Stroke and Intracranial Hemorrhage (5Q)

Question 1

Transient ischemic attack: Pt.

Answer 1

Patient at risk for embolization due to cardiac (A-fib, rheumatic heart disease, mitral valve disease, endocarditis, mural thrombi in MI, ASD), vascular disease (esp in brain, carotid bifurcation- bruits), AIDS. Older patients.

Question 2

subclavian steal syndrome

Answer 2

localized stenosis or occlusion of one subclavian artery proximal to the source of the vertebral artery (blood is stolen) from artery). Causes ischemia.

Question 3

TIA: Hx/Px

Answer 3

Acute onset changes in mental status, focal weakness (similar to stroke) that are recovered rapidly (in minutes). Rarely causes loss of consciousness or acute confusion. Increases risk of stroke.

Question 4

Who is at the highest stroke risk?

Answer 4

Pts > 60yo, those with diabetes, or after TIA lasting longer than 10 minutes, and with symptoms or signs of weakness, speech impairment, or gait disturbance.

Question 5

TIA: Imaging

Answer 5

CT or MRI within 24 hours of attack is indicated to exclude the possibility of small cerebral hemorrhage or cerebral tumor.

Next: MR or CT angiography to visualize any stenosis of cervical vasculature.

Carotid duplex US is useful for visualizing stenosis of internal carotid. May also do Echocardiogram to see if source can be identified.

GS is conventional arteriography (if others reveal nothing)

Question 6

TIA: Labs

Answer 6

Assess for hematologic disorders (CBC, homocysteine), heart disease (lipids), diabetes (blood glucose) and serologic tests for syphillis.

Also get EKG, BP

Question 7

TIA: medical

Answer 7

Obv. use meds to prevent future attacks by reducing risk (HTN, lipids, DM).
Medical anti-coagulation is initiated in patients who are poor surgical candidates or have widespread vascular disease or have evidence embolization from heart.

Tx is anti-coagulants: tissue plasminogen activator (tPA)

Question 8

ABCD score:

Answer 8

establishes risk of TIA occurance: Age over 60- 1
BP > 140/90- 1
Clinical Sx of focal weakness- 2 points OR speech impairment without weakness (1)
duration >60 mins = 2, 10-59 mins (1), DM=1

ABCD > 3 should be admitted.

Question 9

How to manage a thrombus in the heart

Answer 9

to prevent stroke, give anticoagulants (tPA) to break up clot. Don’t worry about hemhorrage, risk of another embolus is much higher.

Question 10

How to medically prevent non-cardioembolic attacks

Answer 10

low-dose aspirin should be given to prevent future attacks. If attacks are refractory to aspirin, then add dipyridamole (PDE inhibitor).

clopidogrel can be used for Pts who cannot tolerate aspirin

Question 11

When is surgery indicated in TIA?

Answer 11

when arteriography reveals an accessible high-grade stenosis (70-99% occlusion) on the appropriate side and there is relatively little atherosclerosis elesewhere in the cerebrovascular system. Not indicated for stenosis <50%.

Question 12

Lacunar infarction

Answer 12

small lesions <5mm that occur in the distribution of the short penetrating arterioles in the basal ganglia, pons, cerebellum, internal capsule, thalamus, an deep cerebral white matter.

Present as contralateral pure motor or pure sensory deficit, ipsilateral crural (mild) paresis, and dysarthria + clumsiness of hand.

Question 13

Clinical evaluation of suspected stroke or TIA should always include (in PE):

Answer 13

examination of heart and auscultation over subclavian and carotid vessels.

Question 14

Occlusion of anterior cerebral artery:

Answer 14

Only causes sx if distal to junction with anterior communicating artery.

Sx: weakness and cortical sensory loss in the contralateral leg (loss of proprioception) and maybe mild proximal arm weakness.

Urinary incontinence is UNCOMMON. Bilateral infarcts will cause behavior change.

Question 15

Occlusion of middle cerebral artery:

Answer 15

Sx: Contralateral hemiplegia, hemisensory loss, homonymous hemianopsia w/ eyes deviated toward side of lesion.

If dominant hemisphere is involved, there will be global aphasia.

More distal infarcts cause more limited Sx.

Question 16

Occlusion of the posterior cerebral artery:

Answer 16

thalamic syndrome- contralateral hemisensory disturbance occurs followed by spontaneous pain and hyperpathia. Macula-sparing homonymous hemianopsia.

Question 17

Occlusion of vertebral artery:

Answer 17

depends on location and extent of collateral circulation. Silent if good. If poor- then coma with pinpoint pupils, flaccid quadriplegia, sensory loss, cranial nerve abnormalities.

Question 18

Occlusion of the posterior inferior cerebellar artery (PICA)

Answer 18

ipsilateral spinothalamic sensory loss involving the face, IX and X CN lesions, limb ataxia/numbness, and Horner syndrome
+contralateral spinothalamic sensory loss of limbs

Question 19

Quick review: fine touch, vibration, 2 pt discrimination, and proprioception are carried by with sensory pathway? Where does it decussate?

Answer 19

Posterior column-medial lemniscus pathway. Decussates at level of brainstem.

Question 20

Quick review: nociception and temperature are carried by which sensory pathway? Where does it decussate?

Answer 20

Spinothalamic pathway. Decussates at spinal cord, a few levels above root.

Question 21

What is the name of the pathway that carries motor information from the brain?

Answer 21

pyramidal tracts (corticospinal + corticobulbar tracts)

Question 22

Occlusion of basilar artery (or both vertebral arteries):

Answer 22

coma with pinpoint pupils, flaccid quadriplegia, sensory loss, and variable cranial nerve anomolies.

If partially occluded: diplopia, visual loss, vertigo, dysarthria, ataxia, weakness, sensory loss in some limbs or discrete CN palsies.

Question 23

Occlusion of a major cerebellar artery:

Answer 23

vertigo, nausea, vomiting, nystagmus, ipsilateral limb ataxia, contralateral spinothalamic sensory loss.

Question 24

When does coma occur in stroke?

Answer 24

Either due to infarction of carotid or vertebrobasilar artery, or due to compression of brainstem after cerebellar infarct.

Question 25

Stroke: Imaging

Answer 25

CT without contrast before administering aspirin or thrombolytics to exclude cerebral hemhorrage.

Diffusion-weighted MRI to visualize infarct and imaging of vasculature via CT or MR angiography to locate source of stroke.

Question 26

Stroke: treatment

Answer 26

in stroke care unit: IV rTPA or tPA as bolus is indicated no more than 4.5 hours after the onset of symptoms for patients WITHOUT CT evidence of hemorrhage.

CI: bleeding, sBP>185, dBP>110.

Mannitol to reduce CSF pressure, elevate head.

Question 27

Stroke prevention

Answer 27

low-dose aspirin should be given to prevent future attacks. If attacks are refractory to aspirin, then add dipyridamole (PDE inhibitor).

clopidogrel can be used for Pts who cannot tolerate aspirin

Question 28

How do you manage patient BP within 2 weeks of stroke?

Answer 28

Do not reduce it drastically because of risk of increased ischemia. If sBP is >220, it can be lowered with IV labetolol to 170-200, then <140 AFTER 2 weeks.

Question 29

What is usually the cause of intracerebral hemorrhage in patients with no vascular anomaly or trauma?

Answer 29

Hypertension.
In elderly cerebral amyloid angiopathy is an important cause.
Hematologic disorders, anticoagulants, liver disease, and EtOH can also cause.

Question 30

Cerebellar hemorrhage: Sx

Answer 30

sudden onset nausea and vomiting, dysequilibrium, headache, loss of consciousness.

Question 31

intracerebral hemorrhage: imaging

Answer 31

CT is best for bleeds. CT angiography or MR angiography can follow to determine whether an AV malformation or aneurysm is present.

Question 32

intracerebral hemorrhage: tx

Answer 32

conservative and supportive, even with profound deficits and brainstem compression. Includes: ventilator support, blood pressure regulation, seizure prophylaxis, control of fever, osmotherapy.
Ventricular drainage is required in acute hydrocephalus,
Decompression is useful for patients at risk for herniation.

Cerebellar hemorrhage should always be treated surgically.

Question 33

Most common cause of spontaneous (atraumatic) subarachnoid hemorrhage:

Answer 33

rupture of berry aneurysm or AV malformation.

Question 34

Subarachnoid hemorrhage: sx

Answer 34

sudden headache (worst of life), nausea, vomiting, loss or impairment of consciousness.

PE: nuchal rigidity and meningeal irritation signs

Question 35

Subarachnoid hemorrhage: imaging

Answer 35

CT and cerebral arteriography— also allows intervention for AV malformations and aneurysmsm.

Question 36

Subarachnoid hemorrhage: treatment

Answer 36

surgical clipping of aneurysm base, coil, or othe endovascular treatment

Question 37

Risk factors for intracranial aneurysm formation

Answer 37

polycystic kidney disease, coarctaion of aorta, smoking, hypertension, hypercholesterolemia.

Question 38

Risk factors for subarachnoid hemorrhage

Answer 38

older age, female sex, non-white ethnicity, HTN, tobacco, high EtOH

Question 39

Intracranial aneurysm: Sx

Answer 39

asymptomatic until ruptured

Question 40

Intracranial aneurysm: imaging

Answer 40

conventional angiography (not CT or MR) is required for intervention, so use it for Dx too.