Stroke Flashcards
Criteria for tPA
within 3 hrs of sxs, adult (not elderly), neg CTH for blood, SBP <185, INR <1.7, plt >100k, stroke territory involves <1/3 of MCA territory
INR for cardiac embolic cause of stroke
2-3
thromboembolism from carotid stenosis use
ASA/dipyridamole
if carotid stenosis >70% and symptomatic
CEA
If thrombotic stroke use
ASA 81 mg
What vessel connects posterior and anterior circulation together
posterior communicating artery
what connects bilateral ACAs
A comm
what connects LV to 3rd ventricle?
foramen of monroe
what connects 3rd and 4th Ventricles
cerebral aqueduct
What comes off of 4th ventricle
foramen of Magendie (medial)
Luschka (lateral
then goes back up to the Lateral ventricle
medial lemniscus
touch and proprioception and vibration (midline)
Lesion of MLF
ipsilateral internuclear ophthalmoplegia (left lesion, left eye cannot adduct to the other side)
midline CN motor nuclei (divide evenly by 12)
3,4,6,12
lateral brainstem structures
spinothalamic tract (contralateral body temp/pain loss), spinocerebellar tract (ipsilateral cerebellar ataxia) sensory nucleus of CN 5 (ipsilateral deficit of pain/temp on face), sympathetic pathway (ipsilateral horner syndrome, ptosis, miosis, anhydrosis)
ACA stroke
leg > arm weakness, incontinence, if bilateral then exectuive function and personality deficits
MCA stroke
conotrallateral face, arm , hand weakness /numbness with either aphasia (lef) or hemineglect (right), usually due to cardiac emboli,
superior div MCA stroke
superior division broca aphasia, with contralateral upper limb weakness
inferior div MCA stroke
wernicke aphasia or contralateral hemineglect
transcortical aphasias
transcontinental railroad, you can repeat [that trip]!!!
mixed transcortical
non fluent, cannot comprehend, CAN repeat
conduction aphasia
fluent, can comprehend, cannot repeat , damage to arcuate fasiculus between Broca and Wernicke area
melodic intonation
recruit right sided brain to help with left lesions, helps with brocas aphasia
PCA stroke
contralateral homonymous hemianopia , bilateral anton syndrome (bilateral visual cortex stroke cortical blindness)…can also get alexia, transcortical SENSORY aphasia, prospagnosia (face recognition problems), CN3 and 4 deficits.
ALEXIA without agraphia
lesion of optic chiasm
bitemporal hemianopia
stroke in subthalamic nucleus gives you
stroke in caudate nucleus
contralateral hemiballimus contralateral hemichorea ( Benedikt syndrome can cause a contralateral chorea as it affects the red nucleus. The red nucleus contributes to coordination and body positioning.)
Dysarthria clumsy hand syndrome lesion
contralateral pontine lesion- PONS
Wallenberg syndrome
lateral medullary syndrome
Dr. Horner Wallenberg at the VA says dont PICA horse that cant eat (Va/PICA stroke, hoarse voice CN 9, dysphagia CN 10, ipsilateral Horner synd, may have cerebellar ataxia (PICA is cerebellar artery)…..no weakness! lateral structure!!
Weber syndrome
Im paralyzed by 3 webs
contralateral hemiparesis, ipsilateral CN 3 palsy, medial midbrain lesion, if its midbrain it’s probably PCA culprit
can also have parkinson features if involvement of substantia nigra
Medial medullary syndrome
you lick your wounds (CN 12), medial in the medulla is motor pathway so contralateral hemiparesis, medial lin the medulla has medial lemniscus so contralateral numbness…insult of penetrating branches of vertebral artery or anterior spinal artery.
Locked in syndrome
basilar artery occlusion, RAS and consciousness is ok, tetraplegia with spared ability to move the eyes vertically and blink
Rood technique
applying stretch, heat , ice “that’s rood” applying cutaneous stimuli to help promote recovery
Proprioceptive neuromuscular facilitation
using diagonal movements with eyes closed
Contraint induced movement therapy
restraining the good limb and using the bad limb, will not work with hemineglect, need 10 deg active wrist extension and also need to voluntarily move fingers
tongue and soft palate rise as tongue compresses bolus and sents into esoph, tongue moves posterior to delivery bolus to esoph
oral phase, voluntary
aspiration happens in what phase
pharyngeal phase , involuntary
Fiberoptic endoscopic eval
direct visual of swallowing, limited by presence of scope , MBSS is gold stand
intention tremor is a what lesion
cerebellar lesion
PD tremor
resting tremor, pill rolling , 3-5 hz
dystonia treatment
some small percentage have dopa responsive dystonia, botox
anterocollils culprit
b/l SCM
retrocollis culprit
bilateral splenius capitis, spinal erectors
torticollis culprit
contralateral SCM, ipsi splenius capitis, levator scapula
Hunt Hess Scale
SAH:
Grade 1: roughly asymptomatic (potentially mild symptoms) with no neurologic deficits. Grade 2: Severe headache, neck stiffness are present with no major neurologic deficit or confusion. Grade 3: Headache, neck stiffness, confusion, with focal neurologic deficit. Grade 4: Extremely confused (think heavily inebriated), headache, neck stiffness, with severe focal neurologic deficit. Grade 5: coma.
Side effects of phenobarbital
Phenobarbital is often associated with dizziness, irritability, confusion, rash, and cerebellar signs. Apparently also gingival hyperplasia but this is classic for phenytoin
Side effects of gabapentin
fatigue, somnolence, ataxia, dizziness
Bobath
inhibit primitive reflexes, work from proximal to distal muscles
wheelchair for hemiplegic patient
Hemi-height chairs are made lower to the ground and allow the user to propel the chair with the unaffected arm and leg. Fixed leg rests would be inappropriate for individuals propelling wheelchairs with their lower limbs. Tilt-in-space systems (entire seat and back are tilted posteriorly as a single unit) pre
Carotid artery stenosis guidelines
carotid artery comes off subclavian artery
For men with recently symptomatic carotid stenosis of 50 to 69 percent, who have a life expectancy of at least five years, CEA is suggested rather than medical management (Grade 2A).
For women with recently symptomatic carotid stenosis of 50 to 69 percent, medical management rather than CEA is suggested.
For patients with recently symptomatic carotid stenosis of 70 to 99 percent who have a life expectancy of at least five years, CEA is recommended rather than medical management alone (Grade 1A).
transcranial magnetic stimulation to the un-injured hemisphere in stroke patients showed improvement in what?
Aphasia
Prolonged PTA puts you at increased risk for
late post traumatic seizures
palatal myoclonus involves what area of brain
The central tegmental tract
which structure is responsible for voice hoarseness and dysphagia
Nucleus ambiguous which affects CN 9 and 10
Unfavorable outcome after stroke is seen with
poor sitting balance, prior stroke, coma at onset, significant cardiovascular disease, unilateral hemineglect, poor upper extremity motor function, older age, bowel and bladder incontinence, lack of motor recovery after 1 month, and greater severity of stroke.
obstruction of the paramedian branches of the posterior cerebral artery. It causes ipsilateral cranial nerve (CN) III paralysis (hence the ptosis, and dilated, downward, and out pupil) and contralateral hemiplegia.
weber syndrome
caused by lesions to the basilar artery and results in ipsilateral CN VI and CN VII palsies with contralateral hemiplegia (lateral rectus and facial muscles)…
Millard-Gubler syndrome
anomic aphasia area
temporo parietal injury, angular gyrus….fluent, good comprehension and repitition, but decreased output of nouns and word finding difficulties….alexia and agraphia may be present
Huntington manifestation, speech and other
Persons with Huntington’s disease often display psychiatric conditions as the first manifestation of their illness. Sometimes psychosis develops and depression is common. Movements may appear fidgety, but ultimately a choreoathetoid movement disorder develops. Speech rate and loudness become variable, and articulation becomes increasingly imprecise (hyperkinetic dysarthria).
Muscles for swallowing
soft palate elevation
laryngeal elevation
adduction of vocal cords to protect airway
coordinated pharyngeal constriction and cricopharyngeal relaxation
The cricopharyngeus (needs to relax for swallowing) pharyngeal constriction.
pharyngeal phase is reflexion, short , bolus propelled into esophagus , req soft palate elevation, laryngeal elevation, and coordination of pharyngeal constriction and cricopharyngeal relaxation
transcortical motor area
frontal lobe, anterior or superior to broccas area or in subcorticl region deep to broca area
prevention of secondary vasospasm after sah/ich
nimodipine x21 days
blood on T2
dark
infarction on T2
bright white
INR goal for cardiac cause of stroke
INR 2-3, can also use Xa /direct thrombin inhibitor (rivaroxaban, apixaban, dabigatran)
if thromboembolism from carotid stenosis, what pharm combo
ASA and dipyridamole
if thrombotic stroke, secondary prevention with
asa 81 mg
motor neucleu
CN 3,4,6,12
dysphagia I, II, III
I: Puree, no chewing
II: mechanically altered
III: soft, some chewing required
watershed lesion that isolatse brocas and wernicke’s areas, lesion to the posterior INFERIOR temporal lobe
perisylvian speech centers, transcortical sensory aphasiaa….
lesion to arcuate fasiculus (parietal operculum)
conduction aphasia- normal fluency, normal comprehension and impaired repetition.
lesion to the border zone of frontal, parietal and temporal areas would produce
transcortical mixed aphasia- imapaired fluency, impaired comprehension, normal repetition.
blood in the sylvian fissures, basal cisterns, or intrahemispheric fissue typically indicate ** aneurysm as opposed to traumatic cause
saccular aneurysm rupture (for SAH)
obstruction of interpenducular branches of posterior cerebral artery or posterior chorodial artery or both causes what
weber syndrome (ipsilateral CN 3, contralateral hemiparesis , contralateral parkinson’s signs
are of brain for wernicke’s aphasia
posterior superior temporal gyrus
area of brain for brocas area
posterior inferior frontal lobe
contraindictation to tPA BP and blood glucose
BP >185/110, glucse <5o or >400
vertebral artery stroke
crossed signs (motor/sensory deficits on ipsi face and contra body) nystagmus, vertigo, absence of cortical signs (aphasias/cog deficit)
Which segment of the MCA supplies the subcortical structures?
M1
vertebral artery comes off of
subclavian artery
Antihypertensive med initiated at what MAP?
130 mmHg
A large, typically left MCA stroke that involves the perisylvian region will likely result in what type of aphasia
global aphasia
what area of stroke is most associated with seizure?
temporal
With an upper division MCA stroke, the inferolateral portion of the primary motor cortex is affected. Therefore, the legs or arms will be more affected????
what about a lower division MCA stroke????
legs will be stronger than the arms and face.
lower division strokes are usually without motor or sensory impairment. However, language, visual deficits and awareness of deficits are usually significant.
