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Neurology > Stroke > Flashcards

Stroke Flashcards

1
Q

What are the features of lateral medullary syndrome?

A

AKA Wallenberg Syndrome

(1) Ipsilateral Horner Syndrome
(2) Ipsilateral Face & Contralateral Body Pain & Temperature Loss
(3) Ipsilateral Cerebellar Ataxia
(4) Ipsilateral dysphasia & dysarthria
(5) Hiccups, nausea, vomiting, vertigo

NO LIMB WEAKNESS!

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2
Q

What vessel is involved in a lateral medullary stroke syndrome?

A

PICA or vertebral artery

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3
Q

What are the signs and symptoms of a medial medullary syndrome?

A

(1) Ipsilateral tongue weakness
(2) Contralateral arm & leg weakness
(3) Contralateral loss of proprioception & vibration.

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4
Q

What vessel is involved in a medial medullary syndrome stoke?

A

Anterior Spinal Artery

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5
Q

What are the signs and symptoms of Weber syndrome?

A

A midbrain stroke, with:

(1) Ipsilateral CN 3 palsy (ptosis, mydriasis, diplopia (down & out).
(2) Contralateral hemiplegia of the face, arm and leg.

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6
Q

What features on exam would be present due to a stroke in the anterior cerebral artery?

A

(1) Contralateral Leg Weakness
(2) Contralateral Leg Numbness
(3) Contralateral Grasp Reflex (& other frontal signs.

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7
Q

What physical exam features would be present due to a stroke in the superior left MCA distribution?

A

(1) Broca’s (expressive, non-fluent) Aphasia
(2) Right weakness of the face and arm > leg.
(3) Gaze deviation to the left.

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8
Q

What would be the physical exam features of a left MCA inferior branch stroke?

A

(1) Wernicke’s Aphasia (receptive, fluent).
(2) Right cortical sensory loss
(3) Right homonymous superior quadrantonopsia.

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9
Q

What physical exam features would you seen in a stroke involving the superior branch of the right MCA?

A

(1) Left weakness face & arm > leg.

(2) Gaze deviation to the right.

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10
Q

What physical exam features would you see in a stoke involving the inferior branch of the right MCA?

A

(1) Left cortical sensory loss.
(2) Left hemineglect
(3) Left homonymous superior quandrantonopsia.

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11
Q

A stroke in which distribution would give a left homonymous hemianopia?

A

Posterior Cerebral Artery

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12
Q

What vessel supplies the majority of the midbrain?

A

The posterior cerebral artery.

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13
Q

What is the timeline cutoff for potential tPA in the setting of stroke?

A

Stroke symptoms < 4.5 hours

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14
Q

What is the timeline cutoff for consideration of endovascular therapy for stroke?

A

< 6 hours

Within 6-24 hours ECT could be considered based on results of a CT perfusion study

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15
Q

What are the relative exclusion criteria for giving tPA (8)?

A

(1) Major surgery within the last 14 d
(2) Arterial puncture within the last 7 days at a non-compressible site.
(3) History of intracranial hemorrhage.
(4) Stroke or serious head trauma within the last 3 months.
(5) On oral DOAC or VKA
(6) HTN (>180/105 mmHg) refractory to tax
(7) Imaging evidence of extensive infarction.
(8) Labs - BG < 2.7 or > 22.2, INR > 1.7 or platelets < 100

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16
Q

What are the absolute exclusion criteria for tPA?

A

(1) Any source of active hemorrhage or any condition that could increase the risk of major hemorrhage with tPA
(2) Hemorrhage on brain imaging.

17
Q

What is considered a “disabling” neurological deficit warranting tPA therapy in the setting of stroke?

A

In general:

(1) NIHSS > or = 6
(2) Aphasia, hemianopia, weakness limiting sustained effort against gravity, visual/sensory extinction.

18
Q

What are the inclusion criteria for EVT (4)?

A

(1) Disabling stroke AND functionally independent, with life expectancy > 3 months.
(2) < 6 hours from onset of stroke or last known well.
(3) CT head shows a small to moderate ischemic core with an ASPECTS score of 6 or higher.
(4) CT shows an occlusion in the anterior circulation of proximal large vessel

19
Q

How long should you wait before starting antiplatelet therapy if a patient received tPA?

A

Wait 24 hours.

Only use ASA (single anti-platelet therapy).

20
Q

What is your target blood pressure if a patient received tPA +/- EVT for their ischemic stroke?

A

< 180/105 mmHg for 24 hours

21
Q

What is your target blood pressure post-stroke if a patient DID NOT receive tPA or EVT?

A

Permissive HTN < 220/120 mmHg x 24 hours

22
Q

Which patients with stroke warrant dual antiplatelet therapy?

A

High risk TIA (ABCD2 score of 4 or more) OR minor stroke (NIHSS < or = 3) of non-cardioembolic origin.

23
Q

What are the components of the ABCD2 score?

A

A - Age > or = 60 (Yes = 1 point)
B - SBP ≥ 140 mmHg or DBP ≥ 90 mmHg (Yes = 1 point)
C - Clinical Features: Unilateral weakness (+ 2 points) OR speech disturbance without weakness (+ 1 point)
D1 - Symptom Duration: < 10 minutes (0 points), 10-59 minutes (+ 1 point) OR ≥ 60 minutes (+ 2 points).
D2 - Diabetes Hx (Yes = 1 point)

0-3 Points = Low Risk
≥ 4 Points = High Risk

24
Q

How would you manage a stroke or TIA due to severe intracranial atherosclerosis?

A

If a patient has had a stroke or TIA within the last 30 days and had evidence of 70-99% stenosis in a major intracranial vessel, consider dual anti-platelet therapy for 3 months, followed by single antiplatelet therapy.

Also requires aggressive management of all vascular risk factors.

25
Q

What is the indication for carotid revascularization in the setting of an acute non-disabling stroke or TIA?

A

If there is ipsilateral 70-99% stenosis, carotid endarterectomy should occur within the first 48 hours of symptom onset (NNT = 3), though the benefit persists up to 2 weeks if not stable within the first 48 hours.

26
Q

How should an asymptomatic or remotely symptomatic (> 6 months) carotid stenosis be managed?

A

If the stenosis is 60-99% and the patients life expectancy is felt to be > 5 years, the patient should be evaluated by a stroke expert for consideration of carotid endarterectomy or carotid artery stent.

27
Q

What is the recommended management for a symptomatic carotid with < 50% stenosis?

A

Maximum Medical Management

28
Q

What is the recommended timing of anticoagulation for a suspected cardioembolic stroke?

A

Expert consensus, depending on characteristics of the stroke.

TIA = within 24 hours of symptom onset
Mild Stroke (NIHSS < 8) = 3 days
Moderate Stroke (NIHSS 8-15) = 6 days
Severe Stroke (NIHSS ≥ 16) = 12 days

Prior to initiating anticoagulation in mild to severe strokes, consider repeat cerebral imaging to exclude hemorrhage transformation within 24 hours of planned OAC initiation.

29
Q

How would you manage a stroke patient that you suspect has had a stroke due to a patent foramen ovale?

A

PFO closure & antiplatelet recommended if all the following met:

(1) Age 18-60
(2) Stroke is NON-LACUNAR
(3) Stroke specialist things PFO is the most likely cause after a thorough evaluation to exclude other causes.

30
Q

How would you manage an extracranial carotid or vertebral dissection?

A

If symptomatic: Can use antiplatelet OR antiocoagulation with IV heparin followed by LMWH or warfarin x 3-6 months, then repeat CTA/MRA. If floating thrombus seen, definitely anticoagulate.

If asymptomatic: anti-platelet

31
Q

How would you treat an intracranial artery dissection?

A

Antiplatelet therapy alone

32
Q

What is the age cutoff for “stroke in the young”?

A

< 55 years old

33
Q

Which imaging modality will best identify vascular lesions as the culprit in the setting of intracranial hemorrhage?

A

CTA (better than MRA)

34
Q

What is the long term blood pressure target in patients who have had a previous hemorrhage stroke or intracranial hemorrhage?

A

Long term BP target is < 130/80 mmHg

35
Q

What is your acute blood pressure target in the setting of intracranial hemorrhage?

A

SBP < 140-160 mmHg for the first 24-48 hours is reasonable.

Favour < 140 mmHg if onset < 6 hours ago, patient was on anticoagulation, evidence of ICH expansion or presenting SBP < 220 mmHg

36
Q

What is the benefit of TXA in the setting of intracranial hemorrhage?

A

May reduce volume of ICH but does not improve 90 days outcomes.

37
Q

How would you reverse anti-Xa anticoagulants in the setting of intracranial hemorrhage?

A

Give PCC at a dose of 50U/kg up to 3000 units.

38
Q

How would you reverse dabigatran in the setting of an acute intracranial hemorrhage?

A

Give idarucizumab or, if unavailable, give activated PCC (FEIBA) at a dose of 50U/kg up to 2000 units.

39
Q

How would you reverse LMWH or unfractionated heparin in the setting of an intracranial hemorrhage?

A

Protamine

Neurology (12 decks)

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