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Neurosurgery Basics > Ch. 10 - Stroke > Flashcards

Ch. 10 - Stroke Flashcards

1
Q

Stroke definition

A

sudden neuro deficit 2/2 vascular etiology lasting > 24 hrs

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2
Q

TIA definition

A

transient neuro deficit lasting < 24 hrs

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3
Q

Stroke types

A

ISCHEMIC (infarct) vs HEMORRHAGIC vs both

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4
Q

Primary stroke prevention

A

lifestyle modification and treatment of risk factors in pt without cerebrovascular sx

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5
Q

Stroke risk factors

A

smoking, HTN, diabetes, heart dz (a fib), hypercholesterolemia, age, males, smoking

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6
Q

most common cause of cardiogenic cerebral infarct

A

non-valvular atrial fibrillation

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7
Q

treatment of atrial fibrillation

A

warfarin with INR 2-3 for pts 60+, ASA adds moderate benefit

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8
Q

Secondary stroke prevention

A

tailored to underlying stroke pathology including antiplatelet therapy, warfarin, CEA, and stenting

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9
Q

ASA mechanism

A

irreversible inhibition of platelet cyclooxygenase (no thromboxane for plt aggregation)

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10
Q

clopidogrel mechanism

A

inhibits platelet ADP (receptor that activates plt aggregation)

  • small ARR compared to ASA but more expensive = second line
  • can combo with ASA
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11
Q

dipyridamole mechanism

A

inhibits PDE, maintaines high levels of cAMP/cGMP to prevent platelet activation
- can combo with ASA

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12
Q

CEA indications

A

beneficial for pts with > 70% stenosis

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13
Q

TIA work up

A

CT, carotid doppler, ECG, +/- echo within 24 hrs

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14
Q

amaurosis fugax sx

A

transient monocular blindness “shade pulled over one eye”

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15
Q

MCA occlusion

A

contralateral hemiplegia (arm > leg), hemianesthesia, homonymous hemianopia, aphasia, inattention, cortical sensory loss

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16
Q

ACA occlusion

A

hemiparesis (mostly leg)

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17
Q

PCA occlusion

A

homonymous hemianopia, disconnecting syndromes, hemianesthesia, amnesia, midbrain/thalamic syndromes

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18
Q

vertebrobasilar thrombosis

A

quadriparesis, bulbar paralysis, impaired gaze, cortical blindness, coma

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19
Q

ventral pontine infarct

A

quadriparesis, bulbar paralysis, absent horizontal gaze, normal consciousness, “locked in” syndrome

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20
Q

lateral medullary syndrome

A

ipsilateral ataxia, horners syndrome, nystagmus, facial numbness, CN9/10 palsy, contralateral spinothalamic loss

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21
Q

lacunar infarcts most likely secondary to

A

HTN causing ‘lipohyalinosis’

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22
Q

most common cause of cardiogenic embolism

A

non-valvular arterial fibrillation > valvular heart dz, MI, post cards surgery, prosthetic valves, endocartis, atrial myxoma

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23
Q

Types of cerebral hemorrhage

A

intracerebral vs subarachnoid hemorrhage

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24
Q

risk factor for intracerebral hemorrhage

A

HTN –> charcot-bouchard microaneurysms

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25
Q

lobar hemorrhage

A

superficial vascular rupture w/i cerebral lobes

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26
Q

risk factor for lobar hemorrhage

A

amyloid angiopathy

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27
Q

Principles of stroke management

A

early recognition, rapid transport to tx facility “time is brain”, early triage/imaging, assess for thrombolysis, monitoring in stroke unit

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28
Q

ddx stroke

A

cerebral tumor, subdural hematoma, abscess, migraine, metabolic disturbances, epilepsy

29
Q

all patients with suspected stroke need a…

A

CT or MRI. MRI better at identifying acute ischemia and just as good at ID’ing hemorrhage

30
Q

Do you ever LP a suspected stroke patient?

A

yes if negative imaging and you suspect meningitis or SAH

31
Q

Major difference in treatment: ischemic vs hemorrhagic stroke

A

ischemic stroke = indication for thrombolysis. hemorrhagic stroke = absolute contraindication

32
Q

clinical factors important for tPA administration

A

ischemic stroke, given w/i 3 hours of stroke onset

33
Q

most common site of cerebral infarct

A

middle cerebral artery. classified as cortical or deep

34
Q

difference between cortical or subcortical infarcts

A

subcortical = deep perforating vessels supplying internal capsule, thalamus, basal ganglia and brainstem

35
Q

lacunar infarct

A

occlusion of single perforating vessel <1.5 cm, assoc. w/ htn

36
Q

classic lacunar infarct presentations

A

pure motor hemiparesis, pure sensory stroke, sensorimotor stroke, ataxic hemiparesis and dysarthria/clumsy hand

37
Q

classic cortical infarct presentations

A

dysphasia, apraxia, anosognosia, sensory/motor/visual agnosia, acalculia, right/left confusion, dysgraphia, cortical sensory loss (2 pt discrimination, astereognosis, dysgraphasthesia)

38
Q

apraxia

A

difficulty with motor planning to produce speach

39
Q

dysphasia

A

inability to comprehend/form speech

40
Q

anosognosia

A

denial of stroke

41
Q

agnosia

A

inattention

42
Q

acalculia

A

inability to perform simple arithmetic

43
Q

dysgraphia

A

inability to write

44
Q

dysgraphesthesia

A

inability to perceive what is written

45
Q

astereognosia

A

inability to id object by touch

46
Q

presentation of hemorrhagic stroke

A

rapid onset of stroke w/ early depression fof conscious state

47
Q

work up of stroke patient

A
  1. blood glucose
  2. ECG - a fib, acute MI (causes of thromboemboli)
  3. CT brain = MRI, also consider MRA/CTA
  4. duplex doppler (less urgent)
48
Q

dedicated stroke units have reduced mortality by __%

A

25%

49
Q

initial management of a stroke

A
  1. monitoring vitals/neuro/cardiac status
  2. ASA (if no tPA)
  3. ID prior fxnal status and current deficits
  4. early mobililization/ROM
  5. aspiration precautions - drop NG if dysphagic
  6. basic precautions: prevention of DVT, pneumonia, bed sores, UTI
50
Q

what hemodynamic instability is tolerated during acute stroke?

A

hypertension is common and settles over 2-3 days. avoid hypotension = decreased cerebral perfusion

51
Q

preferred fluid for acute stroke

A

NS. avoid glc containing fluids (hyperglycemia)

52
Q

most common cause of mortality in stroke patients by week

A

week 1: transtentorial herniation
week 2: secondary systemic factors
week 3: pneumonia, PE, cardiac

53
Q

progressive deteriorating neuro deficit seen in what percent of stroke population? 2/2 to what?

A

33% caused by cerebral edema. NOT helped by corticosteroids, no evidence for mannitol, hemicrani may help some

54
Q

when is heparin indicated following a stroke?

A

pt at high risk for recurrent embolism, otherwise risk of hemorrhagic transformation too risky

55
Q

when is neurosurgical intervention indicated?

A

cerebellar hemorrhage, young patients with lobar hemorrhage = possible evacuation

56
Q

subacute follow up of stroke

A
  1. Tx underlying cause: warfarin @ 1w for a fib, CEA for carotid stenosis
  2. REHAB
57
Q

Rarer causes of strokes, usually younger adults

A

migraine, OCPs, mitral valve prolapse, vasculitis, extracranial arterial dissection, fibromuscular dysplasia, moya-moya dz, hypercoagulability

58
Q

work up of rarer causes of stroke

A

angiogram, TEE, LP, hematologic investigation

59
Q

migraine-induced stroke presentation

A

pt with persistent neuro deficit following classic migraine. dx of exclusion

60
Q

OCP-induced stroke presentation

A

estrogen containing OCPs (hypercoag). dx of exclusion

61
Q

rare cardiac associated with stroke in young pt

A

mitral valve prolapse/PFO, req TEE to tx

62
Q

causes of cerebral vasculitis

A

polyarteritis nodosa, granulomatous angiitis, giant cell arteritis, heroin/amphetamines/cocaine, TB/syphilis, opthalmic herpes zoster

63
Q

lab/imaging findings of vasculitis

A

beading of arteries on angiography, lymphocytosis in CSF, elevated ESR

64
Q

FMD

A

females, assoc. with renal FMD, increased risk of berry aneurysms/dissection. Tx w/ aspirin

65
Q

moya moya

A

obliterative arterial condition = fine telangiectatic web of anastamotic intracranial vessels = “puff of smoke” appearance on angio. Tx with revascularization

66
Q

hypercoagulable states assoc. with stroke

A

lupus, activated protein C resistance, deficiencies in protein C/S

67
Q

cerebral venous thromboembolism presentation

A

insidious HA, papilledema –> hemiplegia, drowsiness, fever, seizures, meningismus in hypercoagulable state (post partum, OCPs, lupus) or in pts with infxn

68
Q

carotid artery dissection presentation

A

neck pain, eye pain and horner’s syndrome

69
Q

Indications for carotid endarterectomy

A

Symptomatic carotid stenosis of 70-99% and life expectancy of at least 5 years PLUS

  • surgically accessible lesion
  • absence of clinically significant comorbid conditions
  • no prior ipsilateral endarterectomy

Neurosurgery Basics (21 decks)

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