Neurology Flashcards
What are the symptoms of a lateral medularry syndrome (Wallenberg)
- Ipsilateral ataxia
- Ipsilateral horners
- Ipsilateral face loss of pain/temp sense
- Controlateral body loss of pain/temp sense
- Vertigo and nystagmus
- Dysphagia and horseness
- hiccups
What vessel is involved in Wallnenbergs
PICA or vertebral
What are the symptoms of a medial medullary syndrome?
- Ipsilateral tongue weakness
- Controlateral arm and leg weakness
- Controlateral body vibration and proprioception loss
What vessel is involved in medial medullary syndrome?
- Anterior spinal artery
What are the symptoms of a midbrain stroke. (Weber)
- Ipsilateral cranial nerve 3 palsy
- Controlateral hemiplegia
What vessel is involved in weber syndrome
PCA
What are the symptoms of an ACA stroke?
- Contralateral leg weakness
- Contralateral leg numbness
- Contralateral grasp reflex
- Other frontal signs
What are the symptoms of a Left MCA stroke in the superior branch
- Broca’s aphasia
- Right weakness in face & arms > legs
- Gaze deviation to the left
What are the symptoms of a left MCA stroke in the inferior branch?
- Wernicke’s aphasia
- Right cortical sensory loss
- Right “pie in the sky”
- R homonymous superior quandrantonopsia
What are the symptoms of a left MCA stroke in the main branch?
- Combination of supperior and inferior branch MCA stroke
- Global aphasia
What are the symptoms of a right MCA stroke, superior branch?
- Left weakness: Face + arm
- Gaze deviation to right
What are the symptoms of a right MCA stroke in the inferior branch?
- Left cortical sensory loss
- Left hemineglect
- Left “pie in the sky”
- left homonymous superior quandrantonopsia
What are the symptoms of a right MCA stroke in thee main branch?
Combination of supperior and inferiot branch
What are the symptoms of a PCA stroke
Controlateral homonymous hemianopsia
What types of stroke can cause pure motor symptoms. What artery is associated with each
- Lacunar strokes
- Posterior limb internal capsule
- Anterior choroidal
- Corona Radiata
- Small MCA branch
- Midbrain – cerebral peduncle
- Small PCA branch
- Ventral pons
- Basilar
- Posterior limb internal capsule
What stroke causes pure sensory deficits and what artery is involved?
- Thalamus
- thalamoperforators from PCA, MCA
What workup should be done for a non-disabling stroke presenting >24hrs to an outpatient setting?
- CT or MRI head
- Ideally CTA or MRA of aortic arch to vertex
- Carotid dopplers are ok but can miss intracranial disease or posterior circulation problems
- Basic BW
- CBC
- lytes
- PTT, INR
- Cr
- Glucose
- Lipids
- A1C
- ECG
- Holter ≥24hrs
- 2 weeks if suspicion of cardioembolic disease
- If suspected embolic stroke or TIA of uncertain cause, ECHO
- If <60, bubble study for ?PFO
How should a patient presenting to the ER with stroke symptoms since less that 24hrs be worked up?
- Immediate evaluation for tPA or EVT
- ABCs + NIHSS + evaluate/treat seizures if present
- Basic bloodwork
- CBC
- Lytes/cr
- glucose
- INR/PTT
- Imaging
- If Sx <4.5 hrs
- CT head. Determine if tPA candidate
- If Sx < 6 hrs
- CT, CTA arch to vertex, determine if EVT candidate
- if Sx 6-14hrs and eligible for late window EVT
- CT, CTA, CT Perfusion
- If Sx <4.5 hrs
What are the tPA inclusion criteria?
- Ischemic stroke causing disabling neurological deficits in patient > 18 years old
- Time from last known well <4.5 hrs
What are the absolute tPA exclusion criteria
- Any source of active hemorrhage
- Any condition that can increase the risk of major hemorrhage with tPA
- If on DOAC, cannot give tPA (Can still get EVT)
- Any hemorrhage on brain imaging
What are the relative tPA exclusion criteria?
- Historical
- Hx intracranial hemorrhage
- Stroke or serious head or spinal trauma in last 3 months
- Major surgery, such as cardiac, thoracic, abdominal, orthopedic in last 14 days. risk varies by procedure
- Arterial puncture at non-compressible site in last 7 days
- Clinical
- Sx suggestive of subarachnoid hemorrhage
- Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd’s paralysis or focal neuro signs 2/2 severe hypo/hyper glycemia
- Hypertension refractory to aggressive hyperacute antihypertensive Tx such that target BP 180/105 cannot be achieved or maintained.
- CT MRI findings
- early signs of extensive infarction
- Lab
- BG <2.7 or above 22.2
- Elevated APTT
- INR>1.7
- plt <100
What is considered a dissabling neurological deficit in the context of stroke?
- Judgement call biu in general:
- NIHSS ≥6
- Dissabling =
- aphasia
- hemianopsia
- weakness limiting sustained effort against gravity
- visual/sensoory extinction
What are the EVT inclusion criteria?
- >18 years of age
- Dissabling stroke AND functionally independent AND life expectancy >3 months
- <6hrs from Sx onset or last known well
- 6-24hrs in highly selected patients (clinical and imaging criteria)
- CT head: small to moderate ischemic core
- CTA showing occlusion in the anterior circulation of proximal large vessels (distal MCA or ICA)
- No evidence for EVT in proximal posterior circulation stroke but can consider it for basilar thrombus because of the high risk of morbidity/mortality
What are the target blood pressures in acute ischemic stroke
- tPA: 180/105 for 24hrs
- tPA and EVT: 180/105 for 24hrs
- no tPA: 220/120
- EVT only: Whatever the EVTer wants… ?220/120



















