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Neurology Clerkship > Strokes > Flashcards

Strokes Flashcards

1
Q

Ddx for Stroke

A

—Intracranial Abscess/Neoplasm
Bell Palsy
Botulism
Encephalitis
Hyperglycemia/Hypoglycemia
Hypertensive urgency/emergency
Psychiatric disorders/conversion disorder
Seizure
Spinal injury
Uremia
Ingestions (eg, ethanol)

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2
Q

What is the most important modifiable risk factor for stroke?

A

HTN

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3
Q

What are some other modifiable risk factors for a stroke?

A

–Diabetes mellitus

–Cardiac disease - Atrial fibrillation, valvular disease, mitral stenosis, and structural anomalies allowing right to left shunting, such as a patent foramen ovale and atrial and ventricular enlargement

–Hypercholesterolemia

–Transient ischemic attacks (TIAs)

–Carotid stenosis

–Hyperhomocystinemia

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4
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A
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5
Q

What is an irreversible infarct?

A

Sustained CBF below 10-12 ml/100g/min leads to rapid (less than 30 min) tissue necrosis

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6
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A
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7
Q

What are the most common etiolgoies of strokes?

A
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8
Q

What are the most common sources of cardioembolic strokes?

A
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9
Q

MCA distribution

A
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10
Q

When will a patient qualify for BOHT IV TPA and mechanical embolectomy

A

IF the stroke the is a large vessel occlusion (LVO) (i.e. carotid, M1/M2 MCA occlusions, or vertebrobasilar occlusions)

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11
Q

How is mechanical embolectomy accomplished?

A

Mechanical embolectomy in acute ischemic stroke employs the use of novel endovascular devices to revascularize occluded intracerebral arteries. Devices like the Merci Retiever and other endovascular snares, laser thrombectomy and rheolytic/obliterative microcatheters, intracranial balloon angioplasty and stenting, and intra-arterial and transcranial ultrasound-enhanced chemical thrombolysis are intended to improve tissue rescue and diminish reperfusion hemorrhage while broadening the population eligible for therapy. Patient selection with MRI- and CT-based stroke protocols can detect tissue at risk and may obviate the classic limitations of the stroke therapeutic time window. These devices are being developed and modified at a rapid pace, requiring mounting endovascular expertise, and are being used successfully alone or in conjunction with chemical thrombolysis with relative safety.

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12
Q

What is the timeframe for IV TPA?

A

4.5 hrs

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13
Q

What is the timeframe for IV mechanical embolectomy?

A

Up to 8 hrs, —preferrably on the angio table 6 hours after the onset.

NOTE: —If there is a contraindication to IV TPA in a patient with LVO, they may qualify for embolectomy alone.

—Do not forgo the IV TPA in a patient who will have embolectomy unless there is a relative or absolute contraindication to IV TPA, but not mechanical embolectomy

—In LVO, IV TPA ( without mechanical embolectomy) is successful in recanalizing the vessel in 10—15% of cases

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14
Q

—If you give IV TPA within 3 hours from the time of onset, you need to mention in your dictation that you discussed the possible complications, you do not necessarily need to have then sign a consent

—When you give IV TPA in the 3—4&1/2 hours, it a standard of care, you should not forgo it in eligible candidates, however you need to have a signed consent, unless the patinet is unaccompanied & cannot consent

A
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15
Q

T or F. Patients must be 18+ years old to receive TPA

A

T.

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16
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17
Q
A

Newer embolectomy devices-

—Stent retrievers

—Trevo

—Solitaire

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18
Q

What is the the fastest and most effective way of making the initial evaluation of acute stroke patients?

A

—non contrast CT scan of the brain—

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19
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20
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21
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22
Q

What is the most sensitive imaging modality for ischemia?

A

Diffusion weighted imaging probably the most sensitive measure of ischemia.

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23
Q
A
24
Q

—Diffusion-weighted MRI (DW-MRI) can detect areas of ischemic brain injury earlier in the evolution of ischemia than standard T1/T2-weighted MRI images or CT scan by detecting __________

A

changes in water molecule mobility.

25
Q

—Perfusion MRI (PW-MRI) uses injected contrast material to demonstrate areas of decreased perfusion. These sequences in combination with DW-MRI yields areas of diffusion-weighted imaging/perfusion-weighted imaging (DW-MRI/PW-MRI) mismatch, theoretically identifying potentially salvageable tissues.

—

—MRA: This noninvasive technique demonstrates vascular anatomy and occlusive disease of the head and neck.

A
26
Q

What labs should be obtained for a suspected/confirmed stroke?

A
27
Q

Any other labs?

A
28
Q

What is a good test for those suspectd of a cardioembolic stroke?

A

—Echocardiography: Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are useful tools in evaluating patients with possible cardiogenic sources of their stroke. TEE is more sensitive than TTE and can evaluate the aortic arch and thoracic aorta for plaques or dissections.

29
Q

Other tests for a suspected stroke?

A

—Electrocardiography/ECG: Stroke and cardiovascular disease share many risk factors. ECG may demonstrate cardiac arrhythmias, such as atrial fibrillation, or may indicate acute ischemia. All patients with stroke should have an ECG as part of their initial evaluation.

—Chest radiography should be performed when clinically indicated.

30
Q

How effective is TPA?

A
31
Q

What is the major AE of TPA?

A

hemorrhage

32
Q

How might a complete MCA stroke/infarct present?

A

Contralateral weakness and sensory loss of upper and lower extremity and lower face.

Aphasia- receptive or expressive

Ipsilateral gaze preference

Contralateral homonymous hemianopia

33
Q

How might an infarct of the superior division of the MCA present?

A
34
Q

How might an infarct of the inferior division of the MCA present?

A
35
Q

How might an infarct of the dominant larietal lobe present?

A
36
Q

What is apraxia?

A

Apraxia is a motor disorder caused by damage to the brain (specifically the posterior parietal cortex), in which the individual has difficulty with the motor planning to perform tasks or movements when asked, provided that the request or command is understood and he/she is willing to perform the task. The nature of the brain damage determines the severity, and the absence of sensory loss or paralysis helps to explain the level of difficulty

37
Q

How does Weber’s syndrome (occlusion of the tip of the basillar artery and/or branches of the PCA affecting the BASE of the mdibrain) present?

A

Ipsilateral CN III paresis (down and out)

Contralateral hemiparesis

38
Q

How does Claude’s syndrome (occlusion of the tip of the basillar artery and/or branches of the PCA affecting the TEGMENTUM of the mdibrain) present?

A

Ipsilateral CN III paresis with contral. tremor AND ataxia

39
Q

What structures are affected by Claude’s syndrome?

A

CN III fascicles

red nucleus

superior cerebellar peduncle

40
Q

How does Benedikt’s syndrome (occlusion of the tip of the basillar artery and/or branches of the PCA affecting the BASE AND TEGMENTUM of the midbrain) present?

A

Ipsilateral CN III paresis

Contral. hemiparesis, tremor, and ataxia

41
Q

What structures are affected by Benedikt’s syndrome?

A

CN III fascicles

red nucleus

superior cerebellar peduncle

substantia nigra

42
Q
A
43
Q

What are the main medullary stroke syndromes?

A

Medial and Lateral (Wallenberg’s)

44
Q

What vessels are occluded in Medial medullary syndrome?

A

vertebral aa. paramedian branches

45
Q

What structures are invovled in Medial medullary syndrome?

A

corticospinal tract

CN XII

Medial lemniscus

46
Q

How does Medial medullary syndrome present?

A

Contral. arm/leg weakness

Contral. decrease in positional/vibration

Ipsilateral tongue weakness and deviation

47
Q

What vessels are occluded in Wallenberg’s syndrome?

A

PICA

48
Q

How does Wallenberg’s syndrome present?

A

Ipsilateral ataxia (vest. nuclei), N/V

Ipsilateral Horner’s syndrome (nucleus ambiguus)

Dysphagia (nucleus solitarius)

Contral. decreased in pain/temp sensation on body

Ipsilateral decrease in facial pain/temp sensation

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53
Q

What are some options for antiplatelet therapy in patients released after stroke?

A

◦Aspirin, taken daily in low-to-medium doses (50-325 mg), is an effective and inexpensive first-choice agent for reducing recurrent stroke risk.

–Newer antiplatelet agents, such as clopidogrel (Plavix) and aspirin/dipyridamole combinations (Aggrenox) are also effective in reducing recurrent stroke rate but may cause adverse effects that must be monitored.

Initiating long-term anticoagulation (eg, warfarin) reduces the risk of recurrent stroke in patients at risk for cardioembolic stroke

54
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Neurology Clerkship (32 decks)

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