Vascular Neurology Flashcards
What are the factors of ABCD2 in TIA and what does it measure?
ABCD2 score provides an evaluation of this risk of stroke.
Age of 60 years or more (1 point); Blood pressure of 140/90 mm Hg or greater (1 point); Clinical symptoms (1 point for speech impairment without weakness and 2 points for focal weakness); Duration of symptoms (1 point for 10 to 59 minutes and 2 points for 60 minutes or more) Diabetes (1 point).
2-day risk of stroke 0-1 = 0% 2-3= 1.3% 4-5= 4.1% 6-7=8.1%
What is the maximum score of NIHSS?
maximum score is 42, with higher scores representing worse neurologic deficits
In a patient presenting with acute neurologic symptoms, the first thing to do is to obtain a brain CT scan to rule out an intracranial hemorrhage (ICH). True or False?
True
What is the tPA dose and mode of giving it?
The dose is 0.9 mg/kg, with a 10% bolus and the rest over 1 hour, with a maximum dose of 90 mg.
In venous sinus thrombosis, what is the most frequent symptom?
Headache, 90% of cases
Thrombosis of Sagittal Sinus leads to?
infarcts in the parasagittal cortex bilaterally along the sinus
What are the components of Lateral Medullary Syndrome What is the vessel involved? Eponym?
Wallenberg’s syndrome
Due to occlusion of the posterior inferior cerebellar artery (PICA)
components:
- Vestibular nuclei, causing vertigo, nystagmus, nausea, and vomiting.
- Descending tract and nucleus of the fifth cranial nerve, producing impaired sensation on the ipsilateral hemiface.
- Spinothalamic tract, producing loss of sensation to pain and temperature in the contralateral hemibody.
- Sympathetic tract, manifesting with ipsilateral Horner’s syndrome with ptosis, miosis, and anhidrosis.
- Fibers of the ninth and tenth cranial nerves, presenting with hoarseness, dysphagia, ipsilateral paralysis of the palate and vocal cord, and decreased gag reflex.
- Cerebellum and cerebellar tracts, causing ipsilateral ataxia and
lateropulsion.
- Nucleus of the tractus solitarius, causing loss of taste.
What is most common site of a vertebral dissection?
at the level of C1-C2 (artery is mobile as it is leaving the transverse foramina and entering cranium)
What is the gold standard diagnostic test for an arterial dissection? Findings?
catheter angiogram to evaluate the cervicocerebral arteries
Findings: narrowing of the vessel, the extension of the dissection with an intimal flap, or double lumen
What is the risk for symptomatic ICH after rTPA?
6.4%
What is the etiology of transient monocular blindness or amaurosis fugax?
which may be caused by atherosclerotic stenosis of the ipsilateral ICA.
Retinal artery originates from the ophthalmic artery, which is a branch of the ICA. Transient occlusion of the retinal or ophthalmic arteries may manifest as amaurosis fugax.
In AICA infarct, what is the most striking symptom?
hearing loss has been attributed to involvement of the lateral pontomedullary tegmentum
What may produce bilateral thalamic infarction?
Occlusion of the artery of Percheron (a single artery called the artery of Percheron will arise from the P1 segment on one side and will supply the medial thalami bilaterally)
Thrombosis of the deep venous structures
What does the recurrent artery of Heubner supply? It is a branch of?
recurrent artery of Heubner is a branch of the ACA that supplies the anterior limb of the internal capsule, the inferior part of the head of the caudate, and the anterior part of the globus pallidus.
What are the common locations of lacunar infarction?
Lacunar infarcts occur in the putamen, caudate nuclei, thalamus, basis pontis, internal capsule, and deep hemispheric white matter.
What are the syndromes of lacunar infarction and location?
Pure motor: lenticulostriate branch (posterior limb of internal capsule); lacunes of ventral pons
Pure sensory: lacune in thalamus
Clumsy-hand dysarthria: lacune in the paramedian pons; lacune in posterior lmb of internal capsule
ataxic hemiparesis: lacune in pons, midbrain, internal capsule or parietal white matter
Lacunar infarct may produce sudden onset symptoms; however, it is not infrequent to see a stepwise “stuttering” progression of the neurologic deficits over minutes, and sometimes over hours to even days. True or False?
True
What are the structures that Lenticulostriate branches of MCA supplies?
These lenticulostriate branches provide vascular supply:
- putamen
- part of the head and body of the caudate nucleus
- the outer globus pallidus
- the posterior limb of the internal capsule
- the corona radiata
In the superior division of MCA, what are the symptoms?
Contralateral hemiparesis affecting mainly arm and face (lateral hemispheric surface)
Eye deviation ipsilateral (frontal eye fields)
Broca’s or motor aphasia (dominant inferior frontal gyrus)
What is the presentation of an ACA occlusion distal to the anterior communicating artery?
- contralateral sensorimotor deficits of the lower extremity, sparing the arm and face
- urinary incontinence due to involvement of the medial micturition center in the paracentral lobule;
- deviation of the eyes to side of the lesion and paratonic rigidity occur.
What does artery of Heubner supply?
- anterior limb of the internal capsule
- the inferior part of the head of the caudate nucleus
- anterior part of the globus pallidus.
What are the four major arteries supplying the thalamus?
- Thalamoperforating or Paramedian artery- originates from P1 segment of PCA –> medial aspect of thalamus; dorsomedial nucleus
- Thalamogeniculate artery - originates from P2 segment of PCA –> lateral aspect of thalamus; ventral lateral group nuclei
- Posterior choroidal artery –> originates from P2 segment of PCA ; posterior aspect of the thalamus; pulvinar
- Tuberothalamic artery (Polar Artery) - originating from posterior communicating artery –> anterior portion of thalamus; ventral anterior nucleus
ANTERIOR CHOROIDAL ARTERY DOES NOT SUPPLY THE THALAMUS
What does superior cerebellar artery (SCA) supply?
-superior half of the cerebellar hemisphere (superior vermis, superior cerebellar peduncle, upper lateral pons)
What does anterior inferior cerebellar artery (AICA) supply?
inferolateral pons, middle cerebellar peduncle, and a strip of the ventral cerebellum between the posterior inferior cerebellar and superior cerebellar territories
What does posterior inferior cerebellar artery (PICA) supply?
lateral medulla, most of the inferior half of the cerebellum and the inferior vermis
What cortical part is affected in Wernicke’s aphasia (receptive)?
posterior aspect of the superior temporal gyrus
Anterior choroidal artery arise from ____ and supplies _____.
ICA just above the origin of the posterior communicating artery;
internal segment of the globus pallidus
part of the posterior limb of the internal capsule
part of the geniculocalcarine tract
choroid plexus of lateral ventricle (temporal horn)
What are the segments of ACA?
A1 segment - from the ICA terminus to the anterior communicating artery
A2 segment- from the anterior communicating artery to the bifurcation into pericallosal and callosomarginal arteries
A3 segment- distal branches after this bifurcation
What are the clinical manifestations of watershed infarcts?
- proximal weakness, affecting the proximal upper and proximal lower extremities, with weakness at the shoulder and at the hip
- in severe cases, “person-in-a-barrel” syndrome
What is medial medullar syndrome? What is the occlusion?
caused by occlusion of the vertebral artery or one of its medial branches
affecting the pyramid: contralateral arm and leg weakness, sparing the face
medial lemniscus: contralateral loss of sensation to position and vibration
emerging hypoglossal fibers: ipsilateral tongue weakness
65/Female
complains of headaches, associated with generalized constitutional symptoms, jaw claudication, and tenderness of the scalp around the temporal artery. Diagnosis and management?
Temporal Arteritis/Giant Cell Arteritis
CBC: Leukocytosis
Elevated ESR and CRP
Biopsy of temporal artery (granulomatous inflammation)
If with visual manifestation: Start steroids ASAP
49/F presents with acute contralateral hemiplegia with ipsilateral facial palsy. Diagnosis?
Millard–Gubler syndrome (pons: corticospinal tract + CN VII nerve/nucleus)
49/F presents with acute contralateral hemiplegia with ipsilateral facial palsy with conjugate gaze paralysis. Diagnosis?
Foville syndrome
pons: corticospinal tract + CN VII nerve/nucleus + MLF
Posterior circulation aneurysms have a lower risk of rupture when compared with anterior circulation aneurysms. True or False?
False.
Posterior circulation have higher risk of rupture
What are the risks of Aneurysmal rupture?
Size >7mm Aneurysmal location (posterior>>anterior) smoking uncontrolled hypertension previous history of aneurysmal rupture
Occipital strokes in the dominant hemisphere may manifest with…
alexia (inability to read)
anomia
achromatopsia (color anomia)
other visual agnosias
Benedikt’s Syndrome, components and location?
ipsilateral third nerve palsy (CN III fascicle)
contralateral involuntary movements such as tremor and choreoathetosis (red nucleus, brachium conjunctivum)
mesencephalic tegmentum in its ventral portion
What is the trial involved with intracranial stenosis and antiplatelet vs anticoagulation?
Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial
What is the target INR for warfarin anticoagulation? Also, what is the targe for those on mechanical valves?
INR between 2.0 and 3.0
If with MV: INR is 2.5 to 3.5
Which trial studied the effect of atorvastatin at a dose of 80 mg daily in patients with a recent (within 6 months) TIA or stroke, with low-density lipoprotein (LDL) between 100 and 190 mg/dL?
Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL)
Which trial compared best medical therapy versus intracranial stenting in patients with intracranial stenosis (70% to 99% stenosis) and recent stroke or TIA, demonstrating that medical therapy is superior.
SAMMPRIS (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) trial
