Stroke and neuroanantomy

Question 1

UMN signs

Answer 1

Tone increased
Power reduced
Reflexes increased
Plantar upgoing
Clonus present

Question 2

LMN signs

Answer 2

Tone decreased
Power reduced
Reflexes none
Plantars down
Clonus Nil

Question 3

Frontal lobe functions

Answer 3

Primary motor cortex
Personality
Primitive reflexes
Dysphasia expressive if dominant
Anosmia
Optic nerve compression
Gait apraxia

Question 4

Parietal lobe functions

Answer 4

Primary sensory cortex
Gerstmann syndrome - dominant, acalculia, agraphia, L-R disorientation, finger agnosia (ALF)
Sensory, visual and spatail inattention
Construction and dressing apraxia
Lower quandrantanopia

Question 5

Temporal lobe functions

Answer 5

Primary auditory cortex
Receptive dysphasia (dominant)
Memory loss
Upper quandrantanopia

Question 6

Occipital lobe functions

Answer 6

Homonymous hemanopia
Anton’s syndrome (individual denies their blindness)
Alexia

Question 7

Blood supply to internal capsule?

Answer 7

Lenticulostriate arteries which are penetrating branches from the MCA M1

Question 8

Course of the corticospinal tract?

Answer 8

Primary motor cortex
through internal capsule
Crus cerebri in midbrain
Pons
Medulla
Crosses over at Lower medulla
Spine

Question 9

Function of the thalamus? Rules of 4

Answer 9

Anterior nuclei involved with language and memory function
Lateral nuclei involved mainly with motor and sensory function
Medial nuclei important for maintaining arousal and memory
Posterior nuclei involved mainly with visual function

Question 10

Course of spinothalamic tract?

Answer 10

Sensory nerve -> dorsal root ganglion of the spine and crosses over immediately
Medulla
Pons
Midbrain
Thalamus
Primary sensory cortex

Question 11

Course of dorsal column tract (vibration, light touch, propioception)

Answer 11

Senosry nerve -> dorsal root ganglion -> dorsal column
Lower medulla -> crosse over at medial leminiscus
Medulla
Pons
Midbrsin
Thalamus

Question 12

Brainstem. Rule of 4s?

Answer 12

4 cranial nerves in the medulla, 4 in the pons and 4 above the pons

There are 4 structures in the midline beginning with M

4 structures to the side beginning with S

4 motor nuclei that are midline are those that divide equally into 12 (except for 1 and 2) i.e. 3,4,6,12

Question 13

The 4 medial structures are?

Answer 13

Motor pathway
Medial lemniscus
Medial longitudinal fasciculus and
Motor nucleus

Question 14

4 side structures are?

Answer 14

Spinocerebellar pathways
Spinothalamic
Sensory nucleus of 5th CN
Sympathetic tract

Question 15

Blood supply of the brainstem

Answer 15

Superior cerebellar artery
Anterior inferior cerebellar artery
Posterior inferior cerebellar artery

Occlusion of unilateral verterbrals can cause lateral brainstem syndromes

Question 16

What are the lacunar syndromes (5 types)?

Answer 16

1. Pure motor
   - 33-50% of lacunar strokes
   - posterior limb of internal capsule or anterior portion of pons
2. Ataxic hemiparesis
   - posterior limb of internal capsule
   - combination of cerebellar and motor symptoms
   - usually affects the legs more than the arms hence it is known as homolateral ataxia
3. Dysarthria/Clumsy hand
   - Basis pontis
4. Pure sensory
   - Thalamic infarct
5. Mixed sensorimotor
   - thalamus and posterior limb of internal capsule

Question 17

Post stroke BP care. What are the limits?

Answer 17

tPA - BP 180/105 and then lower
No tPA - BP 220/120 and then lower
Increased systemic BP will improve blood flow tot he cerebral infarct via collateral blood vessels

Question 18

Cause of anterior circulation stroke?

Answer 18

Intracranial stenosis
Severe carotid stenosis
Aortic arch
AF

Question 19

Cause of posterior circulation stroke?

Answer 19

Atheroembolic disease

AF

Question 20

What is the single most important modifiable RF for ischaemic and haemorhhagic stroke?

Answer 20

HT
Goal 120-140 mmHg
ACE/ARB and thiazide diuretic have better evidence

Question 21

When do you give antiplatelets in stroke?

Answer 21

Post CTB and 24 hrs post t-PA

Aspirin, clopidogrel and asasantin are all appropriate 1st line therapy

Question 22

what is the reversal agent for Dabigatran?

Answer 22

Idarucizumab (Praxbind)

Question 23

Dabigatran and Rivaroxiban had higher rates of GI bleed compared with warfarin. T/F

Answer 23

True

Question 24

Apixiban 5 mg BD demonstrated what benefits?

Answer 24

Superior to warfarin
Decreased rates of all cause bleeding
Decreased rates if ICH
Mortality benefit

Question 25

Intracranial atherscerlosis. Tx? Risk of recurrence

Answer 25

Tx - aspirin and aggressive medical Mx
No difference between aspirin and warfarin with more complications on warfarin
No role for intracranial stenting due to increasing complications

Recurence is 12-14% in 2 years despite antiplatelets
Higher rates amongst Asians

Question 26

ICH. Location of bleed and corresponding aetiology?

Answer 26

Intracerebral

• basal ganglia = HTN
• Lobar = amyloid angiopathy
• Pontine = HTN, vascular malformation
• Cerebellar = HTN, vascular malformation, tumour

Intraventricular

• Primary = tumours and malformations
• secondary = ICH, SAH

Question 27

What is the Mx of an ICH stroke?

Answer 27

Aim BP 140/80 mmHg

Question 28

AICA stroke. Areas affected.

Answer 28

CN V, VII and VIII
Inner ear, lateral pons, middle cerebellar peduncle and anterior inferior cerebellum
pseudo-labrynthitis

Question 29

PICA stroke. Areas affected?

Answer 29

CN VI, VIII, IX, X
Lateral medullary syndrome
Acute vestibular syndrome without hearing loss or pseudo-neuritis

Question 30

Head impulse test. Positive in which lesions?

Answer 30

Peripheral lesions

Asent in central lesions

Question 31

How does a dissection present?

How do you differentiate between a vertebral and carotid artery dissection?

Answer 31

H/O trauma, headache, neck pain and Horner’s syndrome.

Both will present with Horner’s syndrome.

Dizziness is associated with vertebral artery dissection.

Question 32

Cervical nerves exit above or below the vertebra?

Spinal nerves?

Answer 32

Exit above
Except for C8, exits above T1

Spinal nerves exit below the vertebra starting with T1

Question 33

Grey matter:
Anterior horn
Posterior horn

Answer 33

Anterior horn:
lower motor neurons as well as interneurons that help to fine tune the motor output

Posterior horn:
Secondary sensory neurons and interneurons receiving input from the dorsal root ganglia (primary sensory neurons)
Outermost layer serves as superficial sensations including pain, temp and light touch.

Question 34

Cerebral venous thrombosis.
Epid
Patho
Presentation
Mx

Answer 34

Epid:
Increased risk with hormonal Tx and post partum
12 in 100 000 pregnancies

Patho:
Thrombosis leads to increased capillary and venous pressure -> ischaemia, haemmorhage
Sinus obstruction leads to poor CSF absorption -> raised ICP

Presentation:
Raised ICP 90%
- subacute headache, visual changes, papilloedema
Focal neurological abnormalities 44%
Seizures 33%
Encephalopathy - usually elderly pts

Mx:
Anticoagulation
- Heparin infusion or therapeutic clexane
- transition to warfarin
- 3-6 months in provoked and 6-12 months in unprovoked
Fibronolysis in severe cases

Raised ICP

• acetazolamide
• may need Sx intervention if severe

Hemicranectomy

Question 35

OCP and stroke. What are the risk?

Answer 35

Slightly higher risk in older age groups.
No difference between 2nd and 3rd generation OCP.
No increased risk with low oestrodial.