Stroke Flashcards
Two main etiologies of stroke
Ischemic (80%) and hemorrhagic (20%)
What are the main causes of local arterial obstruction that lead to focal cerebral ischemia?
Atherosclerosis (e.g. rupture) Fibromuscular dysplasia Arteritis Dissection of arterial wall Coagulopathies Lipohyalinosis 2/2 HTN Migraine (?)
What can cause ischemic stroke secondary to impaired venous drainage?
Thrombosis of a cerebral sinus or vein, usually in patients with coagulopathy or who are severely dehydrated
What is hemorrhagic transformation?
After an ischemic stroke, the blood vessels in the area are more likely to rupture upon reperfusion, leading to hemorrhage
What usually causes parenchymal hemorrhages?
Rupture of small dilatations of penetrating arteries 2/2 chronic hypertension
What is the most common etiology of subarachnoid hemorrhage?
Ruptured berry aneurysm
What usually causes ischemic stroke?
Obstruction of an artery
What are the key presenting clinical features of stroke?
Acute, focal symptoms and signs
Clinical features of stroke in the MCA territory
Weakness in contralateral face, arm>leg
Sensory loss in contralateral face, arm>leg
Visual deficit in contralateral hemifield
Impaired gaze in contralateral direction
Aphasia if dominant hemisphere
Visuospatial impairment and neglect if non-dominant
Clinical features of stroke in the ACA territory
Weakness in contralateral leg>arm
Sensory loss in contralateral leg>arm
Deficits in attention and/or motivation
Clinical features of stroke in the PCA territory
Visual deficit in contralateral hemifield
If dominant hemisphere, alexia without agraphia
Clinical features of stroke in territory of the lateral medullary artery (e.g. Wallenberg’s syndrome)
Sensory loss in ipsilateral face and contralateral arm, leg, trunk Ipsilateral Horner's syndrome Ipsilateral ataxia Dysarthria and dysphagia Nystagmus Vertigo
Clinical features of stroke in territory of the medial medullary artery
Weakness of contralateral arm, leg
Sensory loss of contralateral arm, leg
Ipsilateral tongue weakness
Clinical features of pontine stroke
Weakness of ipsilateral face and contralateral leg and arm
Sensory loss of contralateral arm, leg, trunk and ipsilateral face
Impaired gaze in ipsilateral direction
Nystagmus
Ipsilateral Horner’s syndrome
Ataxia (ipsi or contra)
Clinical features of midbrain stroke
Contralateral hemiparesis
Ipsilateral CNIII palsy
+/- contralateral ataxia
Wallenberg’s syndrome?
- IPSI face reduced pain and temp
- Contra limbs and trunk reduced pain and temp
- IPSI Horner’s syndrome
- Dysarthria, dysphagia, ataxia, vertigo and nystagmus
Most common locations for lacunar infarcts?
Basal ganglia, thalamus, pons, or internal capsule
Presentation of subarachnoid hemorrhage
Acute severe headache
Meningeal signs
Management of acute stroke
- tPA within 4.5 hours of symptom onset
Other options: - Catheter-directed thrombolytics
- Thrombectomy
Most significant complication of acute stroke?
Increased ICP
Other complications of stroke?
Seizures
SIADH
Depression
Primary prevention of stroke
- Control BP in pts with HTN (ACEs and ARBs, man)
- Quit smoking
- Control diabetes, consider adding statin even if pt doesn’t have dyslipidemia
- Control lipids (STATINS!)
- Warfarin (or DOACs) for pts with AFib or mechanical heart valves
- CEA for pts with bad carotid disease
- Screen sickle cell patients using transcranial doppler, and transfuse if high risk of stroke
Secondary prevention of stroke in patients who have had a TIA or stroke
- Warfarin/DOAC if cardioembolic source
- CEA if carotid source
- Anti-platelet agents for everybody
- Statin if LDL-C >100 mg/dL
- See all the primary prevention stuff, which still applies to these patients
Secondary prevention of stroke caused by arterial dissection
Anti-coagulate for 3-6 months after stroke
Lenticulostriate artery supplies what structure? What would a lesion here show?
Striatum and internal capsule. Stroke —> contralateral hemiparesis/plegia
Medial medullary syndrome
Stroke of anterior spinal artery
Damage to lateral corticospinal tract –> contralateral hemiparesis in limbs
Damage to medial lemniscus –> loss of proprioception contralaterally
Damage to caudal medulla/CNXII –> tongue deviates toward lesion
Lateral medullary syndrome
Stroke of PICA
Lesions to CNVIII nucleus, spinal trigeminal nucleus, lateral spinothalamic tract, nucleus ambiguus, sympathetics, and inferior cerebellar peduncle –> vertigo, decreased pain and temp ipsi face and contra body, dysphagia, ipsilateral Horner’s syndrome, ataxia
Lateral pontine syndrome
Stroke of AICA
Lesions to CNVIII nucleus, CNVII nucleus, CNV nucleus, sympathetics, and middle and inferior cerebellar peduncles –> Vertigo, nystagmus, facial paralysis, decreased lacrimation/salivation, ipsilateral loss of pain and temp of face, contralateral loss of pain and temp of body, ataxia and dysmetria
Most common site of saccular (berry) aneurysm
Anterior communicating artery and anterior cerebral artery. Associated with ADPKD, Ehlers-Danlos
