Cerebrovascular Case Studies - Ifergane

Question 1

How is hemiparesis distinguished from Brown-Sequard?

Answer 1

In Brown-Sequard, pain and temperature is contralateral to motor paresis and proprioception and vibration.

Question 2

What are the 5 mechanisms in the TOAST classification for stroke?

Answer 2

1. Small vessel disease
2. Large vessel disease
3. Cardioembolic
4. Undetermined
5. Other (hypercoaguability for whatever reason, vasculitis, dissection of arteries, etc.)

Question 3

What is the Penumbra and how does it function in the treatment of ischemic stroke?

Answer 3

The core that dies quickly received 0 perfusion but around it are areas that are partially perfused (collateral vessels, etc-Penumbra) and can live for a few hours. Ischemic stroke is more progressive and less immediate than thought in the past. As time progresses, Penumbra gets smaller and eventually it will all become ischemic core. This is the rationale behind reperfusion therapy.

Question 4

What are the contraindications for use of tPA?

Answer 4

1. CT scan showing infarct (old) or hemorrhagic origin
2. INR > 1.7

Question 5

What are the causes of stroke in the young?

Answer 5

Hypercoaguability

Birth control pills

Vasculitis

Lupus (hypercoaguability through APLA and renal disease)

Question 6

What are the clinical findings in venous thrombosis (infarct)?

Answer 6

Progressive onset

Papilledema/increased ICP

Sinus vein thrombosis: causes increased intracranial pressure, infarcts or hemorrhage, high tendency of seizures. Can be caused by an infection that spreads to the sinuses, Hypercoaguability, women just after or before given birth, or Behcet’s disease.

Question 7

Where are the perforating arteries in the brain?

Answer 7

Lenticulostriate arteries reaching the thalamus, basal ganglia, cerebellum and pons.

Cause lobar hemorrhages

Question 8

What is the mechanism of hypertension causing weakness of the vessels in the brain (and hemorrhage)?

Answer 8

Lypohyalinosis

Charcot-Bouchard aneurisms

Most common in lenticulostriate arteries

Question 9

What is the treatment for hemorrhagic stroke?

Answer 9

Surgery not for basal ganglion and rarely posterior fossa, only for lobar hemorrhage close to skull.

Osmotic agents for edema (mannitol)

Reduce blood pressure

Conservative treatment including secondary disease