Stroke/Neuro HY Flashcards
Biggest risk factor for strokes?
HTN
Elderly with asymmetric motor and/or sensory deficits
Stroke is suspected, NBSIM?
NC-CT Head
(differentiates between ischemic & hemorrhagic)
Pt has Transient ischemic attack (TIA) a temporary, focal cerebral ischemic event that results in neurological symptoms which self resolve
It is not associated with a ____ on neuroimaging.
List the 2 mcc of TIA
visible acute infarct
Cardioembolic (atrial fibrillation, recent MI)
Atherosclerosis (carotid artery stenosis)
Pt with hx of Atrial Fibrillation (or recent MI) presents after a TIA/Stroke.
NCCT → pharmacotherapy?
Anticoagulation
Warfarin
(not antiplatelet drug like the other pts if the cause of stroke was cardioembolic use anti coagulant)
60M smoker with a history of HTN and DM
presents after transient, painless vision loss (or a recent TIA)
NBSID?
Carotid duplex U/S
Recent TIA
carotid duplex u/s shows >50% stenosis
NBSIM?
Carotid Endarterectomy
Asymptomatic with carotid bruit
found to have less than 80% carotid stenosis of duplex u/s
NBSIM?
Wait for pt to become symptomatic or have ≥ 80% stenosis
then do Carotid Endarterectomy
Until then, statin, smoking cessation, Aspirin
━━
Symptomatic means pt has:
contralateral motor/sensory deficits (TIA/Stroke)
ipsilateral transient blindness (Amaurosis fugax)
Patient found to have ischemic stroke on head CT.
What is the next best step in diagnosis?
Carotid duplex Ultrasound
Pt found to have carotid stenosis.
What medication do you start (1st-3rd line)?
Aspirin (1st line) antiplatelet
Clopidogrel (2nd line) antiplatelet
Dipyridamole (3rd line)
Pt found to have 100% stenosis on carotid duplex u/s
NBSIM?
No carotid endarterectomy
━
Start Aspirin (2nd line Clopidogrel), Statin (high intensity), Manage risk factors (smoking cessation, HTN, DM)
━
pt’s body has developed collateral circulation → no surgery
Pt is elderly/smoker/ and/or hx of HTN
presents with sudden and severe headache, nausea & vomiting
FMH (+) renal dz, brain bleeds (AVMs/Aneurysms)
± nuchal rigidity or AMS
NCCT Head negative
Suspected Dx/NBSIM?
Lumbar Puncture (xanthochromia: RBCs in CSF)
Subarachnoid Hemorrhage (still suspected despite negative imaging)
NCCTH (+) hyperdensities in the subarachnoid space
Once SAH is confirmed, ____ is always necessary in order to identify the source of bleeding (aneurysms or AVMs) and plan definitive treatment.
angiography
Recent DVT now has a stroke.
Dx/Dxt?
PFO (Patent Foramen Ovale)
Cryptogenic Stroke
TEE with a Bubble Study
(bubbles travel to left side heart)
Management of hemorrhagic stroke focuses on
1st: Secure ABCs (posturing = herniation = intubate)
───
Then preventing further bleeding
1st: BP control (Nicardipine, Labetalol)
2nd: AC Reversal (Warfarin: PCC or Heparin: Protamine)
3rd: Lowering ICP (HOB, Sedation, Mannitol)
Pure motor (Upper & Lower Extremity) stroke
Dx/location/artery/Patho
Lacunar Stroke
Internal Capsule
microatheroma–lipohyalinosis
thrombotic small-vessel occlusion of lenticular striate a
Left side FACE sensory sxs
Right Side BODY sensory sxs
Tongue deviates left
Localize Lesion. List arteries involved.
Lateral set up (Face and Body Opposite)
Left face sxs = ipsilateral to lesion
CN12 (medulla)
Lateral Left Medulla
PICA
(Vertebral artery if s/t next extension)
Pure sensory (Upper & Lower Extremity) stroke
Contralateral numbness & paresthesia of the face & L/UE
dx/location
Lacunar stroke
Thalamus VPL (ventral posterolateral )
Pt with Ischemic stroke develops worsening stroke sxs and AMS the next day? NBSIM?
Repeat CT Head
(hemorrhagic transformation)
FYI: Putaminal hemorrhage always involves the internal capsule (Hemiparesis)
Elderly woman
R sided Headache + ↑ ESR
NBSIM (2)?
Start Prednisone
& get Temporal Artery Biopsy
Giant cell arteritis
Negative CT Head
LP: elevated opening pressure, and elevated red blood cell count that does not decline with successive samples.
Dx?
Subarachnoid Hemorrhage
Depending on the time of presentation (<__ hr for thrombolysis, <__ hr for mechanical thrombectomy) tx considered independently
Mind Contraindications before tx
<4.5hr → TpA
<24hr → Embolectomy
Pt with mechanical valves and suspected TIA NBSIM (aside from NCCT Head)
Echocardiography
Brain Stem Blood supply (Medial to lateral)
Midbrain →
Pons →
Medulla →
Midbrain → PCA/SCA
Pons → Basilar/AICA
Medulla → Vertebral/ PICA
Brainstem CN locations
Midbrain →
Pons →
Medulla →
Midbrain → CN 3,4
Pons → CN 5,6
Pontine medullary Jxn → CN 7, 8
Medulla → CN 9, 10 & 12
CT scan of the head: biconvex (lens-shaped) hyperdensity that does not cross suture lines
Epidural Hematoma
CT scan of the head: Concave (Crescent-shaped) hyperdensity that crosses suture lines
(Banana-shaped)
Subdural Hematoma
Rupture of Bridging veins
Subdural Hematoma
Trauma to sphenoid bone with tearing of middle meningeal artery
Epidural Hematoma
BRF for Subdural Hematoma (3)
Age (Old)
Alcoholism (Chronic)
AntiCoagulant use
Elderly with
*Fluctuating Cognition
*Visual hallucinations (before motor sxs)
*Parkinsonism
± REM sleep behavior disorder
dx?
dementia with Lewy bodies
Medication C/I in lewy body dementia?
Severe sensitivity to antipsychotics
50+ y.o. Patient with
Executive dysfunction + Behavior changes:
Disinhibition (sexual/ Rude comments)
Apathy (unconcerned/uninterested)
Compulsions or ritualistic behaviors
Hyperorality (chewing, sucking)
Executive dysfunction (low MOCA score)
frontotemporal dementia
(Frontal lobe atrophy)
Pt with h/o HTN
Sudden or stepwise decline in executive function + memory
± FND
Imaging: multiple small cortical and subcortical infarctions.
Vascular dementia
BRF: HTN
Presents with
shuffling gait with quick, short steps
Bradykinesia
Muscle Rigidity
Resting Tremor (improves w/ voluntary movement)
Parkinson’s
Dopaminergic neurons degeneration in the substantia nigra pars compacta
rapidly progressive dementia + Executive dysfunction
startle myoclonus/hyperreflexia/babinski
mood symptoms
sleep disturbances
Dx?
CJD
Enhancement of putamen & caudate head (hockey stick sign)
not atrophy like HD
Executive dysfunction
Mood symptoms (rude)
Repeated abrupt, involuntary movements in the upper extremities, Head, or Neck.
Dx?
Disorder?
Patho:
Neuro imaging:
Huntington disease (AD)
CAG trinucleotide repeat expansion disorder
Loss of GABA-ergic neurons
Caudate & putamen atrophy
Presents with progressive cognitive decline that impairs activities of daily living (bathing, dressing, preparing meals) and eventually leads to mood sxs (apathy, withdrawal)
Dx/Mcc?
Dementia
MCC: Alzheimer’s
Cognitive decline precedes mood sxs
Early on presents with isolated impairments in memory.
Then progresses to apathy, social withdrawal, and
± Hallucinations
Can mimic depression.
Dx/Tx?
Alzheimer’s Dementia
Donepezil, Rivastigmine, and galantamine
Cholinesterase inhibitors
(Donna & Riva going to the Gala)
Subacute (>1 week) back pain + radiating down leg +
impaired motor/sensory/reflex activity in the BLE (LMN sxs)
bowel/bladder/sexual dysfunction
and/or saddle anesthesia.
Cauda equina syndrome
Classic triad
Fever + Focal/severe back pain +
Neurologic findings (motor/sensory change, bowel/bladder dysfunction)
↑ ESR
Dx? Dxt (2)?
Mcc?
Spinal Epidural Abscess
MRI Spine + Blood cx
mcc: Staph a.
