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PassPMR - 01 Stroke > Chapter 1 - Medical Knowledge > Flashcards

Chapter 1 - Medical Knowledge Flashcards

1. Anatomy of Brain (Lobes & Blood Supply) 2. Risk Factors 3. Etiology: Ischemic Stroke & Hemorrhagic Stroke 4. Acute Medical Management - Investigations - ICP Management - Thrombolytic Therapy - Antihypertensive Therapy - Anticoagulation Therapy - Antiplatelet Therapy - Deep Venous Thrombosis

1
Q

What regions are supplied by the anterior cerebral artery ACA (3), middle cerebral artery MCA (3), and posterior cerebral artery PCA (2)? 🔑🔑

A

Anterior cerebral artery

  1. Medial cerebral hemispheres
  2. Superior frontal lobes
  3. Superior parietal lobes
  4. Internal capsule

Middle cerebral artery

  1. Inferiorlateral frontal lobe
  2. Inferolateral parietal lobe
  3. Lateral temporal lobe
  4. Internal capsule

Posterior cerebral artery

  1. Medial temporal lobe (posterior inferior surface)
  2. Occipital lobes (visual cortex)
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2
Q

Draw Arterial Blood Supply to the Brain 🔑🔑

A

ANTERIOR CIRCULATION

💡 Cerebral hemispheres

Origin: Internal Carotid Artery

  1. Ophthalmic artery
  2. Anterior choroidal artery
  3. Middle cerebral artery (MCA)
    • Lateral lenticulostriate arteries
      Lacunar strokes, suppling posterior limb of internal capsule
  4. Anterior cerebral artery (ACA)
    • Medial lenticulostriate arteries
      Suppling head of the caudate and anterior inferior internal capsule)

POSTERIOR CIRCULATION

💡 Brain stem and posterior hemispheres

Origin: Anterior Spinal & Vertebo-basilar Artery

  1. Vertebro-basilar Artery
    • Posterior inferior cerebellar artery (PICA)
    • Anterior inferior cerebellar artery (AICA)
    • Pontine Artery
    • Superior cerebellar artery (SCA)
  2. Posterior cerebral artery (PCA)
    • Posterior choroidal arteries
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3
Q

Blood supply to brainstem 🔑

A

Midbrain

  1. Superior cerebellar artery (SCA)
  2. Basilar artery
  3. Posterior cerebral artery (PCA)

Pons

  1. Superior cerebellar artery (Medial branches)
  2. Basilar Artery (Pontine branches)

Medulla

  1. Posterior inferior cerebellar artery (PICA)
  2. Vertebral artery branches
  3. Anterior spinal artery
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4
Q

Blood supply for primary motor and sensory areas for the right lower extremity. 🔑🔑
Blood supply for Broca’s and Wernicke’s language areas 🔑🔑

A

Left middle cerebral artery (MCA)

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5
Q

Blood supply for Broca’s and Wernicke’s language areas 🔑🔑

A

Dominant (Left) middle cerebral artery (MCA)

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6
Q

Coronal Cerebral and Circulation Anatomy 🔑

A

Coronal Cerebral and Circulation Anatomy 🔑

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7
Q

Circulation Coronal view Cerebral Hemisphere 🔑

A

Circulation Coronal view Cerebral Hemisphere 🔑

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8
Q

What are some hypercoagulable states that can increase the risk of stroke? List 4

A
  1. increased hematocrit, RBC, fibrinogen
  2. protein C and S deficiencies
  3. Cancer
  4. sickle cell anemia
  5. antiphospholipid syndrome (APL).
  6. factor 5 leiden deficiency.
  7. antithrombin 3 deficiency.

Ref: Stroke recovery and rehab textbook pg 657, 382.

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9
Q

What is the definition of stroke? TIA?

A

BRADDOM pg 1178:

“A nontraumatic brain injury caused by occlusion or rupture of cerebral blood vessels that results in sudden neurologic deficit characterized by loss of motor control, altered sensation, cognitive or language impairment, disequilibrium, or coma.”

CUCCURULLO pg 1:

“A cerebrovascular event with rapidly developing clinical signs of focal or global disturbances of cerebral function with signs lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin.” WHO.

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10
Q

What is the most common type of stroke? 🔑🔑

What are the other types of ischemic stroke?

What are the features of each?

A

Thrombotic strokes (Large artery thrombosis) 48% of all strokes

  1. Thrombotic 48%
    • Thrombus formation led to occlusion
    • Occurs during sleep → early morning
    • 50% with preceding TIA
  2. Embolic 26%
    • 75% of cardiogenic emboli go to the brain (cardiac thrombus caused by AF)
    • Sudden, immediate presentation, seizures may occur at onset of stroke.
    • Occurs during waking hours
  3. Lacunar 13%
    • Small lesions (<15–20 mm)
    • Strong correlation with HTN (up to 81%)

Cuccurollo 4th Edition Chapter 1 Stroke pg7

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11
Q

Causes of cardiogenic embolic ischemic stroke 🔑

A
  1. Atrial fibrillation
  2. Post-MI
  3. Vegetations on heart valves (bacterial endocarditis)
  4. Prosthetic heart valves.
  5. Rheumatic heart disease (e.g., mitral stenosis)

Cuccurollo 4th Edition Chapter 1 pg8

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12
Q

Sources of embolic stroke other than cardiac. What other embolism? 🔑

A
  1. Fat (from fractured long bones)
  2. Air (in decompression sickness)
  3. Venous clot that passes through a PFO with shunt (paradoxical embolus).

Cuccurollo 4th Edition Chapter 1 Stroke pg8

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13
Q

Locations of lacunar infarctions 🔑🔑

A
  1. Caudate
  2. Putamen
  3. Thalamus
  4. Internal capsule / corona radiata
  5. Pons

Cuccurollo 4th Edition Chapter 1 Stroke pg7 Table 1-1

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14
Q

Why lacunar stroke have better prognosis? 🔑

A

Absence of higher cortical function involvement (language, dysphagia, apraxis, neglect, vision).

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15
Q

Subtype of hemorrhagic stroke.

A
  1. ICH—hypertensive 10%
  2. SAH—ruptured aneurysm 3%

Cuccurollo 4th Edition Chapter 1 Stroke pg7

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16
Q

Where do intracerebral hemorrhages from cerebral amyloid angiopathy (CAA) generally occur?

A

(A) Lobar hemorrhages.

Ref: Delisa pg 554.

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17
Q

List 6 causes of Hemorrhagic stroke. 🔑

A
  1. HTN (70%)
  2. Ruptured aneurysm
  3. Arteriovenous malformation(AVM)
  4. Blood dyscrasias/bleeding disorders
  5. Anticoagulants
  6. Tumors
  7. Vasculitis
  8. Drugs: Cocaine, methamphetamine
  9. ETOH
  10. Hemorrhagic transformation of ischemic stroke

Cuccurollo 4th Edition Chapter 1 Stroke pg16

Neurology Secrets 6th Edition Chapter 19 pg241

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18
Q

Risk factors for Subarachnoid Hemorrhage (the rarest stroke 3%)

A
  1. HTN
  2. Alcohol abuse
  3. Drug abuse (eg. cocaine)
  4. Smoking
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19
Q

List 3 locations most likely to develop an aneurysm

A
  1. Anterior communicating arteries (Acom)
  2. Posterior communicating arteries (Pcom)
  3. MCA
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20
Q

List 3 Locations where hypertensive intracerebral hemorrhages occur.

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21
Q

Criteria for Admission to a Comprehensive Rehabilitation Program 🔑🔑

A
  1. Significant persisting neurologic deficit
  2. Stable neurologic status
  3. Sufficient cognitive function to learn
  4. Sufficient communicative ability to engage with the therapists
  5. Physical ability to tolerate the active program (at least 3 h/d)
  6. Achievable therapeutic goals

DeLisa Chapter 23 Stroke pg559 Table 23.5

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22
Q

Most common causes of mortality 1 month after stroke. 🔑

A

💡 Cardiorespiratory arrest or brain

  1. Cerebral edema and herniation
  2. Aspiration Pneumonia
  3. Pulmonary Embolism
  4. Cardiac event (MI, arrhythmia, heart failure)

PMR Secrets 3th Edition Chapter 54 pg447

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23
Q

What pharmacological treatment would to prescribe for patient with previous stroke?

List 4 medication you would like start for newly admitted stroke patient.

A
  1. Anti-platelet: Aspirin +/- Plavix
  2. Anti-coagulant: mechanical heart valve or atrial fibrillation.
  3. Anti-lipid: Crestor 40-80mg
  4. ACE inhibitor: Zestril 10mg target <130/80

PMR Secrets 3rd Edition Chapter 54 pg444

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24
Q

What is the ABCD2 score? What is it used for?

A

ABCD2

It is a tool to triage patients with a TIA. It is one part of the process to determine how quickly a patient needs to be worked up for stroke.

A: Age > 60

B: Blood pressure > 140/90

C: Clinical signs: Unilateral weakness (2 points), just aphasia, no weakness (1 point)

D: Duration of symptoms: > 60 minutes (2 points), 10-59 minutes (1 point)

D: Diabetes

2 DAY STROKE RISK BASED ON SCORE:

0-3: 1%.

4-5: 4%.

6-7: 8%.

Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S. (2007) Lancet, 369, 283-292.

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25
Q

List 5 causes of early deterioration following ischemic stroke. 🔑🔑

A
  1. failure of collaterals.
  2. recurrent stroke.
  3. hemorrhagic transformation.
  4. cerebral edema.
  5. seizures.
  6. malignant MCA syndrome.
  7. infection.
  8. metabolic disturbance.
  9. venous thromboembolism.
  10. pulmonary edema.

Postgrad Med J2010;86:235e242.

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26
Q

Complications of angiography

A
  1. Aortic or carotid artery dissection
  2. Embolic stroke
  3. Vascular spasm
  4. Vascular occlusion

Cuccurollo 4th edition Chapter 1 Stroke pg21

27
Q

Cerebrospinal fluid (CSF) production and pathway

A

CSF circulates from the lateral ventricles to the foramina of Monro (interventricular foramina), third ventricle, aqueduct of Sylvius (cerebral aqueduct), fourth ventricle, foramen of Magendie (Median aperture) and foramina of Luschka (lateral apertures), and subarachnoid space over brain and spinal cord.

28
Q

What is elevated ICP? What is CPP?

A

Values ( H2O ⇒ 20 )

Normal ICP ranges from 5 to 15 mmHg (7.5 to 20 cm H2O)

Elevated ICP is >20 cm H2O for >10 minutes

Cerebral Perfusion Pressure (CPP)

Difference between the mean arterial pressure (MAP) and ICP.

CPP = MAP − ICP

CCP should be from 50 to 70 mm Hg to ensure cerebral blood flow

Values <50 mm Hg are associated with ischemia and poor outcome.

Neurology Secrets Chapter 19

Cuccurollo 4th Edition Chapter 1 Stroke pg23 ICP Management

29
Q

List 4 underlying factors exacerbating elevated ICP (things to correct) 🔑

A

Vitally unstable (BP, HR, O2, Temp)

  1. Hypoxia
  2. Hypercarbia
  3. Acidosis
  4. Hypotension
  5. Hypovolemia (Avoid glucose solutions)
  6. Hyperthermia

Cuccurollo 4th Edition Chapter 1 Stroke pg23

30
Q

List 4 factors might increase ICP. 🔑

A
  1. Turning head
  2. Loud noise
  3. Suction
  4. Elevated BP
  5. Vigorous physical therapy
  6. Chest physiotherapy

Cuccurollo 4th Edition Chapter 1 Stroke pg23

31
Q

List 4 methods to reduce elevated ICP

A
  1. Positioning Elevate head of bed to 30
  2. Hyperventilation
  3. Hyperosmolar therapy with mannitol
  4. Neurosurgical decompression

Cuccurollo 4th Edition Chapter 1 Stroke pg23

32
Q

List 4 symptoms of elevated ICP.

A
  1. Headache
  2. Visual disturbance, photophobia
  3. Nausea, Vomoting
  4. Stupor
  5. Coma
  6. Respiratory abnormalities

Braddom Chapter 43

33
Q

List 4 signs of elevated ICP.

A

💡 Neuro Examination: GCS, CN, Limb

  1. Decreased LOC (GCS)
  2. Papilledema
  3. Diplopia
  4. Motor and sensory deficit
34
Q

List 4 ways to monitor elevated ICP?

A
  1. CT scan
  2. Papilledema
  3. Lumbar puncture (LP) if no papilledema
  4. Intraventricular ICP monitoring

Cuccurollo Chapter 2

35
Q

What are contraindications to intravenous tissue plasminogen activator? 8 🔑🔑

A

Neurology Secrets 6th Edition Chapter 18 Stroke

36
Q

Target blood pressure for stroke vs DM? 🔑🔑 EXAM

A

Previous stroke/TIA target BP <140/90 mmHg

DM/non-diabetic chronic kidney disease <130/80 mmHg.

37
Q

List 4 non-pharmacologic interventions to manage hypertension.🔑

A
  1. Exercise: moderate intensity accumulative 30-60 minutes/day x 4-7 days/week (Grade D)
  2. Weight loss (D)
  3. Reduce alcohol consumption (low risk drinking guidelines - <14/week for men, <9/week for women) (B)
  4. Dietary changes (DASH diet): emphasize fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources reduced in saturated fat and cholesterol (B)
  5. Controlled sodium: 1500mg/day = 50yo, 1300mg/day 51-70yo, 1200mg/day >70yo (B)
  6. Stress management: individualized cognitive behavioural interventions and relaxation techniques (B)

Ref: 2013 CHEP guidelines for HTN

https://www.ahajournals.org/doi/full/10.1161/JAHA.120.016804

https://www.aafp.org/afp/2006/0601/p1953.html

38
Q

What is the targeted blood pressure in the acute stroke setting (<72 hours) 🔑🔑

A

PATIENTS ELIGIBLE FOR THROMBOLYTIC THERAPY:

  • Treat BP if >185/110 mmHg in pts receiving thrombolytic therapy

PATIENTS NOT ELIGIBLE FOR THROMBOLYTIC THERAPY

  • Treat extremely high Bps (SBP >220 or DBP > 120 mmHg).
  • Reduce BP by 15%.
  • Do not reduce by more than 25% over the first 24 hr period (may worsen/induce ischemia)

Ref: 2011 CHEP recommendations for management of HTN pg 25-26.

39
Q

Name 2 indications of warfarin after stroke.🔑

A
  1. Cardiac arrhythmia (atrial fibrillation).
  2. Mechanical heart valve
  3. Clot/thrombosis (PE or DVT).

Medscape website.

40
Q

List 4 Anticoagulation agents and their mechanism of action 🔑

A
  1. Warfarin (Coumadin) inhibits vitamin K–dependent coagulation factors
  2. Dabigatran (Pradaxa) is a direct thrombin inhibitor
  3. Rivaroxaban (Xarelto) is a factor Xa inhibitor
  4. Apixaban (Eliquis) is a factor Xa inhibitor

Cuccurollo 4th Edition Chapter 4 Stroke pg25

41
Q

List 4 contraindications to warfarin for primary stroke prevention in Pt with non-valvular A.fib.🔑🔑

A
  1. Severe/active bleeding diathesis.
  2. Non-adherence to medication & INR monitoring.
  3. Pregnancy (1st trimester and at least 4 weeks before delivery).
  4. Allergy/intolerance to warfarin.
  5. Malignant hypertension
42
Q

How long will you keep patient on dual therapy? 🔑🔑

A

In patients presenting with minor stroke, treatment for 21 days with dual antiplatelet therapy (aspirin and clopidogrel) that is started within 24 hours can be beneficial for early secondary stroke prevention for a period of up to 90 days from symptom onset.

Cuccurollo 4th Edition Chapter 1 Stroke pg26

43
Q

List 3 anti-platelets with mechanism of action.🔑🔑 EXAM

A
  1. Aspirin
    Irreversible inhibition of COX-1 and modifies the enzyme activity of COX-2
  2. Clopidogrel (Plavix)
    Inhibitor of ADP-induced platelet aggregation acting by direct inhibition of adenosine diphosphate (ADP) binding to its receptor and of the subsequent ADP-mediated activation of the glycoprotein GPIIb/Ila complex.
  3. Abciximab
    Glycoprotein IIb/IIIa receptor antagonis
44
Q

Virchow’s Triad 🔑🔑

A
  1. Hypercoagulability
  2. Venous stasis
  3. Endothelial injury
45
Q

Negative diagnosis for DVT. How to rule out DVT?

A

💡 Negative on assessment (wells) and investigations.

  1. Wells → Low clinical suspicion for DVT
  2. D-dimer test → Negative
  3. Venous ultrasound → Normal
46
Q

List 6 Risk factors for DVT 🔑🔑

A
  1. OCP
  2. Immobility
  3. Obesity
  4. Pregnancy
  5. Malignancy
  6. Coagulopathy
  7. Trauma
  8. Surgery
47
Q

List 4 diagnostic tools for DVT 🔑

A
  1. Wells Criteria
  2. Venous Ultrasound
  3. D-Dimer
  4. Contrast venography
48
Q

Treatment of Venous Thromboembolism

A
  1. Heparin Therapy
    1. LMHW 5000 IU S/C q8h
    2. Clexane 40mg/0.4ml S/C OD
    3. Paradexa 150mg PO BID
    4. Xarelto 15mg PO BID 3 weeks → 20mg PO BID
  2. Warfarin INR 2-3
  3. Compression stockings (pneumatic)
49
Q

Recently admitted patient with hemiparesis post stroke. Patient is on LMWH (Clexane) as prophylactic anticoagulation. When do you consider stopping Clexane? 🔑🔑

A

It is common practice to use ambulation of 150 ft (45 meter) as the threshold to discontinue prophylactic anticoagulation.

In PMR hospital we have parallel bar which measure 10 meter for full cycle x 5 = 50 meter.

Braddom 6th Edition Chapter 44 Stroke pg963

50
Q

Which vessels make up the circle of Willis? 🔑🔑

A

Anterior circulation (internal carotid)

  1. Middle cerebral arteries
  2. Anterior communicating artery
  3. Anterior cerebral arteries

Posterior circulation (basilar artery)

  1. Posterior cerebral arteries.
  2. Posterior communicating artery

Neurology Secrets 6th Edition Chapter 2 Clinical Neuroanatomy

Braddom 6th Edition Chapter 44 Stroke Rehabilitation pg956

51
Q

Carotid endarterectomy in Stroke 🔑🔑

A

Symptomatic Carotid Stenosis

  • Some benefit for 50% to 69% symptomatic stenosis (absolute risk reduction 4.6%)
  • Highly beneficial for 70% to 99% stenosis (absolute risk reduction 16.0%)
  • CEA for symptomatic lesions with >70% stenosis (70%–99%) is effective in reducing the incidence of ipsilateral hemisphere stroke

Asymptomatic Carotid Stenosis

  • Recommendation that it be considered for asymptomatic patients with stenoses of 60% to 99%
  • Reduces the risk of ipsilateral stroke and any stroke by approximately 30% over 3 years
  • Absolute risk reduction is small (approximately 1% annually over the first few years of follow-up)
  • The evidence for carotid endarterectomy is less compelling for patients with asymptomatic carotid stenosis

Carotid Stenting

  • Carotid stenting has been studied as an alternative to carotid endarterectomy, particularly in patients who may be at poor surgical risks.

Cuccurullo 4th Edition Chapter 1 Stroke pg2 & pg26

DeLisa 5th Edition Chapter 23 Stroke Rehab pg558

52
Q

List common contraindications to performing a lumbar puncture.

A
  1. Infection: cellulitis, abscess
  2. Space-occupying lesion
  3. Uncal, central, transtentorial, or cerebellar herniation
  4. Coagulopathy: thrombocytopenia, liver failure, anticoagulant use

Neurology Secrets 4th Edition Chapter 25 pg353 Q2

53
Q

Types of stroke 🔑🔑 OSCE

54
Q

List 8 etiologies/causes of elevated ICP

A

ANY STROKE

  1. Ischemic stroke
  2. Subarachnoid hemorrhage
  3. Intracerebral hemorrhage

PRESSURE

  1. Brain tumors
  2. Subdural hematoma
  3. Epidural hematoma
  4. Abscess
  5. Idiopathic intracranial hypertension

INFECTION

  1. Encephalitis
  2. Meningitis

ELECTROLYTES

  1. Hyponatremia
  2. Diabetic ketoacidosis

Neurology Secrets Chapter 19

55
Q

What are 4 indications for ICP monitoring in severe TBI patients?

A
  1. GCS <6 with deep coma
  2. GCS <8 with CT shows ICH
  3. GCS <8 with CT shows ↑ ICP
  4. GCS <12 with face and chest injury

Cuccurollo 4th edition Chapter 2 TBI pg72

56
Q

List 4 findings that raise the suspension of herniations 🔑 List four signs that suggest progressive increase in ICP.

A
  1. Hemiparesis or hemplegia (corticospinal tracts)
  2. Cheynes–Stokes pattern of breathing. (Respiratory center)
  3. Cushing’s triad (bradycardia, widened pulse pressure, irregular respirations).
  4. Altered mental status, coma or stupor (RAS)
  5. Papilledema
  6. Blown/Dilated pupil,
  7. Ocular palsies (CN 3, 4, 6).
  8. Decerebrate posturing (brainstem)

Braddom Chapter 43 6th Edition pg925

Smith, evaluation and mgmt of elevated ICP in adults – http://www.critical.med.ualberta.ca/en/FileArchive/~/media/criticalcare/Documents/EvaluationandManagementofElevatedIntracranialPressure.pdf.

57
Q

What is the Cushing’s triad? Hint: opposite of dehydration. 🔑

A

💡 Occurs during terminal brain herniation (High ICP)

  1. Severe hypertension
  2. Bradycardia
  3. Irregular respiration

Neurology Secrets Chapter 19

58
Q

CT findings in high ICP 🔑🔑

A
  1. Brain midline shift over 5 mm
  2. Ventricular effacement
  3. Sulcal effacement
  4. Compression of basal cisterns

ERABI Module 8 pg24

59
Q

List 3 contraindications for lumbar puncture. 🔑🔑

A
  1. Coagulopathy (increased INR)
  2. Increased ICP (tumour, brain injury)
  3. Infection over area of LP.
60
Q

List 6 ways to decrease ICP 🔑🔑

A

Non-Pharmacological

  1. Correction of underlying factors exacerbating elevated ICP
  2. Positioning: Avoid flat, supine position; instead, elevate head of bed to 30°.
  3. Hyperventilation: Reduces brain tissue PO2, Risk of metabolic acidosis
  4. Hypothermia: Active cooling to 32 to 34° C is used for refractory elevated ICP.
  5. Fluid Restriction: Avoid glucose solutions; use normal saline; maintain euvolemia.

Pharmacological

  1. Hyperosmolar therapy: Mannitol or hypertonic saline
  2. Furosemide (Lasix)
  3. Sedatives (propofol, pentobarbital) to decrease cerebral metabolism

Surgical

  1. Decompression Craniectomy

Cuccurollo 4th Edition Chapter 1 Stroke pg23 & Chapter 2 TBI pg73

61
Q

What is one concern for prolonged hyperventilation following an ABI? 🔑🔑

A

Metabolic acidosis

ERABI Module 8 pg15

62
Q

What two osmolar therapies are regularly used in clinical settings, despite mixed evidence on their efficacy?

A
  1. Hypertonic saline
  2. Mannitol

ERABI Module 8 pg15

63
Q

List 3 Locations most likely to develop an aneurysm. 🔑

List 3 Risk factors for aneurysmal rupture.

At what stage should surgical intervention be undertaken for asymptomatic intracerebral aneurysms?

A

LOCATIONS

  1. Anterior communicating arteries (Acom)
  2. Posterior communicating arteries (Pcom)
  3. MCA

RISK OF RUPTURE

  1. HTN
  2. Sudden rise in BP
  3. Smoking
  4. ETOH
  5. Size (>1.0 cm)
  6. Blood transfusions.

Ref: Stroke. 2005 Dec;36(12):2773-80. Epub 2005 Nov 10; Stroke 2003 Dec;34(12):2781; good review on dynamed article on subarachnoid hemorrhage.

OPERATION

10 mm in diameter due to increased risk of rupture

Ref: Delisa pg 554.

PassPMR - 01 Stroke (6 decks)

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