Strokes Flashcards
Cortical strokes most commonly affect vessels in [order]
Cortical strokes most commonly affect MCA > PCA > ACA
The underlying pathology of subcortical strokes is _
The underlying pathology of subcortical strokes is lipohyalinosis
* Occurs in the small perforating arteries
Combined face, arm, and leg deficits on one side is more suggestive of [stroke]
Combined face, arm, and leg deficits on one side is more suggestive of subcortical stroke
* A cortical stroke would only affect region of vessel perfusion (ie arm and face or just leg)
Cerebellar findings are more common in [stroke type]
Cerebellar findings are more common in subcortical strokes
* Ex: unstable gait, poor intentional movement
Ipsilateral cranial nerve deficits are more common in [stroke type]
Ipsilateral cranial nerve deficits are more common in subcortical strokes
Aphasia, neglect, gaze preference are indicative of [stroke type]
Aphasia, neglect, gaze preference are indicative of cortical stroke
ID the structures on ventral brainstem
ID the structures of the dorsal brainstem
Information from the inferior visual field travels via fibers in _ lobe
Information from the inferior visual field travels via fibers in parietal lobe
Information from the superior visual field travels via fibers in _ lobe
Information from the superior visual field travels via fibers in temporal lobe
* Meyers loop involved
Deficits in bladder control most commonly result from a cortical stroke in the [vessel]
Deficits in bladder control most commonly result from a cortical stroke in the ACA
Contralateral arm and face deficits, think _ stroke
Contralateral arm and face deficits, think MCA stroke
* Will see motor and sensory loss
Contralateral leg deficits, think _ stroke
Contralateral leg deficits, think ACA stroke
* Will see motor and sensory loss
Expressive aphasia is most likely to indicate _ stroke (specifically)
Expressive aphasia is most likely to indicate superior MCA stroke
* Broca’s is in the frontal lobe, gets supplied by the superior MCA
Receptive aphasia is most likely to indicate _ stroke (specifically)
Receptive aphasia is most likely to indicate inferior MCA stroke
* Wernicke’s area is in the temporal lobe and supplied by inferior MCA
The superior branch of the MCA supplies _ and _ lobes
The superior branch of the MCA supplies frontal and parietal lobes
* Includes broca’s area
The inferior branch of the MCA supplies _ lobe
The inferior branch of the MCA supplies temporal lobe
* Includes wernicke’s area
The PCA supplies _ and _ lobes
The PCA supplies temporal and occipital lobes
* PCA stroke will not only affect vision but memory as well
Eyes deviating to the side of the stroke is most commonly from [location] stroke
Eyes deviating to the side of the stroke is most commonly from superior MCA stroke
* Superior MCA supplies frontal lobe where frontal eye fields are found
Hemianopsia is most commonly a result of cortical stroke in [vessel] or [vessel]
Hemianopsia is most commonly a result of cortical stroke in PCA or Inferior MCA
ID the structures
ID the vessels
The medial midbrain is supplied by [vessel]
The medial midbrain is supplied by PCA
The lateral midbrain is supplied by [vessel]
The lateral midbrain is supplied by PCA
The medial pons is supplied by [vessel]
The medial pons is supplied by basilar artery
The lateral pons is supplied by [vessel]
The lateral pons is supplied by AICA
The medial medulla is supplied by [vessel]
The medial medulla is supplied by ASA
The lateral medulla is supplied by [vessel]
The lateral medulla is supplied by PICA
ID the level
Midbrain
ID the level
Medulla
ID the level
Pons
The first microscopic change in brain tissue after stroke is _ (within 12-24 hours)
The first microscopic change in brain tissue after stroke is red cytoplasm, pyknotic nuclei (within 12-24 hours)
Name the syndrome
Medial medullary syndrome (Dejerine)
Name the syndrome
Lateral medullary syndrome (Wallenberg)
Name the syndrome
Lateral pontine syndrome (Marie-Foix)
Most strokes will involve sudden onset of focal neurological deficits; the exception to this is _
Most strokes will involve sudden onset of focal neurological deficits; the exception to this is subarachnoid hemorrhage
* SAH may not produce focal deficit
The vast majority of strokes (85%) are (ischemic/hemorrhagic)
The vast majority of strokes (85%) are ischemic
* Ischemic strokes involve embolic, thrombotic, lacunar
Hemorrhagic strokes are caused by either [bleeding] or [bleeding]
Hemorrhagic strokes are caused by either subarachnoid hemorrhage or intracerebral hemorrhage
The pathology shown may cause [type stroke]
The pathology shown may cause ischemic stroke
* ie atherosclerosis –> thrombotic stroke
Name some causes of embolic stroke:
Name some causes of embolic stroke:
* Atrial fibrillation
* Infective endocarditis
* Cardiomyopathy
* Prosthetic valves
* Patent foramen ovale
Ipsilateral transient monocular blindness can be caused by a cortical stroke of the (anterior/posterior) circulation
Ipsilateral transient monocular blindness can be caused by a cortical stroke of the anterior circulation
* Aka amaurosis fugax (curtain falling)
* ICA –> opthalmic artery –> central retinal artery
Name the symptoms of disruption to blood flow in the anterior circulation
Name the symptoms of disruption to blood flow in the anterior circulation:
* Visual field deficits, amaurosis fugax
* Contralateral weakness
* Language disturbances
* Neglect
* Forced gaze (frontal eye fields)
* Disinhibition, personality changes, etc
Name the symptoms of disruption to blood flow in the posterior circulation
Name the symptoms of disruption to blood flow in the posterior circulation:
* Diplopia
* Visual field deficits
* Unilateral or bilateral motor weakness
* Dysphagia, dysarthria
* Vertigo, staggering
(3) examples of overlap between the anterior and posterior circulations of the brain:
(3) examples of overlap between the anterior and posterior circulations of the brain:
1. Circle of willis
2. Leptomeningeal vessels
3. Communication between extra and intracranial arteries
Lenticulostriate arteries are branches off of the [major artery] which supply the _ and _
Lenticulostriate arteries are branches off of the MCA which supply the basal ganglia and internal capsule
Small vessels from the [major artery] supply the midbrain and thalamus
Small vessels from the PCA supply the midbrain and thalamus
* Artery of percheron supplies both thalami
Small vessels from the [major vessel] supply the head of the caudate
Small vessels from the ACA supply the head of the caudate
* Called the recurrent artery of Heubner
_ are “small vessel strokes” to the thalamus, basal ganglia, pons
Lacunar strokes are “small vessel strokes” to the thalamus, basal ganglia, pons
_ and _ are the two most common risk factors of lacunar strokes
Hypertension and diabetes are the two most common risk factors of lacunar strokes
* Lipohyalinosis –> thickening of the media, microatheroma
Pure motor loss to the face, arm, leg is most likely due to stroke in [location]
Pure motor loss to the face, arm, leg is most likely due to stroke in contralateral posterior limb of the internal capsule
* Anterior choroidal artery
Pure sensory loss to the face, arm, leg is most likely due to stroke in [location]
Pure sensory loss to the face, arm, leg is most likely due to stroke in contralateral thalamus
* Affects all sensation modalities
Ataxic hemiparesis is most commonly due to a stroke in [location]
Ataxic hemiparesis is most commonly due to a stroke in contralateral pons
_ syndrome is facial weakness + dymetria of one upper extremity ; results from lacunar stroke
Dysarthria-Clumsy Hand Syndrome is facial weakness + dymetria of one upper extremity ; results from lacunar stroke
Acute treatment for an ischemic stroke that is caught early is _
Acute treatment for an ischemic stroke that is caught early is tissue plasminogen activators (tPA)
* Acute treatment also includes aspirin and clopidogrel
Damage to a cranial nerve nucleus will result in [side] symptoms; the only exception is [CN]
Damage to a cranial nerve nucleus will result in ipsilateral symptoms; the only exception is CN IV
* The trochlear nerve causes contralateral deficits
Damage to the PCA will affect [brainstem]
Damage to the PCA will affect midbrain
Damage to the AICA will affect [brainstem region]
Damage to the AICA will affect lateral pons
Damage to the basilar artery will affect [brainstem]
Damage to the basilar artery will affect medial pons
* Also some of the medial midbrain could be affected, though most supply comes from PCA
Damage to the ASA will affect [brainstem]
Damage to the ASA will affect medial medulla
Damage to the PICA will affect [brainstem]
Damage to the PICA will affect lateral medulla
* The vertebral artery also supplies some of the medulla
_ syndrome is a unilateral lesion of the red nucleus which results in [findings]
Benedikt syndrome is a unilateral lesion of the red nucleus which results in ipsilateral oculomotor palsy, contralateral tremor + hemiparesis
* Red nucleus is egg shaped = eggs benedikt
The constellation of upward gaze palsy, convergence retraction nystagmus, light-near dissociation is indicative of a problem at [location]
The constellation of upward gaze palsy, convergence retraction nystagmus, light-near dissociation is indicative of a problem at dorsal midbrain (compression of tectum)
* This is Parinaud syndrome
Damage to the ventral midbrain may cause _ syndrome with [findings]
Damage to the ventral midbrain may cause Weber syndrome with ipsilateral CN III palsy + contralateral hemiparesis
A medial pontine stroke will hit (3) major structures:
A medial pontine stroke will hit (3) major structures:
1. Abducens nucleus
2. Medial lemniscus
3. Corticospinal UMNs
Localize the stroke…
1. Ipsilateral loss of eye abduction
2. Contralateral loss of touch, pressure, vibration
3. Contralateral weakness with UMN signs
Medial pontine syndrome
1. Ipsilateral loss of eye abduction
2. Contralateral loss of touch, pressure, vibration
3. Contralateral weakness with UMN signs
Because the facial nerve loops around the abducens it can sometimes be affected
Name (6) major structures located in the lateral pons
Name (6) major structures located in the lateral pons:
1. Spinothalamic tract
2. Hypothalamospinal tract
3. Trigeminal sensory nucleus
4. Facial nerve
5. Vestibular and cochlear nuclei
6. Middle cerebellar peduncle
Name (6) major symptoms of the lateral pontine syndrome
Name (6) major symptoms of the lateral pontine syndrome
1. ipsilateral loss of facial sensation
2. contralateral loss of pain and temperature
3. ipsilateral horner syndrome
4. ipsilateral facial weakness
5. vertigo/nystagmus/hearing loss
6. ipsilateral ataxia
Name (3) major structures affected by a medial medullary stroke
Name (3) major structures affected by a medial medullary stroke:
1. Hypoglossal nucleus
2. Medial lemniscus
3. Corticospinal UMNs
Name (3) symptoms of medial medullary syndrome:
Name (3) symptoms of medial medullary syndrome:
1. Ipsilateral tongue weakness
2. Contralateral loss of touch, pressure, vibration
3. Contralateral UMN weakness
Name (6) major structures affected by a lateral medullary syndrome:
Name (6) major structures affected by a lateral medullary syndrome:
1. Spinothalamic tract
2. Hypothalamospinal tract
3. Spinal nucleus of V
4. Vestibular nuclei
5. Nucleus ambiguus
6. Inferior cerebellar peduncle
Name (6) symptoms of lateral medullary syndrome
Name (6) symptoms of lateral medullary syndrome:
1. Ipsilateral loss of facial sensation
2. Ipsilateral horner’s syndrome
3. Contralateral loss of pain and temperature
4. Vertigo/nystagmus
5. Diminished gag reflex/dysphagia
6. Ipsilateral ataxia
The most common risk factor for intracerebral hemorrhage is _
The most common risk factor for intracerebral hemorrhage is hypertension
ID the anterior corticospinal tract
ID the anterior spinothalamic tract
Recall that the anterior spinothalamic is responsible for crude touch, pressure
Lesion of the subthalamic nucleus can cause _
Lesion of the subthalamic nucleus can cause contralateral hemiballismus
Decerebrate posturing is a worse prognosis compared to decorticate; it is a result of lesion at [location]
Decerebrate posturing is a worse prognosis compared to decorticate; it is a result of lesion at or below red nucleus
Diagnosis?
Epidural hematoma
Most likely cause?
Rupture of the middle meningeal artery; often secondary to pterion skull fracture
Diagnosis?
Subdural hematoma
Etiology/cause?
Rupture of bridging veins (can be acute or chronic)
* Hemorrhage crosses suture lines; poor prognosis
Diagnosis?
Subarachnoid hemorrhage
Etiology/cause?
Bleeding due to trauma or rupture of aneurysm or AV malformation
Diagnosis?
Intraparenchymal hemorrhage
Most common etiology/cause?
Most commonly caused by systemic hypertension
Shaken baby sydrome is associated with [hemotoma]
Shaken baby sydrome is associated with subdural hematoma –> rupture of bridging veins
[Hematomas] can present as transient loss of consciousness followed by lucid interval before deterioration
Epidural hematoma can present as transient loss of consciousness followed by lucid interval before deterioration
Patients with [hemorrhage] may complain of “worst headache of their lives”
Patients with subarachnoid hemorrhage may complain of “worst headache of their lives”
* Rapid time course
Diffuse axonal injury will show _ on MRI
Diffuse axonal injury will show multiple punctate hemorrhages involving white matter tracts on MRI
* This is caused by traumatic shearing forces during rapid acceleration or deceleration of the brain (like MVA)
[Hemorrhage] usually occurs in premature infants or those of low birth weight. Symptoms, if present, include seizure, flaccid weakness, hypoventilation, and cranial nerve abnormalities
Intraventricular hemorrhage usually occurs in premature infants or those of low birth weight. Symptoms, if present, include seizure, flaccid weakness, hypoventilation, and cranial nerve abnormalities
Damage to the medial brainstem at any level (ie medial medulla, medial pons or Benedikt syndrome) may damage [pathway] and [pathway]
Damage to the medial brainstem at any level (ie medial medulla, medial pons or Benedikt syndrome) may damage medial lemnisucs and corticospinal tract
* Contralateral loss of touch, vibration, proprioception
* Contralateral hemiparesis
Lateral medullary and lateral pontine syndromes can cause [side] horner syndrome due to damage of the [tract]
Lateral medullary and lateral pontine syndromes can cause ipsilateral horner syndrome due to damage of the hypothalamospinal tract
Damage to the right inferior cerebellar peduncle (due to brainsem stroke) will cause [side] ataxia
Damage to the right inferior cerebellar peduncle (due to brainsem stroke) will cause right ataxia
* Damage to any cerebellar peduncles/tracts will cause ipsilateral deficit
Both lateral pontine syndrome and lateral medullary syndrome cause ipsilateral facial numbness due to the [nucleus] running throughout the brainstem
Both lateral pontine syndrome and lateral medullary syndrome cause ipsilateral facial numbness due to the trigeminal sensory nucleus running throughout the brainstem
Both [brainstem stroke] and [brainstem stroke] can result in nystagmus/vertigo
Both lateral pontine stroke and lateral medullary stroke can result in nystagmus/vertigo
* CN VIII nuclei straddle the pons and medulla so can be affected in both syndromes
