Strokes

Question 1

What are the most vulnerable areas of the brain to ischemic stroke

Answer 1

Hippocampus (MOST)
Neocortex (layers 3, 5, 6)
Cerebellum (purkinje cells)
Watershed areas

Question 2

When will an ischmic change be detected on MRI and CT

Answer 2

CT: in 6-24 hours (will exclude hemmorage though)
MRI: within 3-30 minutes

Question 3

What is seen Histologically post stroke?

12-24 hours

Answer 3

Eosinophilic cytoplasm + pyknotic nuclei (red neurons)

Question 4

What is seen Histologically post stroke?

24-72 hours

Answer 4

Necrosis + neutrophils

Question 5

What is seen Histologically post stroke?

3-5 days

Answer 5

Macrophages (microglia)

Question 6

What is seen Histologically post stroke?

1-2 weeks

Answer 6

Reactive gliosis (astrocytes) + vascular proliferation

Question 7

What is seen Histologically post stroke?

>2 weeks

Answer 7

Glial scar

Question 8

What are the 3 types of ischemic stroke and how do they tend to differ

Answer 8

Thrombotic: clot formation directly at site of infaction (usually atherosclerotic) (commonly MCA)

Embolic: embolus from another part of body; can affect MULT vascular territories (afib, DVT w/ patent foramen, carotid stenosis)

Hypoxic: due to hypoperfusion or hypoxia; common during cv surgeries tends to affect watershed areas

Question 9

Presentation of altered level of consciousness, bulging fontanelle, hypotension, seizures, and coma in a preme infant

Answer 9

intraventricular hemorrhage into ventricles/perivent white matter; commonly due to rupture in germinal matrix due to reduced glial fiber support and impaired BP autoreg in premature infants

Question 10

What intracranial hemorrhage does not cross suture lines

Answer 10

Epidural hematoma (mm artery damage)

Question 11

What intracranial hemorrhage does cross suture lines

Answer 11

Subdural hematoma (bridging veins tear)

Question 12

What is one possible associated risk with an Epidural Hematoma

Answer 12

Transtentorial herniation –> CN III palssy

Question 13

What causes a hypodense vs a hyperdense subdural hematoma

Answer 13

Hyperdense: acute (trauma or high impact)

HypOdense: chronic (mild trauma, cerebral atrophy, elderly, alcoholism)

Question 14

Which type of brain bleed would you see in a shaken baby

Answer 14

Subdural hematoma (also may see broken ribs)

Question 15

If a spinal tap is bloody or xanthochromic what would the associated hemorrhage be

Answer 15

Subarachnoid hemorrhage ( can be due to trauma, rupture of aneurysm or arteriovenous malformation
(worst headache of my life, rapid time course)

Question 16

What is the relationship of vasospasm to stroke pathology

Answer 16

After a stroke (usually subarachnoid) 3-10 days after due to blood breakdown or rebleed –> vasospasm occurs
This leads to an ischemic infarct
(pts given nimodipine to prevent/reduce)

Question 17

A subarachnoid hemorrhage puts you at greater risk for what in the future

Answer 17

developing communicating and/or obstructive hydrocephalus

Question 18

What are the most common causes of intraparenchymal hemorrhage?

Answer 18

Systemic hypertension (most common)
Amyloid angiopathy (recurrent lobar hemorrhagic stroke in elderly) 
Vasculitis
Neoplasm
Secondary to reperfusion from ischemic

Question 19

Where are hypertensive hemorrhages most commonly seen?

Answer 19

(charcot bouchard microaneurysms- not visible on CT)
Basal ganglia (lenticulostriate) (MC)
Thalamus
Pons
Cerebellum

Question 20

A stroke in this artery covers what areas:

Middle Cerebral Artery (3)

Answer 20

Motor/Sensory Cortices (upper limb/face)
Temporal lobe (wernicke area)
Frontal lobe (brocas area)

Question 21

A stroke in this artery presents with what symptoms:

Middle Cerebral Artery

Answer 21

Contralateral paralysis and sensory loss (face and upper limb)

Aphasia if in dominant hemisphere
Hemineglect if on nondominant

Wernicke aphasia is associated with a right superior quadrant visual field defect due to temporal lobe involvement

Question 22

A stroke in this artery covers what areas:

Anterior Cerebral Artery (1)

Answer 22

Motor/Sensory Cortices (lower limb)

Question 23

A stroke in this artery presents with what symptoms:

Anterior Cerebral Artery

Answer 23

Contralateral paralysis and sensory loss lower limb- URINARY INCONTINENCE

Question 24

A stroke in this artery covers what areas:
Lenticulostriate Artery (2)

Answer 24

Striatum

Internal Capsule

Question 25

A stroke in this artery presents with what symptoms: | Lenticulostriate Artery

Answer 25

Contralateral paralysis ABSENCE OF CORTICAL SIGN (common location of lacunar infarcts due to hyaline arteriosclerosis due to hypertension)

Question 26

A stroke in this artery covers what areas: | Anterior Spinal Artery (3)

Answer 26

Lateral Corticospinal Tract Medial lemniscus Caudal medulla-hypoglossal nerve

Question 27

A stroke in this artery presents with what symptoms: | Anterior Spinal Artery

Answer 27

Contralateral paralysis (upper and lower limb) (lateral corticospinal) Dec Contralateral proprioception (med lem) Ipsilateral hypoglossal dysfunction (tongue deviates ipsilaterally (lick your lesion)

Question 28

A stroke in this artery covers what areas: | Posterior Inferior Cerebellar Artery (6)

Answer 28

``` Lateral Medulla: Nucleus ambiguus (CN IX, X, XI) Vestibular nuclei Lateral spinothalamic tract Spinal Trigem nucleus Sympathetic fibers Inferior Cerebellar peduncle ```

Question 29

A stroke in this artery presents with what symptoms: | Posterior Inferior Cerebellar Artery

Answer 29

Dysphagia, hoarseness, dec gag reflex, hiccups (nuc ambiguus) Vomiting, vertigo, nystagmus Dec pain/temp from CONTRA body IPSI face (spino thal, spinal trigem nuc) Ipsilateral horner (symp fibers) Ipsilateral ataxia, dysmetria (inf ped)

Question 30

A stroke in this artery covers what areas: | Anterior Inferior Cerebellar Artery (8)

Answer 30

``` Lateral Pons: Facial Nucleus Vestibular Nuclei Spinothalamic tract Spinal trigeminal nucleus Sympathetic fibers Middle Cerebellar peduncles Inferior Cerebellar peduncles Labyrinthine Artery ```

Question 31

A stroke in this artery presents with what symptoms: | Anterior Inferior Cerebellar Artery

Answer 31

Paralysis of face (LMN vs UMN in cortical stroke) (dec lac, sal, taste from ant 2/3 tongue) (CNVII) Vomiting Vertigo Nystagmus (VN) Dec pain/tem from CONTRA body IPSI Face (spinothal, spinal trigem nuc) Ipsilateral horners (symp fibers) Ataxia, dymetria (mid/inf ped) Ipsilateral sensorineural defness/vertigo (lab)

Question 32

``` A stroke in this artery covers what areas: Basilar Artery (5) ```

Answer 32

``` Pons, Medulla, Lower midbrain Corticospinal tract Corticobulbar tract Ocular cranial nerve nuclei Paramedian pontine reticular formation ```

Question 33

A stroke in this artery presents with what symptoms: | Basilar Artery

Answer 33

RAS spared- So preserved consciousness Quadriplegia (CS/CB) loss of voluntary face, mouth, tongue movements (CS/CB) Loss of horizontal but not vertical eye movements (Ocular/PPRF)

Question 34

A stroke in this artery covers what areas: | Posterior Cerebral Artery (1)

Answer 34

Occipital lobe

Question 35

A stroke in this artery presents with what symptoms: | Posterior Cerebral Artery

Answer 35

Contralateral hemianopia with macular sparing alexia without agraphia (dominant hemisphere/ PT CAN WRITE BUT NOT READ)

Question 36

What would be seen with a: | Cingulate (subfalcine) herniation under falx cerebri

Answer 36

Can compress anterior cerebral artery

Question 37

What would be seen with a: | Transtentorial (central downward herniation)

Answer 37

caudal displacement of brain stem | can rpture paramedian basilar artery branches --> duret hemorrhages

Question 38

What would be seen with a: | uncal herniation

Answer 38

Uncus=medial temporal lobe Compresses ipsilateral CNIII and contralateral crus cerrebri against kernohan notch see CNIII palsy and or ipsilateral hemiparesis (false localizing sign)

Question 39

What would be seen with a: | Cerebellar tonsillar herniation into foramen magnum

Answer 39

Coma and death when they compress the brainstem