Stroke and Neurocritical Care Flashcards
Embolic strokes most commonly affect which artery.
MCA
Headaches associated with MCA strokes are usually localized to ___; while they occur in the ___ in PCA strokes.
MCA: temporal
PCA: retro-ocular
Lesions to NONDOMINANT parietal lobe cause:
Isolated agitated delirium
This direct branch of the ICA supplies the internal segment of the globus pallidus and posterior limb of the internal capsule and optic tract. Occlusion leads to which symptoms.
Anterior choroidal artery
Hemiplegia, hemisensory loss, homonymous hemianopia, sparing cognition and language
Components of Gerstmann syndrome.
Where is the lesion?
Finger agnosia
Acalculia
Right/left confusion
Agraphia
Dominant inferior parietal lobule / angular gyrus
APRAXIA QUIZ
Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia
Where is the lesion?
Inability to perform complex learned movements with preserved understanding of intended movement
Ideomotor
Dominant parietal lobe
APRAXIA QUIZ
Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia
Where is the lesion?
Inability to perform complex learned movements with impaited understanding of intended movement
Ideational
Dominant parietal lobe
APRAXIA QUIZ
Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia
Where is the lesion?
Inability to construct a whole from its parts
Constructional apraxia.
Nondominant parietal lobe
APRAXIA QUIZ
Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia
Clumsiness of skilled acts with preserved understanding of intended movement
Limb-kinetic
Premotor or dominant parietal lobe
APRAXIA QUIZ
Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia
Loss of topographical orientation resulting in inability to dress in an organized manner
Dressing apraxia
Nondominant parietal lobe
NAME THAT SYNDROME
Bilateral cortical blindness with normal-appearing optic disks and preserved pupillary light reflexes, with denial of blindness and visual hallucinations
Anton’s syndrome
NAME THAT SYNDROME
Simultagnosia (Inability to synthesize disparate images within the visual field into a coherent whole)
Optic ataxia (Inability to reach targets under visual guidance)
Gaze apraxia (Inability to direct gaze at a target)
Where is the lesion?
Balint’s syndrome
Bilateral occipitoparietal border zone strokes
Patient presents with purely visual hallucinations that are well formed, complex, and appear cartoonish and nonthreatening, and are perceived as unreal by the patient. If due to a stroke, where is the lesion?
Peduncular hallucinosis
Stroke of the MIDBRAIN in the vicinity of the cerebral peduncles related to PCA occlusion
Inability to recognize and identify familiar faces, interpret facial expressions or judge age or gender based on facial features. If due to a stroke, where is the lesion?
Prosopagnosia
Bilateral ventromesial occipitotemporal stroke
Name that syndrome.
Ipsilateral CN III lesion +
Contralateral hemiparesis
Weber’s syndrome
Midbrain stroke due to PCA thrombus
Name that syndrome.
Ipsilateral CN III lesion +
Contralateral ataxia / tremor
Claude’s syndrome
Midbrain stroke due to PCA thrombus
Name that syndrome.
Ipsilateral CN III lesion +
Contralateral hemiparesis +
Contralateral ataxia / tremor
Benedikt’s syndrome
Midbrain stroke due to PCA thrombus
Name that syndrome.
Ipsilateral CN V, IX, X and XI palsy + Horner syndrome + Cerebellar ataxia + Contralateral pain and temperature loss + Vertigo, nausea, hiccups
Wallenberg’s syndrome
Lateral medullary stroke due to vertebral or PICA thrombus
Palatal tremor that persists during sleep and is audible to the patient. If due to stroke, where is the lesion?
Palatal myoclonus
Stroke in the dentato-rubro-olivary triangle of Guillan-Molere (usually pontine tegmentum)
Name that syndrome.
Hemisensory loss +
Painful paresthesias
Where is the lesion?
Thalamic syndrome of Dejerine and Roussy
VPL/VPM stroke
All CN nuclei are ipsilateral to the nerve except ____ and the ____ subnucleus of ____, which cross contralaterally.
- CN IV
2. Superior rectus subnucleus of CN III
As a rule of thumb, sensory nuclei are located laterally/medially within the brainstem; while motor nuclei are located laterally/medially.
Sensory nuclei are lateral while motor nuclei are medial.
Normal cerebral blood flow (in mL/100g/min).
What is the critical threshold for functional impairment? Infarction?
Normal: 55
Functional impairment: 23
Infarction: 12
Autoregulation occurs within this range of mean arterial pressures.
50 - 150 mmHg
CT signs of stroke
Cortical effacement
Loss of grey-white distinction
Spontaneous HYPERdensity along an occluded proximal MCA (hyperdense MCA sign) or MCA branches within the Sylvian fissure (MCA dot sign)
What is the gold standard for imaging stroke?
MRI
Hyperintensity on DWI and hypointensity on apparent diffusion coefficient maps present within 30 minutes
Trials have demonstrated the superiority of this anticoagulant for primary and secondary prevention of stroke in patients with AF (SPAF II trial)
Warfarin
Indication for elective carotid endarterectomy for low-risk patients
> 70% SYMPTOMATIC carotid stenosis (stroke or TIA) (NA-SCET Trial)
> 60% ASYMPTOMATIC (ACAS trial)
For patients with dilated cardiomyopathy, warfarin is recommended as prophylaxis if EF is < ___.
20%
Syndrome of episodic migraine-like headache and cyclic vomiting with focal neurologic deficits and seizure. May have sensorineural hearing loss, pigmentary retinopathy and myopathy.
Mitochondrial myopathy, encephalopathy, lactic acidosis and strokes (MELAS)
Renovascular hypertension, renal artery stenosis, and internal carotid stenosis associated with aneurysm formation and dissection. Angiogram shows “chain-of-lakes” pattern
Fibromuscular dysplasia
Indications for use of tPA in ischemic stroke
- Ischemic stroke within 3 hours of onset
- NIHSS > 3
- No hemorrhage on head CT
- Clear time of onset
Contraindications for use of tPA
- Rapidly resolving deficits
- Seizure at onset
- Prior stroke or head trauma 14 days
- Prior ICH
- SBP >185
- DBP > 110
- GI or GU tract hemorrhage 400
Most common site of an ICH
Putamen
Indications for neurosurgical consultation re: ICH
Posterior fossa hemorrhage >3cm in maximal diameter; or significant mass effect on the 4th ventricle or rapidly expanding superficial supratentorial ICH in a young patient with a rapidly declining neuro exam
Recommendations for clipping or coiling unruptured aneurysm
Anterior circulation aneurysms >7mm
Posterior circulation aneurysms >3mm
Remote aneurysm in a patient with prior rupture
Rapidly enlarging aneurysm
CSF Physiology
- Normal volume
- Rate of CSF production
- Normal ICP
- 150 mL
- 20mL/h (450 - 500 mL)
- <15 mmHg
In hyperosmolar therapy for patients with increased ICP, what is the target serum osmolarity? What is the risk of higher serum osmolarity?
Target: 300 - 310 mOsm/L
Acute tubular necrosis if serum osmolarity is higher
Target PCO2 range in patients with increased ICP
28 - 32 mmHg
Goal ICP in patients with increased ICP
<20 mmHg
Describe grading of concussions.
Grade 1: No LOC, sx (ex. confusion) 15 mins
Grade 3: (+) LOC
Patient with severe brain injury is comatose; CT is normal. Diagnosis?
Diffuse axonal injury
Most common locations of punctate hemorrhages in diffuse axonal injury
Gray-white junction
Corpus callosum
Middle cerebral peduncles
How many percent of TBI patients have C-spine injuries?
5 - 10%
In DAI, what is the goal CPP and goal ICP?
CPP > 60
ICP < 20
Is seizure prophylaxis recommended for brain trauma patients?
YES. For 1 week in setting of moderate to severe
Total caloric needs of patients with severe TBI
140%
Criteria for intubation in GBS
- VC < 15 mL/kg
- Negative inspiratory force < -25 mL/kg
- 30% decrement in forced vital capacity or NIF over 24h
- Severe uncompensated respiratory acidosis
- Severe bulbar involvement with inability to control secretions
Tetrad of neuroleptic malignant syndrome
Fever
Rigidity
Autonomic instability
Mental status changes
Serotonin syndrome antidote
Cyproheptadine
Name that syndrome.
Action myoclonus occurring in chronic survivors of cardiac arrest
Lance-Adams syndrome
Postanoxic myoclonus
