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PMR 01 - Stroke > Day 1 - Anatomy, Localization & Medical Managment > Flashcards

Day 1 - Anatomy, Localization & Medical Managment Flashcards

1
Q

4 Non-Modifiable Risk Factors 🔑🔑

A
  1. Age (55+) the single most important risk factor for stroke worldwide
  2. Sex (male > female)
  3. Race (African Americans 2× > Caucasians > Asians)
  4. Family history of stroke
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2
Q

4 Modifiable (Treatable) Risk Factors for Stroke 🔑🔑

A

Medical Conditions

  • Hypertension
  • Hyperlipidemia
  • Diabetes
  • Sleep apnea
  • History of TIA/prior stroke
  • Carotid stenosis (and carotid bruit)

Clot Forming Conditions

  • Atrial fibrillation (AF)
  • High-dose estrogens (birth control pills)
  • Systemic diseases associated with hypercoagulable states (cancer)

LifeStyle

  • Physical activity
  • Cigarette smoking
  • Ethyl alcohol (ETOH) abuse/cocaine use
  • Nutrition: Compliance with a Mediterranean-style diet that was higher in nuts and olive oil was associated with a reduced incidence of stroke

Cuccurollo Chapter 1

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3
Q

Mention the blood supply to the brain 🔑🔑

A
  1. The middle cerebral artery (MCA) → lateral aspect of the hemisphere.
  2. The anterior cerebral artery (ACA) → medial aspect of the hemisphere
  3. The posterior cerebral artery (PCA) → posterior inferior surface of the temporal lobe and the visual cortex.
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4
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.

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5
Q

Types of stroke

A

ISCHEMIC (87%)

  1. Thrombotic
    • Thrombus formation led to occlusion
    • Most common 48%
    • Occurs during sleep → early morning
    • 50% with preceding TIA
  2. Embolic
    • 75% of cardiogenic emboli go to the brain.
    • Sudden, immediate presentation
  3. Lacunar
    • Small lesions (<15–20 mm)
    • Strong correlation with HTN (up to 81%)

HEMORRHAGIC (13%)

  1. ICH—hypertensive
  2. SAH—ruptured aneurysm
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6
Q

10 Risk Factors for Poor Functional Outcome in Stroke 🔑

Patient - Stroke - Psych - Function

A

Patient

  • Old age
  • Medical comorbidity
  • Prior stroke

Psychosocial History

  • Unmarried
  • Unemployed
  • Depression
  • Poor social support

Functional History

  • Low FIM on admission to rehab
  • Inability to perform ADL
  • Poor sitting balance

Stroke

  • Coma at onset
  • Cognitive deficits
  • Large Lesion
  • Aphasia
  • Urinary incontinence
  • Bowel incontinence
  • Dense hemiplegia
  • Visuospatial perceptual deficits
  • Homonymous hemianopsia

Ref: PM&R Secrets 3rd Ed Page 454

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7
Q

Draw Arterial Blood Supply to the Brain (Circle of Willis). 🔑🔑

A
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8
Q

Superior vs Inferior MCA Division Involvement 🔑

A

Superior

  • Contralateral hemiparesis/ hemiplegia face and arm > leg.
  • Contralateral sensory loss face and arm > leg.
  • Left hemispheric: Broca’s aphasia, Apraxia, Dysphagia
  • Right hemispheric: hemineglect, constructional apraxia, dressing apraxia, anosognosia
  • Eyes towards the lesion

Inferior

  • Superior quantrantonopsia or homonymous hemianopsia (SQHH)
  • Left hemispheric: Wernicke’s aphasia
  • Right hemispheric: Left visual neglect
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9
Q

List 6 different findings in left & right MCA. (3 each)

A

Left

  • Aphasia
  • Apraxia
  • Dysphagia

Right

  • Neglect
  • Apraxia: dressing and construction
  • Anosognosia
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10
Q

Bilateral ACA Involvement

A

Patient sitting on floor peeing and can’t talk.

  1. Frontal lobe/personality dysfunction
  2. Aphasia
  3. Paraplegia
  4. Incontinence
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11
Q

Anterior Cerebral Artery (ACA) Clinical features 🔑

A

Remember anterior lobe: No motivation, micturition center, legs > arms, gait apraxia

  • Contralateral weakness/sensory loss (distal contralateral leg > upper extremity)
  • Eyes towards the lesion
  • Gait apraxia
  • Mutism (Abulia)
  • Urinary incontinence
  • Contralateral grasp reflex (primitive reflexes)
  • Paratonic rigidity
  • Transcortical motor aphasia (on left)
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12
Q

Posterior cerebellar artery supply which areas in the brain? (3)

A
  1. upper brainstem
  2. inferior parts of the temporal lobe
  3. medial parts of the occipital lobe.
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13
Q

Two cranial nerves supplied by PCA

A

Remember it supplies upper brainstem:

  • Oculomotor cranial nerve (CN3)
  • Trochlear (CN4) nuclei and nerves.
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14
Q

Clinical presentation of Posterior Cerebral Artery (PCA) Stroke.

A
  • Can’t recognize his visual loss → Visual agnosia
  • Can’t recognize faces → Prosopagnosia
  • Can’t recognize text → Alexia, Aphasia (TCS)
  • Vision: HH, Hallucinations
  • Impaired Memory
  • Contralateral sensory loss (Thlamus)
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15
Q

What deficits that are absent in posterior cerebral artery strokes?

A

Absent of cortical deficits (aphasia, apraxia, neglect)!

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16
Q

Clinical presentation of Vertebro-basilar Artery Stroke.

A

Ipsilateral C.N. and cerebellum + Contralateral body

  • Cranial nerves

CN lll, IV, VI → Dysconjugate gaze

CN V → Ipsilateral facial hemiparesis

CN VII → LMN Facial Palsy

CN VIII → Vertigo, Nystagmus

CN IX → Dysphagia

  • Cerebellum (Ataxia)
  • Crossed corticospinal tract
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17
Q

List 8 Symptoms and Site of Lesion of Wallenberg Syndrome

A

Ipsilateral (Face and Cerebellar)

  1. Horner’s syndrome (ptosis, anhidrosis, and miosis)
  2. Decrease in pain and temperature sensation on the ipsilateral face
  3. Cerebellar signs such as ataxia on ipsilateral extremities (patient falls to side of lesion)

Contralateral side (Eyes - Ear - Mouth - Body)

  1. Nystagmus, diplopia
  2. Vertigo, nausea, and vomiting
  3. Dysphagia, dysarthria, hoarseness, vocal cord paralysis
  4. Hiccups
  5. Decreased pain and temperature on contralateral body
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18
Q

Weber’s vs Benedikt’s syndrome

A

Weber (Web on my eye)

  • Ipsilateral oculomotor paralysis
    1. Dilated pupil
    2. Lateral gaze
    3. Ptosis
  • Contralateral hemiparesis (face and body)

Benedikt’s (Ataxic Web)

  • Ipsilateral oculomotor paralysis
  • Contralateral hemiparesis (face and body)
  • PLUS Contralateral limb ataxia (substantia nigra/red nucleus)
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19
Q

Pontine Infarction

A

Ipsilateral CN 5-6-7-8

Ipsilateral Cerebellar

Contralateral Cortico-Spinal

Contralateral Spino-Thalamic

20
Q

Raymond’s vs Millard-Gubler

A

Raymond 6 Letters

  • Abducens nerve palsy
  • Pyramidal Tract → Contralateral hemiparesis

Millard-Gubler 7+6 Letters

  • Abducens nerve palsy
  • Facial nerve palsy
  • Pyramidal Tract → Contralateral hemiparesis
21
Q

Medial Medullary Syndrom (3)

A
  1. Ipsilateral hypoglossal palsy (with deviation toward the side of the lesion)
  2. Contralateral hemiparesis
  3. Contralateral lemniscal sensory loss (proprioception and position sense)
22
Q

List 5 Lacunar Infarction Syndromes

23
Q

List 3 Signs of CN3 involvement

A
  1. Deviation of ipsilateral eye to lateral side (lateral or divergent strabismus) because of unopposed action of lateral rectus muscle.
  2. Ptosis
  3. Mydriasis (dilated pupil) and paralysis of accommodation due to interruption of parasympathetic fibers in CN3.
24
Q

Seizure post stroke, what is your 1st line of management?

A

Benzodiazepines

  • First-line agents for treating seizures
  • IV lorazepam or diazepam

If seizures do not respond to IV benzodiazepines, treat with long-acting anticonvulsants

  • Phenytoin—18 mg/kg
  • Phenobarbital—1,000 mg or 20 mg/kg
25
Q

What is elevated ICP? What is CPP?

A

Values

Normal ICP ranges from 5 to 15 mm Hg (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

50 to 70 mm Hg, and values <50 mm Hg are associated with ischemia and poor outcome.

Neurology Secrets Chapter 19

26
Q

List 4 factors exacerbating elevated ICP? “Vitally unstable”

A
  1. Hypercarbia → Acidosis
  2. Hypoxia
  3. Hyperthermia
  4. Hypotension
  5. Hypovolemia
27
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
28
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

29
Q

List 4 signs of elevated ICP.

A
  1. Decreased LOC (GCS)
  2. Papilledema
  3. Diplopia
  4. Motor and sensory deficit
30
Q

List 8 etiologies of elevated ICP

A
  1. Ischemic stroke
  2. Brain tumors
  3. Subarachnoid hemorrhage
  4. Intracerebral hemorrhage
  5. Subdural hematoma
  6. Epidural hematoma
  7. Abscess
  8. Encephalitis
  9. Meningitis
  10. Idiopathic intracranial hypertension
31
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

32
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 Chapter 2

33
Q

List 4 ways to monitor elevated ICP?

A
  • CT scan
  • Papilledema
  • Lumbar puncture (LP) if no papilledema
  • Intraventricular ICP monitoring

Cuccurollo Chapter 2

34
Q

Inclusion Criteria for tPA Use 🔑

A
  • Age 18 years or older
  • Informed consent of the patient
  • Time of symptom onset well established and is <4.5 hours
  • Patients with measurable neurologic deficits
  • Head CT negative for blood.
35
Q

8 Contraindications for anticoagulation

36
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
37
Q

Virchow’s Triad 🔑

A

Hypercoagulability

Hemodynamic changes (stasis/turbulence)

Endothelial injury

38
Q

Symptomatic pulmonary embolus presents with

A
  1. Tachycardia
  2. Tachypnea
  3. Fever.
  4. Hemoptysis
  5. Pleuritic chest pain
  6. Pleural friction rub
  7. Consolidation
39
Q

Treatment of Venous Thromboembolism

A
  1. LMHW 5000 IU S/C q8h
  2. Clexane 40mg/0.4ml S/C OD
  3. Warfarin INR 2-3
  4. Compression stockings
40
Q

List 6 medical complications after stroke

A
  1. Recurrent Stroke
  2. Seizure
  3. Fall
  4. DVT
  5. PE
  6. Pain
  7. Depression
  8. Anxiety
41
Q

Most common causes of mortality 1 month after stroke.

A

After stroke, 3 vital organs might get affected:

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

PMR Secrets

42
Q

What actions should be taken to prevent medical complications after stroke?

A
  1. Recurrent stroke → modifiable risk factors
  2. Aspiration pneumonia → swallowing assessment and manage accordingly
  3. DVT → LMWH, compression and stocking.

PMR Secrets

43
Q

Diagnosis and management of thalamic pain post stroke.

A

Sever disabling pain that is not responsive to treatment.

Signs are allodynia and hyperpathia

Treated by TCA (Amitriptyline) or Anticonvulsant (Gabapentin)

44
Q

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

A
  1. Anti platelet: Aspirin or Plavix
  2. Anti coagulant: if indicated
  3. Statin
  4. ACE inhibitor if hypertensive
45
Q

Locked in syndrome, location, risk factors & presentation 🔑🔑

A

Locations

  • bilateral ventral pontine lesions

Risk factors

  1. Pontine hemorrhage
  2. Trauma
  3. Central pontine myelinolysis
  4. Tumor
  5. Encephalitis.

Presentation

  1. Quadriplegia → Corticospinal
  2. Unable to speak and incapable of facial movement → Corticobulbar tracts.
  3. Horizontal eye movements → Intact CN VI
  4. Vertical eye movements and blinking → Intact CNIII
  5. Consciousness → Intact RAS

Neurology Secrets Chapter 9

PMR 01 - Stroke (8 decks)

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