Stroke and Brain Flashcards
In order to preserve brain health and function in stroke/TBI patients, intracranial pressure (ICP) is best kept at what level?
A < 25 mmHg
B < 20 mmHg
C < 10 mmHg
D < 5 mmHg
Answer: B
Explanation:
• ICP is best kept under 20 mmHg in order to preserve brain health.
• Normal patients typically have an ICP of 2-5 mmHg.
• Remember, CPP = MAP - ICP.
• CPP: cerebral perfusion pressure. MAP = mean arterial pressure. ICP = intracranial pressure.
Which of the following is most strongly associated with spina bifida?
A All of these choices are equally associated with spina bifida
B Latex allergy
C Thoracic myelopathy
D Progressive weakness
Answer: B
Explanation:
• Patients with spina bifida have high rates of latex allergy, due to frequent exposure to procedures in early life. Spina bifida most commonly happens in the lumbosacral regions, not thoracic. Symptoms should NOT be progressive, unless abnormal cord tethering occurs or hydrocephalus worsens.
The most likely cause of a subarachnoid hemorrhage is which of the following?
A Rupture of a saccular (berry) aneurysm at the posterior communicating artery
B Rupture of a saccular (berry) aneurysm at the anterior communicating artery
C Rupture of the bridging veins between the dura and the arachnoid mater
D Rupture of the middle meningeal artery
Answer: B
Explanation:
• In subdural hematoma, rupture of the bridging veins between the dura and the arachnoid causes a crescent-shaped opacity along the left or right hemisphere.
• These veins are more likely to be stretched and more prone to rupture in cases of brain atrophy (e.g. alcoholism or the aging process).
• Epidural hematoma is a lens-shaped opacity due to rupture of the middle meningeal artery.
• Berry aneurysm rupture causes subarachnoid hemorrhage, but the source is more likely an Acomm aneurysm rupture than a Pcomm aneurysm rupture.
Global aphasia involves impairments in which of the following?
A All of the listed choices are correct
B Repetition
C Comprehension
D Fluency
Answer: A
Explanation:
In global aphasia, virtually every facet of language is impaired.
A 77 year-old female presents with sudden-onset right hemiplegia and Wernicke (receptive) aphasia. How would you characterize their language output?
A Intact fluency, intact comprehension, intact repetition, impaired naming
B Impaired fluency, intact comprehension, impaired repetition
C Intact fluency, impaired comprehension, impaired repetition
D Impaired fluency, impaired comprehension, impaired repetition
Answer: C
Explanation:
• Wernicke aphasia presents with intact fluency but impaired comprehension and repetition.
• This results in the classic “Wernicke word salad”: a lot of jargon and meaningless words that don’t make sense but are articulated very well and fluidly by the patient.
Which of the following signs/symptoms is not typical of cerebral palsy (CP)?
A Progressive motor weakness
B Seizures
C Choreoathetosis
D Crouch gait
Answer: A
Explanation:
• CP is a static, nonprogressive neurologic disease due to a periuterine insult to the developing brain, resulting in motor, sensory, and/or cognitive deficits.
• The two most common subtypes are spastic (usually spastic diplegia) and dyskinetic (choreoathetosis, ataxia, dystonia can develop).
• Seizures, intellectual disability, sensorineural hearing loss, and bowel/bladder dysfunction are common.
• Patients with spastic diplegia exhibit scissoring, spasticity, toe-walking, and crouch gait during ambulation.
Patients should be able to walk if they can sit independently by age 2.
Which of the following is not classically a sign or symptom of multiple sclerosis (MS)? ABowel/bladder dysfunction BFatigue CHeat intolerance DPsychiatric disease
Answer: D
Explanation:
• Answers B, C, and D are common symptoms of MS.
• Psychiatric disease commonly occurs in patients with MS, but this is not a classic, defining symptom of the disease.
A 56 year-old male presents with sudden-onset right hemiparesis and Broca (expressive) aphasia. How would you characterize their language output?
AIntact fluency, intact comprehension, intact repetition, impaired naming
BImpaired fluency, intact comprehension, impaired repetition
CIntact fluency, impaired comprehension, impaired repetition
DImpaired fluency, impaired comprehension, impaired repetition
Answer: B
Explanation:
• Broca aphasia is impaired fluency (difficulty getting the words out; highly effortful speech), intact comprehension (patient follows all commands), and inability to repeat phrases.
Secondary injury in traumatic brain injury (TBI) is defined as:
AImpaired consciousness as an indirect result of the TBI
BWhite matter abnormalities resulting from axonal shear forces
CPathologic biochemical cascades causing excitatory toxicity
DBrain edema
Answer: C
Explanation:
• Primary injury in TBI is defined as the initial concussive forces that impact the brain, causing physical disruption and shearing of white matter axons.
• Secondary injury follows the primary injury, and is due to the detrimental biochemical cascades that occur as a result of the primary injury (namely, massive neurotransmitter surge causing glutamate excitatory toxicity, whereby the brain essentially “burns out”).
The proprioceptive neuromuscular facilitation (PNF) technique of rehabilitating a stroke patient involves which of the following principles?
AEliminate all primitive reflexes and flexor synergy patterns
BProvide cutaneous and other sensory stimulation to enhance motor control and activity
CEncourage diagonal planes of motion, as these are what we perform naturally in life
DEncourage primitive reflexes and flexor synergy patterns to “use what the patient has”
Answer: C
Explanation:
• Neurodevelopmental approach to rehabilitation seeks to eliminate abnormal spasticity, flexor synergy, and primitive reflexes.
• Brunnstrom approach involves promoting these factors (abnormal spasticity, flexor synergy) to facilitate function in ambulation and ADLs.
• Rood approach involves sensory stimulation to help retrain proper movement patterns.
• Proprioceptive neuromuscular facilitation (PNF) involves performing diagonal movement patterns to facilitate a more natural movement for the limbs.
A 73 year-old male presents with several months of progressive headaches, cognitive dysfunction, and weakness. You are concerned about intracranial neoplasm and order a contrast MRI of the brain. Out of the following choices, what are you most likely to find on the MRI? AMedulloblastoma BGlioblastoma multiforme CMeningioma DEpendymoma
Answer: B
Explanation:
• In adults, the most common primary brain tumor is glioblastoma multiforme.
A patient suffers a stroke and is admitted to your inpatient rehabilitation unit. Your therapy team comes to you with concerns that he keeps walking into walls and other objects in his path. On exam, the patient demonstrates 5/5 strength in all limbs. When asked if he can see your hand waving in front of him, he says, “Of course, doc!” You ask him to read something that you wrote in large letters in front of him, and he says, “I can read it just fine! When am I going home?” What disorder is this patient presenting with? AAnton Syndrome BProsopagnosia CWeber Syndrome DBenedikt Syndrome
Answer: A
Explanation:
• Anton Syndrome is the result of bilateral PCA (posterior cerebral artery) strokes, leading to intact visual signal pathway from the eye proximally until the posterior cerebral cortices, namely the occipital cortex, which has been infarcted.
• The patient demonstrates “cortical blindness”, as their eyes can “see”, but their visual cortex is NO longer functional, and thus, cannot interpret the visual signals transmitted from the eyes.
• These patients also may deny their cortical blindness when confronted that they are blind, as shown by this patient.
An 82 year-old male develops sudden-onset left hemiparesis. On physical exam, he fails to direct his gaze across to the left side of midline. At rest he looks toward his right side. He has a left facial droop. He has impaired sensation to light touch and pinprick over his left upper and lower limbs. When asked to move his left arm, he raises his right arm in the air. His speech is fluent, and he follows all commands. Where is the most likely site of the lesion? ARight MCA BRight PCA CRight pons DRight ACA
Answer: A
Explanation:
• A patient with left hemiparesis and facial droop, but intact fluency and comprehension, raises suspicion for right MCA stroke.
• The addition of contralateral hemineglect makes right MCA stroke the most reasonable answer choice.
• ACA strokes present with incontinence and contralateral lower > upper limb weakness without aphasia or hemineglect.
• Pontine strokes present with variable sensorimotor findings but lack higher cortical deficits such as impairments in fluency, comprehension, visual field attention, and executive function.
• PCA strokes classically present with impaired coordination (cerebellar deficits) and visual field cuts (often contralateral homonymous hemianopsia).
A 72 year-old male is found to have sudden-onset bilateral lower extremity weakness, incontinence, and is socially disinhibited and saying inappropriate things to hospital staff. Where is the most likely location of the lesion? ABilateral MCA BBilateral ACA CMedulla DPons
Answer: B
Explanation:
• ACA (anterior cerebral artery) strokes produce contralateral lower > upper limb weakness; thus, a bilateral ACA stroke will exhibit bilateral lower limb weakness along with incontinence.
• Classically a bilateral ACA stroke will affect enough frontal lobe tissue that executive function becomes impaired, and patients will demonstrate this via social disinhibition, personality deficits, etc.
Which of the following arteries does not play a major role in supplying blood to the medulla?
A Vertebral artery
B Anterior spinal artery
C PICA (posterior inferior cerebellar artery)
D Basilar artery
Answer: D
Explanation:
• The PICA, ASA, and VA all supply the medulla to varying degrees.
• The basilar artery arises from the fusion of the bilateral vertebral arteries as they ascend superiorly along the brainstem.
• The basilar artery, thus, forms at the level of the pons, and continues superiorly from there.
• Thus, the basilar artery has arises superior to the medulla, and does NOT play a major role in vascularization of the medulla.
• The basilar artery is a major source of blood for the pons; when it is occluded, it may cause Locked-In Syndrome.
What is the most common cause of traumatic brain injury (TBI) in the elderly?
A Sporting activities
B Abuse
C Falls
D MVAs (motor vehicle accidents)
Answer: C
Explanation:
• The most common cause of overall TBIs is MVAs.
• The most common cause in elderly patients is falls.
• The most common cause in children is MVAs.
A 72 year-old male is admitted to your inpatient rehabilitation unit after sustaining a traumatic brain injury (TBI) in a motor vehicle accident (MVA). On initial physical examination you note impaired attention and memory, diminished arousal (yet opens eyes to voice), symmetric face and eyes, and spontaneous movement of all four limbs. Later, while on home call, you receive a page from the bedside nurse, noting that the patient seems more “out of it”, won’t open his eyes to commands, and exhibits a much smaller right pupil compared to the left. What is the next most appropriate step?
A Stat neurosurgery consult
B Leave home to go evaluate the patient
C Initiate neuro checks Q2 hours
D MRI brain
Answer: A
Explanation:
• This patient with a recent TBI and worsening neurologic status (worsened arousal, no longer opening eyes to commands, widened left pupil) raises immediate suspicion for impending uncal herniation on the left side.
• Being able to compare the previous physical exam to the current exam is key here. Previously the patient had symmetric pupils, but now the left pupil is more dilated than the right (i.e. the right pupil is smaller than the left, when previously they were symmetric).
• A unilateral blown pupil raises concern for uncal herniation until proven otherwise. Uncal herniation is a neurosurgical emergency. Thus, a stat neurosurgery consult is the safest and most appropriate next step.
Neuroplasticity following a stroke or traumatic brain injury (TBI) involves all of the following except:
A All of the choices listed are mechanisms of neuroplasticity
B Completely unrelated areas to a now-dead area can start to perform the dead area’s previous function
C Existing brain areas are repurposed to perform the functions of dead areas
D Existing neurons sprout new connections
Answer: A
Explanation:
• All are correct choices; thus, all of the above is the best answer.
Your 23 year-old traumatic brain injury (TBI) patient has been exhibiting increasing thirst and dry mucous membranes for the past few days. His vitals include heart rate of 122 and blood pressure of 100/60. Labs are drawn, and the sodium level is 155. What is the next best step?
A DDAVP
B IV fluids
C Restrict water
D Oral salt tablets
Answer: A
Explanation:
• This patient with increased thirst, hypovolemia, and sodium of 155 is suffering from central diabetes insipidus (CDI), which can occur following a TBI.
• In CDI the patient fails to produce antidiuretic hormone (ADH), thus their body urinates out water freely, and the patient cannot keep up with fluid intake (they are thirsty with dry mucous membranes).
• They exhibit hypernatremia on labs due to water loss concentrating the blood with sodium.
• First line treatment for CDI is to simply administer ADH (in the form of DDAVP = Desmopressin).
A 75 year-old female presents with several months of progressive headaches and weakness. Contrast MRI of the brain reveals glioblastoma multiforme. The patient undergoes whole-brain radiation and begins a chemotherapy regimen. However, she begins to complain of worsened, unrelenting headaches since beginning this treatment. What is the most reasonable intervention that could have been taken to prevent this problem?
A Dexamethasone
B Peri-treatment antibiotics
C Peri-treatment migraine cocktail
D Complete chemotherapy before attempting radiation
Answer: A
Explanation:
• Steroids such as dexamethasone are prescribed following whole brain irradiation in order to reduce the expected brain swelling that occurs as a result of the radiation.
What is the most common presenting symptom of a brain tumor?
A Visual field deficits
B Weakness
C Gait dysfunction
D Headaches
Answer: D
Explanation:
• Headaches are the most common presenting symptom of a brain tumor. Cognitive deficits are also common. Weakness is the most common presenting objective sign of a brain tumor.
What is the definition of cerebral perfusion pressure (CPP)?
A ICP + MAP
B MAP - ICP
C ICP - MAP
D MAP / ICP
Answer: B
Explanation:
• CPP = cerebral perfusion pressure. MAP = mean arterial pressure. ICP = intracranial pressure. CPP = MAP - ICP.
• The goal is to maintain CPP > 60 mm Hg to preserve brain perfusion.
• Another goal is to maintain ICP < 15-20 mm Hg, again to promote proper cerebral perfusion and reduce the risk of cerebral herniation.
A 60 year-old male is brought to the ED with sudden-onset right hemiparesis, right facial droop, and on further evaluation is noted to have impaired fluency, intact comprehension, and intact repetition. This patient’s language disorder can be classified as:
A Transcortical sensory aphasia
B Transcortical motor aphasia
C Wernicke (receptive) aphasia
D Broca (expressive) aphasia
Answer: B
Explanation:
• In transcortical motor or transcortical sensory aphasia, the patient can repeat.
• In Broca and Wernicke aphasia, the patient cannot repeat.
• Once you’ve narrowed it down to transcortical motor or transcortical sensory aphasia, remember that transcortical motor is otherwise similar to Broca (expressive) aphasia, while transcortical sensory is otherwise similar to Wernicke (receptive) aphasia.
The Rood approach to rehabilitating a stroke patient involves which of the following?
A Eliminate all primitive reflexes and flexor synergy patterns
B Encourage primitive reflexes and flexor synergy patterns to “use what the patient has”
C Provide cutaneous and other sensory stimulation to enhance motor control and activity
D Encourage diagonal planes of motion, as these are what we perform naturally in life
Answer: C
Explanation:
• Neurodevelopmental approach to rehabilitation seeks to eliminate abnormal spasticity, flexor synergy, and primitive reflexes.
• Brunnstrom approach involves promoting abnormal spasticity, flexor synergy, primitive reflexes to facilitate function in ambulation and ADLs.
• Rood approach involves sensory stimulation to help retrain proper movement patterns.
• Proprioceptive neuromuscular facilitation (PNF) involves performing diagonal movement patterns to facilitate a more natural movement for the limbs.
An 87 year-old female is found down on the sidewalk. In the ED, noncontrast head CT is unremarkable. EKG and echocardiogram reveal atrial fibrillation without a patent foramen ovale (PFO). The patient The patient follows all commands, but when asked to repeat words, struggles immensely to speak. Physical examination further reveals right facial droop, impaired right hand grip strength, and inability to raise her right arm from her side. What is the most likely type and location of the lesion?
A Acute hemorrhagic right MCA stroke
B Acute hemorrhagic left MCA stroke
C Acute ischemic right MCA stroke
D Acute ischemic left MCA stroke
Answer: D
Explanation:
• This patient with acute expressive (Broca) aphasia, right arm > right leg weakness, lack of blood on stat noncontrast head CT, and cardiac evidence of atrial fibrillation raises strong suspicion for acute ischemic left MCA stroke due to cardiac embolism.
• The negative head CT makes hemorrhagic stroke less likely, as blood would show up as bright white on noncontrast head CT.
• The presence of aphasia suggests a left-sided brain lesion, and in combination with right upper limb weakness, the most reasonable answer is A.
A 64 year-old male sustains a traumatic brain injury (TBI). On noncontrast head CT you observe a white lens-shaped opacity over the right hemisphere. What structure was most likely damaged to cause this opacity?
A Parietal cortex
B Skull
C Middle cerebral artery
D Middle meningeal artery
Answer: D
Explanation:
• This patient’s MRI findings are suggestive of an epidural hematoma (EDH).
• EDH is caused by focal trauma to the middle meningeal artery.
Redundancy in the brain is the concept that:
A None of these answers is true
B If a TBI patient hears a cue repeatedly, they will begin to remember it as part of their learning
C Certain brain regions can “back up” other regions when there is a microbial threat to brain tissue
D “Backup” brain areas can step in to perform the functions of a damaged brain area
Answer: D
Explanation:
• Redundancy is the idea that if one brain region is damaged, the brain can call in “backup” areas to perform the functions of the damaged area.
• This is similar to the aviation industry, in which one part of an airplane may have multiple different backups in place to avoid flight systems failures.
In the Brunnstrom stages of recovery from hemiparetic stroke, at what stage does the patient develop peak spasticity?
A 5
B 4
C 3
D 2
Answer: C
Explanation:
• Brunnstrom hemiparetic stroke recovery stages are as follows:
• 1 = totally flaccid
• 2 = spasticity, hyperreflexia, UE flexor synergy pattern, LE extensor synergy pattern
• 3 = spasticity peaks; Control over synergy patterns begins
• 4 = spasticity decreases; Control is maximized
• 5 = complex voluntary movements
• 6 = spasticity gone
• 7 = normal
