs vs next 2 wks

A

4% first 24h

1% daily x 2 wks

116
Q

diffusion imaging findings acute stroke

A

bright DWI

dark ADC

117
Q

popcorn appearance on MRI?

A

cavernous malformation

118
Q

familial cavernous malformation is what gene and what chromosome

A

CCM1 on chr 7

119
Q

DWI vs ADC, beware of what on DWI

A

DWI bright, but beware of T2 shine through and look for ADC dark correlate

120
Q

encephalopathy, branch retinal artery occlusions, hearing loss
Dz
Cause
MRI

A

Susac
autoimmune
snowball MRI

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