Neurology (5%)

Question 1

Risk factors for carotid disease

Answer 1

HTN
DM
Smoking
Hypercholeseterolemia

Question 2

A pt with carotid disease may have a history of:

Answer 2

Stroke
TIA
Focal motor deficits, weakness, clumsiness, expressive or cognitive aphasia
May be reversible neurological deficits or fixed

Question 3

Treatment for carotid artery dissection

Answer 3

Anticoagulation for 3-6 mo

Question 4

Signs/Symptoms of carotid disease

Answer 4

Amaurosis Fugax (transient monocular blindness)
Hollenhorst Plaques (found in retinal exam - evidence of previous emboli)
Carotid bruit

Question 5

Amaurosis Fugax

Answer 5

Seen in carotid disease
Transient monocular blindness
Usually described as a shade being pulled down in front of pt’s eye
Due to occlusion of a branch of the ophthalmic artery

Question 6

Diagnosis for carotid disease

Answer 6

1. Carotid duplex screening

2. MRA (magnetic resonance angiogram) - best for degree of stenosis

Question 7

Management of carotid disease

Answer 7

1. Antiplatelet therapy with aspirin to prevent neurologic events
2. Endarterectomy (if indicated)

Question 8

Indications for endarterectomy

Answer 8

1. > 75% stenosis
2. > 70% stenosis and symptomatic
3. Bilateral dz and symptomatic
4. > 50% stenosis with recurrent TIAs despite aspirin therapy

Question 9

Major complications of endarterectomy

Answer 9

MI (major cause of death post-procedure)

Stroke

Question 10

Mechanism behind subarachnoid hemorrhage

Answer 10

Berry aneurysm rupture

Question 11

Signs/Symptoms of subarachnoid hemorrhage

Answer 11

Thunderclap H/A (worst of my life)
\+/- unilateral, occipital area
\+/- LOC, N/V
May have meningeal sx: stiff neck, photophobia, delirium
Usually no focal neurological deficits

Question 12

Diagnosis of subarachnoid hemorrhage

Answer 12

1. CT first
2. If CT negative, perform LP (looking for blood, increased pressure)
3. 4-vessel angiography after confirmed SAH

Question 13

Management of subarachnoid hemorrhage

Answer 13

1. Supportive: bed rest, stool softeners, lower ICP
2. Surgical coiling or clipping
3. +/- BP lowering (Nicardipine, Nimodipine, Labetalol)

Question 14

Mechanism behind subdural hematoma

Answer 14

Tearing of cortical bridging veins

Seen most commonly in the elderly

Question 15

Most common cause of subdural hematoma

Answer 15

Blunt trauma - often causes contrecoup bleeding

Question 16

Signs/Symptoms of subdural hematoma

Answer 16

Varies

May have focal neurological symptoms

Question 17

Diagnosis of subdural hematoma

Answer 17

CT (concave crescent shaped bleed)

Bleeding can cross suture lines

Question 18

Management of subdural hematoma

Answer 18

Hematoma evacuation vs. supportive

Evacuation if massive or > 5 mm midline shift

Question 19

Mechanism behind epidural hematoma

Answer 19

Middle meningeal artery

Most common after temporal bone fracture

Question 20

Signs/Symptoms of epidural hematoma

Answer 20

Brief LOC, lucid interval, coma
Headache, N/V, focal neuro sx, rhinorrhea (CSF fluid)
CN III palsy if tentorial herniation

Question 21

Diagnosis of epidural hematoma

Answer 21

1. CT (convex lens shaped bleed)

Will not cross suture lines, usually in temporal area

Question 22

Management of epidural hematoma

Answer 22

+/- herniation if not evacuated early
Observation if small
If increased ICP: mannitol, hyperventilation, head elevation +/- shunt

Question 23

80% of all strokes are __________, and are due to ________, ________, or ______ _________

Answer 23

Ischemic
Emboli
Thombus
Systemic hypoperfusion

Question 24

Signs/Symptoms of stroke

Answer 24

Abrupt onset of neurological abnormalities
Facial paresis
Arm drift/weakness
Abnormal speech

Question 25

Signs/Symptoms of hemorrhagic stroke

Answer 25

Headache LOC N/V

Question 26

Diagnostic testing of stroke

Answer 26

1. Non-contrast CT to r/o hemorrhage 2. LP if negative but still suspicious 3. MRI - localize extent of infarction (after 24 hrs)

Question 27

Other tests for stroke to r/o other dz:

Answer 27

1. Glucose - r/o hypoglycemia 2. O2 sats 3. EKG - r/o arrhythmia 4. CBC 5. Cardiac enzymes - r/o infarction 6. PT/PTT

Question 28

All patients who present within ______ hours of symptom onset should be offered TPA (ischemic stroke)

Answer 28

4.5 hours

Question 29

All presents who present after 4.5 hour window for ischemic stroke should be given:

Answer 29

Aspirin

Question 30

Patients who have ___________________ should not be given TPA

Answer 30

Rapidly improving stroke symptoms

Question 31

In ischemic stroke, blood pressure should be lowered in the case of:

Answer 31

1. Malignant hypertension 2. Myocardial ischemia 3. BP > 185/110 and if TPA will be administered

Question 32

Indications for mechanical thrombectomy in ischemic stroke

Answer 32

Occlusion of proximal anterior circulation No hemorrhage present Can be done w/n 6 hours

Question 33

Treatment for hemorrhagic stroke

Answer 33

BP therapy - goal is 160/90 Labetalol and nicardipine are 1st line If pt on anticoagulants, give reversal agent Surgical removal or hemorrhage should be done if hemorrhage is > 3 cm in diameter or if patient is deteriorating

Question 34

Ischemic Stroke Interventions:

Answer 34

1. ASA within 48 hours 2. Pneumatic compression stockings or heparin for VTE prophylaxis 3. Statin therapy 4. Smoking cessation

Question 35

Long Term Antiplatelet Therapy after ischemic stroke

Answer 35

Aspirin, clopidogrel, or aspirin-dipyridamole | If patient was previously on aspirin - switch to clopidogrel or add dipyridamole

Question 36

After stroke management (diagnostic modalities):

Answer 36

1. Echocardiogram - look for clot 2. EKG/Holter monitor - r/o AFib/arrhythmia 3. Carotid duplex US - r/o stenosis 4. Duplex Ultrasound, CTA or MRA or head/neck arteries - look for clot