Stroke Flashcards
What are the features of lateral medullary syndrome?
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!
What vessel is involved in a lateral medullary stroke syndrome?
PICA or vertebral artery
What are the signs and symptoms of a medial medullary syndrome?
(1) Ipsilateral tongue weakness
(2) Contralateral arm & leg weakness
(3) Contralateral loss of proprioception & vibration.
What vessel is involved in a medial medullary syndrome stoke?
Anterior Spinal Artery
What are the signs and symptoms of Weber syndrome?
A midbrain stroke, with:
(1) Ipsilateral CN 3 palsy (ptosis, mydriasis, diplopia (down & out).
(2) Contralateral hemiplegia of the face, arm and leg.
What features on exam would be present due to a stroke in the anterior cerebral artery?
(1) Contralateral Leg Weakness
(2) Contralateral Leg Numbness
(3) Contralateral Grasp Reflex (& other frontal signs.
What physical exam features would be present due to a stroke in the superior left MCA distribution?
(1) Broca’s (expressive, non-fluent) Aphasia
(2) Right weakness of the face and arm > leg.
(3) Gaze deviation to the left.
What would be the physical exam features of a left MCA inferior branch stroke?
(1) Wernicke’s Aphasia (receptive, fluent).
(2) Right cortical sensory loss
(3) Right homonymous superior quadrantonopsia.
What physical exam features would you seen in a stroke involving the superior branch of the right MCA?
(1) Left weakness face & arm > leg.
(2) Gaze deviation to the right.
What physical exam features would you see in a stoke involving the inferior branch of the right MCA?
(1) Left cortical sensory loss.
(2) Left hemineglect
(3) Left homonymous superior quandrantonopsia.
A stroke in which distribution would give a left homonymous hemianopia?
Posterior Cerebral Artery
What vessel supplies the majority of the midbrain?
The posterior cerebral artery.
What is the timeline cutoff for potential tPA in the setting of stroke?
Stroke symptoms < 4.5 hours
What is the timeline cutoff for consideration of endovascular therapy for stroke?
< 6 hours
Within 6-24 hours ECT could be considered based on results of a CT perfusion study
What are the relative exclusion criteria for giving tPA (8)?
(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
What are the absolute exclusion criteria for tPA?
(1) Any source of active hemorrhage or any condition that could increase the risk of major hemorrhage with tPA
(2) Hemorrhage on brain imaging.
What is considered a “disabling” neurological deficit warranting tPA therapy in the setting of stroke?
In general:
(1) NIHSS > or = 6
(2) Aphasia, hemianopia, weakness limiting sustained effort against gravity, visual/sensory extinction.
What are the inclusion criteria for EVT (4)?
(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
How long should you wait before starting antiplatelet therapy if a patient received tPA?
Wait 24 hours.
Only use ASA (single anti-platelet therapy).
What is your target blood pressure if a patient received tPA +/- EVT for their ischemic stroke?
< 180/105 mmHg for 24 hours
What is your target blood pressure post-stroke if a patient DID NOT receive tPA or EVT?
Permissive HTN < 220/120 mmHg x 24 hours
Which patients with stroke warrant dual antiplatelet therapy?
High risk TIA (ABCD2 score of 4 or more) OR minor stroke (NIHSS < or = 3) of non-cardioembolic origin.
What are the components of the ABCD2 score?
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
How would you manage a stroke or TIA due to severe intracranial atherosclerosis?
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.
What is the indication for carotid revascularization in the setting of an acute non-disabling stroke or TIA?
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.
How should an asymptomatic or remotely symptomatic (> 6 months) carotid stenosis be managed?
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.
What is the recommended management for a symptomatic carotid with < 50% stenosis?
Maximum Medical Management
What is the recommended timing of anticoagulation for a suspected cardioembolic stroke?
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.
How would you manage a stroke patient that you suspect has had a stroke due to a patent foramen ovale?
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.
How would you manage an extracranial carotid or vertebral dissection?
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
How would you treat an intracranial artery dissection?
Antiplatelet therapy alone
What is the age cutoff for “stroke in the young”?
< 55 years old
Which imaging modality will best identify vascular lesions as the culprit in the setting of intracranial hemorrhage?
CTA (better than MRA)
What is the long term blood pressure target in patients who have had a previous hemorrhage stroke or intracranial hemorrhage?
Long term BP target is < 130/80 mmHg
What is your acute blood pressure target in the setting of intracranial hemorrhage?
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
What is the benefit of TXA in the setting of intracranial hemorrhage?
May reduce volume of ICH but does not improve 90 days outcomes.
How would you reverse anti-Xa anticoagulants in the setting of intracranial hemorrhage?
Give PCC at a dose of 50U/kg up to 3000 units.
How would you reverse dabigatran in the setting of an acute intracranial hemorrhage?
Give idarucizumab or, if unavailable, give activated PCC (FEIBA) at a dose of 50U/kg up to 2000 units.
How would you reverse LMWH or unfractionated heparin in the setting of an intracranial hemorrhage?
Protamine
