Stroke

Question 1

MCA

Answer 1

Contralateral arms&raquo_space; legs weakness/numbness

L: aphasia
R: neglect, flat affect

Question 2

ACA

Answer 2

Contralateral legs&raquo_space; arms weakness/numbness

-mute, disinhibited, perseverative (executive function)

Question 3

PCA

Answer 3

Hemianopia (occipital lobe)

Memory loss (temporal lobe)

Question 4

Brainstem

Answer 4

CN deficits (diplopia, slurred speech, tongue deviation, vertigo, deafness)

Ipsilateral face and contralateral body weakness/numbness

Question 5

Lacunar Strokes (4 types)

Answer 5

1 - pure motor (posterior limb of internal capsule)

2- pure sensory (thalamic)

3 - ataxia-hemiparesis (contralateral ataxia and hemi-paresis&raquo_space; weakness)

4 - Dysarthria-Clumsy Hand (contralateral facial weakness –> slurred speech, contralateral loss of fine motor skills)

Question 6

Hemiballismus/Hemichorea

Answer 6

Subthalamic nucleaus stroke (PCOM)

contralateral limb flailing

Question 7

Cerebellar Stroke

Answer 7

Superior cerebellar artery (SCA), Anterior or posterior inferior cerebellar artery (AICA or PICA)

Ataxia, vertigo, nausea, vomiting, slurred speech

Question 8

NIHSS (12 parts)

Answer 8

Consciousness

Orientation to month and age

Blink eyes / squeeze hands

Horizontal gaze (EOM)

Visual fields

Facial palsy?

Drift in ea limb

Limb ataxia (if able to assess gait)

Sensation

Aphasia

Dysarthria

Inattention (spell WORLD)

Question 9

Mgt of Stroke

Answer 9

1 - ABCs, IV, O2, monitors

2- Fingerstick glucose

3- Hx - last seen well? DM/a fib/ stroke / HTN? On A/C? Trauma?

4 - CT head w/o contrast (r/o bleed and look for loss of gray-white differentiation)

5 - Move on to CT angio or MRI

6- Consider whether tPA candidate or intra-arterial intervention needed

7 - neuro and BP checks q 15 min while infusing tPA, then q 30 min x 6 hrs, q 60 min x 24 hrs (REPEAT CT IF ACUTE HEADACHE, N&V, inc BP)

Question 10

IV tPA Inclusion Criteria (9 clinical, 6 labs, 2 imaging)

Answer 10

0-4.5 hrs

• know exact time of onset
• no head trauma, stroke or MI in last 3 mo
• no GI or GU bleed in last 21 d
• no major surgery in last 14 d
• no arterial puncture at non-compressible site in 7 d
• no hx intracranial hemorrhage
• no hx SAH
• measurable neuro impairment w/o spontaneous recovery (NIHSS >4)
• no evidence of bleed, sz, post-ictal state on exam
• INR 1.7 or less, nl aPTT, plate >100,000, glucose 50+, systolic > 185, diastolic <110
• On CT head … no bleed, no hypodensity >1/3 hemisphere

Question 11

IV tPA Exclusion Criteria @ 3-4.5 hrs (4)

Answer 11

• age >80
• on oral A/C
• baseline NIHSS > 25
• hx of both DM and prior stroke

Question 12

Indications for Inter-arterial Intervention (4)

Answer 12

• large vessel occlusion (proven or presumed)
• < 24 hrs
• Min changes on CT head or less than would expect based on sx
• Last resort if cannot do tPA

Question 13

DAWN Trial

Answer 13

P: Pt both < and > 80 yo w/ low volume infarct via RAPID software

I: standard care + stent retriever

C: standard care alone

O: greater indep @ 90 days in intervention group

Question 14

DIFFUSE Trial

Answer 14

P: low volume infarcts (<70 ml) w/ ischemia:infarct ratio 1.8+ via RAPID software at 6–16 hrs after onset

I: standard care + thrombectomy

C: standard care

O: greater MRS and greater indep @ 90 d in intervention group