Stroke Flashcards
Gerstmann syndrome
Dominant parietal lobe infarction (specifically the angular gyrus)
- Tetrad of:
- Agraphia
- Acalculia
- Left-right confusion
- Finger agnosia (inability to recognize one’s own fingers or the fingers of the examiner)
PICA stroke syndrome
- aka Wallenburg syndrome or Lateral medullary infarction syndrome
- Features:
- Ipsilateral bulbar palsy (dysphagia, dysphonia, hiccups, decreased gag reflex)
- Ipsilateral nystagmus and vertigo
- Contralateral decrease in pain and temperature sensations in the trunk and limbs
- Ipsilateral decrease in pain and temperature sensations in the face
- Ipsilateral limb ataxia and dysmetria
- Ipsilateral Horner syndrome
Stroke algorithm
TIA algorithm
Specific indication for TPA
Age > 18
Time from ischemic infarct within 3 hours
Non-contrast CT shows no evidence of hemorrhage
Only manage blood pressure in a patient with ischemic stroke if. . .
. . . blood pressure is >220 systolic, SEVERE
Deciding how to manage patients with TIA
ABCD2 score
Any patient with 3 or higher should be admitted for inpatient workup
Ischemic penumbra management
If a patient has a large proximal occlusion and a salvagable ischemic penumbra, there is evidence that endovascular treatment with embolectomy or intra-arterial tPA can save a significant amount of brain tissue
Todd’s paralysis
Brief period of paralysis folloing a seizure
On the ddx for acute stroke or TIA
Ischemic stroke is caused by ___, while hemorrhagic stroke is caused by ___.
Ischemic stroke is caused by vacsular insufficiency due to occlusion, while hemorrhagic stroke is caused by mass effect or cytotoxicity related to parenchymal hematoma.
Management of blood pressure in the ischemic stroke patient
- Allow permissive hypertension acutely
- Lower cautiously in days following acute event – abrupt lowering may exacerbate losses in the ischemic penumbra
- Avoid extreme or accelerated hypertension, which may put the patient at risk for hemorrhagic converison
Lacunar stroke syndromes (six)
- Pure motor
- Pure sensory
- Sensorimotor
- Ataxia-hemiparesis
- Dysarthria-Clumsy hand
- Hemiballismus
Lesions of the visual field
What visual defect is Wernicke’s aphasia most commonly associated with?
Right superior quadrantanopia
Aphasia localization
Meyer’s loop
Left MCA stroke syndrome
- Right-sided hemiparesis and sensory loss in the arm and lower face
- Aphasia
- Left gaze deviation (ipsilateral to infarct)
- Homonymous hemianopia OR superior OR inferior quadrantanopia (rare)
Right MCA stroke syndrome
- Left-sided hemiparesis and sensory loss in the arm and lower face
- Left-sided neglect
- Right gaze deviation (ipsilateral to infarct)
- Homonymous hemianopia OR superior OR inferior quadrantanopia (rare)
ACA stroke syndrome
- Contralateral hemiparesis and sensory loss in the lower limb
- Abulia
- Limb apraxia
- Urinary incontinence
- Dysarthria
- Transcortical motor aphasia (nonfluent, but comprehension and repetition are intact)
- Frontal release signs
Left PCA stroke syndrome
- Contralateral homonymous hemianopia with macular sparing
- Contralateral sensory loss (due to lateral thalamic involvement)
- Memory deficits
- Alexia without agraphia
- Dysnomia/anomic aphasia (inability to name)
- Agnosia (inability to recognize a sensory stimulus, usually visual)
Right PCA stroke syndrome
- Contralateral homonymous hemianopia with macular sparing
- Contralateral sensory loss (due to lateral thalamic involvement)
- Memory deficits
- Prosopagnosia (face blindness)
Features of thalamic injury
- Decreased level of arousal
- Variable sensory loss
- Aphasia
- Visual field losses
- Apathy
- Agitation
- Personality change
Lenticulostriate artery strokes
- aka Lacunar strokes or penetrating artery strokes
- More often caused by lipohyalinosis in the setting of hypertension or diabetes than by embolic occlusion
Basilar artery strokes
- Consciousness preserved if the reticular activating system is unaffected
-
Vertebrobasilar insufficiency:
- Vertigo, drop attacks, tinnitus, hiccups, dysarthria, dysphagia
- Ipsilateral cranial nerve deficits
- Diplopia
- Gait ataxia
- Paresthesias
- Pontine syndromes
- Cerebellar syndromes
AICA stroke syndrome
- aka the lateral pontine syndrome or Marie-Foix syndrome
- Features:
- Contralateral loss of pain and temperature sensation
- Ipsilateral limb and gait ataxia
- Ipsilateral loss of facial sensation to pain and temperature
- Ipsilateral facial weakness, loss of lacrimation and salivation, loss of taste sensation on anterior 2/3 of tongue
- Ipsilateral vertigo, nystagmus, hearing loss
- Ipsilateral Horner’s syndrome
Internal carotid artery stroke syndrome
- Ipsilateral amaurosis fugax or sudden onset blindness
- Dysphagia
- Ipsilateral tongue deviation
- Contralateral hemiparesis, paresthesias, hemisensory loss, homonymous hemanopsia, etc etc
Common carotid artery stroke syndrome
- Ipsilateral Horner’s syndrome
- Ipsilateral MCA stroke syndrome
Pure sensory lacunar stroke syndrome
- Most commonly involves the thalamus
- Caused by occlusion of lenticulostriate/penetrating artery
- Contralateral numbness and paresthesias of the arm, face, leg
Pure motor lacunar stroke syndrome
- Most commonly involves the posterior limb of the internal capsule
- Caused by lenticulostriate/penetrating artery occlusion
- Most common type of lacunar stroke
- Features:
- Contralateral hemiparesis of arm, face, leg
- Dysarthria
- No sensory impairment
Sensorimotor lacunar stroke syndrome
- Most commonly involves the posterior limb of the internal capsule
- Caused by lenticulostriate/penetrating artery occlusion
- Total contralateral hemiparesis and sensory impairment
Ataxia hemiparesis lacunar stroke syndrome
- Most commonly involves the posterior limb of the internal capsule
- Caused by lenticulostriate/penetrating artery occlusion
- Ipsilateral weakness and impaired coordination (ataxia, gait instability)
Dysarthria-Clumsy Hand Lacunar stroke syndrome
- Can involve the caudate, posterior limb of the internal capsule, putamen, or pontine base
- Caused by lenticulostriate/penetrating artery occlusion
- Dysarthria plus contralateral facial and hand weakness, but not leg weakness
Hemiballismus lacunar stroke syndrome
- May be caused by multiple locations of infarct, but NOT by the posterior limb of the internal capsule
- Caused by lenticulostriate/penetrating artery occlusion
- Contralateral, involuntary, large flinging movements of the arm or leg
Most common site of lacunar stroke infarct
Posterior limb of the internal capsule
This can produce any lacunar stroke syndrome EXCEPT hemiballismus
Ventral midbrain syndrome
- aka Weber syndrome
- Midbrain infarct syndrome
- Caused by PCA obstruction
- Affects occulomotor fibers + corticospinal tract
- Ipsilateral occulomotor palsy and contralateral hemiparesis
Claude syndrome
- Midbrain infarct syndrome
- Caused by PCA obstruction
- Affects occulomotor fibers + superior cerebellar peduncles and red nucleus
- Ipsilateral occulomotor palsy and contralateral ataxia
Paramedian midbrain syndrome
- Midbrain infarct syndrome
- Caused by PCA obstruction
- aka Benedikt syndrome
- Affects occulomotor fibers and both the corticospinal tract and superior cerebellar peduncles
- Basically a sum of Claude and Weber syndrome
- Ipsilateral occulomotor palsy, contralateral hemiparesis, and contralateral rubral tremor
- Rubral tremor: low frequency (< 4.5 Hz), large amplitude tremor that is present at rest and worsened by maintaining a posture, or by peforming specific activities (a combination of resting, postural, and intention tremor).
Dorsal midbrain syndrome
- aka Parinaud syndrome
- Midbrain infarct syndrome
- Caused by PCA obstruction. Also often results from compression, especially from pinealomas
- Occular abnormalities:
- Vertical gaze palsy
- Eyelid retraction
- Convergence-retraction nystagmus
- Pseudo-Argyll Robertson pupils
Nothnagel syndrome
- Midbrain infarct syndrome
- Caused by PCA obstruction. Also often results from compression, especially from pinealomas
- Affects the superior colliculi and superior cerebellar peduncle
- Ipsilateral or bilatreal occulomotor palsy and ipsilateral cerebellar ataxia
Midbrain syndromes (five)
- Weber syndrome
- Claude syndrome
- Benedikt syndrome
- Parinaud syndrome*
- Nothnagel syndrome*
- All caused by PCA occlusion.
- *Starred also caused by pinealomas
Pontine syndromes (four)
- Ventral pontine syndrome
- Lateral pontine syndrome
- Inferior medial pontine syndrome
- Locked-in syndrome
- Caused by different arteries depending upon level
Ventral pontine syndrome
- Pontine stroke syndrome
- Caused by basilar artery occlusion
- Ipsilateral facial nerve palsy
- Ipsilateral abducens palsy
- Contralateral hemiparesis
Inferior medial pontine syndrome
- Pontine stroke syndrome
- Caused by paramedian-basilar artery branch occlusion
- Contralateral hemiparesis, ipsilateral facial weakness, ipsilatreal abducens palsy, ipsilatreal internuclear ophthalmoplegia (aka injury to medial longitudinal fasciculus)
Medial medullary syndrome
- Caused by occlusion of branches of the anterior spinal artery or the vertebral arteries
- Ipsilateral tongue palsy (with ipsilateral deviation), contralateral hemiparesis, contralateral loss of proprioception
AMBOSS stroke pathway
Signs that raise suspicion for hemorrhagic stroke over ischemic stroke
- Headache
- Depressed level of consciousness
- Cushing’s triad
- Extreme elevation in blood pressure
Contraindications to tPA in the setting of stroke
- Active bleeding
- Recent history of stroke
- History of intracerebral hemorrhage
Secondary stroke prevention
- If in setting of afib: anticoagulation
- If no afib: antiplatelet regimen
- aspirin + clopidogrel OR aspirin + dipyridamole
- Screen for carotid stenosis
tPA must be administered within ___ of a stroke in order to be effective
tPA must be administered within 4.5 hours of a stroke in order to be effective
Endovascular/intra-arterial therapy must be performed within ___ of a stroke in order to be effective
Endovascular/intra-arterial therapy must be performed within 6 hours of a stroke in order to be effective
For patients who are eligible, __ is the best possible treatment for stroke
For patients who are eligible, thrombectomy is the best possible treatment for stroke
But, they have to have an LVO and be within 6 hours of occlusion
Patient has new onset R gaze preference, L sided neglect, L sided paralysis. Patient’s LKW time is 1 hour ago. CT is negative for hemorrhage. No contraindications to tPA or to contrast. What is the next step?
tPA, THEN angiography
After hemorrhage is ruled out, tPA should not be delayed for imaging
Most sensitive imaging technique for suspected ischemic stroke
MRI with DWI and ADC
Hyperintense on DWI, hypointense on ADC
Most sensitive imaging technique for small/micro hemorrhage
Gradient echo sequence-T2-weighted MRI
Where does the blood supply to the medial temporal lobe come from?
The PCA
NOT the MCA
Contraindicatinos to tPA
- Active major bleed
- Active anticoagulation
- Major surgery or TBI within last 10 days
- Non-disabling deficit (somewhat subjective)
- SBP > 185 mmHg
One lab that MUST be sent prior to administering tPA
Glucose
Since hypoglycemia can mimic stroke
Imaging in stroke
- Non-con CT
- CTA head and neck
- Sometimes CT perfusion scan (6-24 hours if there is question of the benefit of late thrombectomy)
Can you do thrombectomy after 6 hours from LKW?
Sometimes
It depends the results of the CT perfusion imaging. If there is a large ischemic penumbra, it is still worth doing.
“High risk TIA” recurrence risk management
- If carotid stenosis and not a candidate for endarterectomy by CTA, aspirin only as bridge to endarterectomy
- If carotid stenosis and not a candidate for endarterectomy by CTA, DAPT for 21 days followed by monotherapy
- If atrial fibrillation or DVT/paradoxical embolism, anticoagulation
- If APLS or mechanical heart valves, warfarin +/- aspirin
Brainstem vasculature
Note that the bottom artery is the anterior spinal artery, an important blood supply to the ventral medulla
Collier’s sign
Unilateral or bilteral eyelid retraction
Caused by dorsal midbrain lesions, such as Parinaud syndrome, Miller-Fisher syndrome, dorsal midbrain infarct, or sometimes MS or encephalitis.
INR cutoff for tPA eligibility
Must be < 1.7
Where does this syndrome localize?
Ataxia, nystagmus, ophthalmoplegia, amnesia, confabulation
The mammillary bodies
Seen in Wernicke-Korsakoff syndrome
Isolated vertical gaze paralysis
Likely a lesion to the superior colliculi
May suspect Parinaud syndrome
Contralateral paralysis, tongue deviates ipsilateral? Artery?
Medial medullary syndrome
Anterior spinal artery
Vomiting, nystagmus, vertigo, ↓ pain/temp from contralateral body and ipsilateral face, ipsilateral Horner, ataxia, dysmetria PLUS dysphagia, hoarseness, ↓ gag reflex? Artery?
Lateral medullary syndrome / Wallenburg syndrome
Posterior inferior cerebellar artery
Paralysis of face, ↓ lacrimation/salivation, ↓ taste from anterior tongue? Artery?
Lateral pontine syndrome
Anterior inferior cerebellar artery
Quadriplegia, loss of facial/mouth/tongue movement? Which artery?
Horizontal or vertical eye movements affected?
Locked-in syndrome
Basilar artery
Horizontal eye movements are affected, vertical are spared (superior colliculi)
