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question
What are the major types of stroke?
answer
Ischemic, hemorrhagic, (hemorrhagic transformation from ischemic)
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What are the primary sources of ischemic stroke?
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Large artery atherosclerosis Cardioembolism Small-vessel occlusion Stroke of other determined etiology Stroke of undetermined etiology (2+ causes, negative evalua
...
tion, or incomplete evaluation)
question
What is the differential diagnosis for stroke?
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Migraine, postictal paresis, hypoglycemia, conversion disorder, subdural hematoma, and brain tumors
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what are the most common causes of ischemic stroke?
answer
Atherosclerosis and cardioembolism
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question
Define the term stroke
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sudden onset of neuro deficits of a vascular basis with infarction of CNS tissue
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Define the term transient ischemic attack
answer
sudden onset of neuro deficits of a vascular basis without infarction
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What are the main ischemic causes of stroke?
answer
-large vessel disease (atherosclerotic) -cardioembolic -lacunar/small artery occlusion -other -undetermined
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What are the main causes of hemorrhagic stroke?
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-intracerebral hemorrhage (ICH) -subarachnoid hemorrhage
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What deficits might an ACA stroke produce?
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Contralateral leg paresis and sensory loss
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What deficits might a MCA stroke produce?
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Proximal occlusion involves: 1. Contralateral weakness and sensory loss of face and arm 2. Cortical sensory loss 3. May have contralateral homonymous hemianopia or quadrantanopia 4. If left hemisphere: aphasia 5. If right: neglect 6. Eye deviation toward side of lesion and away from weak side
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What deficits might a PCA stroke produce?
answer
1. Contralateral hemianopia or quadrantanopia 2. Alexia without Agraphia if left PCA 3. Midbrain findings: CN III and IV palsy/pupillary changes, hemiparesis 4. Thalamic findings: sensory loss, amnesia, decreased LOC 5. If bilateral: cortical
blindness or Prosopagnosia
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What deficits might a basilar artery stroke produce?
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Locked in syndrome 1. Quadriparesis or quadriplegia 2. Anarthria or dysarthria 3. Impaired horizontal eye movements 4. Spared vertical eye movements
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What deficits would a medial medullary infarct produce?
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Anterior spinal artery Contralateral hemiparesis (facial sparing), contralateral impaired proprioception and vibration sensation, ipsilateral tongue weakness
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What deficits would a PICA stroke produce?
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Lateral medullary or Wallenburg syndrome Ipsilateral ataxia, ipsilateral Horner's, ipsilateral facial sensory loss, contralateral limb impairment of pain and temperature sensation, nystagmus, vertigo, n/v, dysphagia, dysarthria, hiccups
question
What deficits would a lacunar infarct produce?
answer
-pure motor hemiparesis: contralateral leg, arm, face -pure sensory loss: hemisensory loss (usually thalamic) -ataxic hemiparesis: ipsilateral ataxia and leg paresis -dysarthria-clumsy hand syndrome
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Describe a large vessel stroke
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Typically involves stenosis or occlusion of the internal carotid artery but can also involve the vertebral and intracranial arteries Underlying processes: atherosclerosis (most common), dissection and vasculitis
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Describe the primary mechanism of small vessel/lacunar strokes
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Primary mechanism: chronic hypertension stimulates cerebral blood vessels resulting in lipohyalinosis and microatheroma (an attempted adaptive response to preserve the blood-brain barrier), which causes vessel wall thickening and decreased luminal diameter - lipohyalinosis affects mainly small penetrating arteries (<200 mm in diameter) usually leading to lacunar infarcts of the basal ganglia, internal capsule and thalamus
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What are the common causes of cardioembolic stroke?
answer
Atrial fibrillation (most common), rheumatic valve disease, prosthetic heart valves, recent MI, fibrous and infectious endocarditis
question
What is hypertension encephalopathy?
answer
Acute severe HTN (typically dBP > 130 or sBP> 200) can cause hypertensive encephalopathy- abnormal fundoscopic exam (papilledema, hemorrhages, exudates, cotton-wool spots), focal neurologic symptoms, nausea, vomiting, visual disturbances and change in LOC.
question
How common is early seizure activity in patients after ICH?
answer
5-25%
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What are the possible mechanisms for ICH?
answer
Hypertensive Trauma, amyloid angiopathy, vascular malformation, vasculitis, drug use
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How common is hemorrhagic transformation following initial infarction?
answer
20-40% of patients with ischemic stroke may develop hemorrhagic transformation within 1 wk after the initial infarction.
question
What investigations are necessary in the assessment of a stroke?
answer
CBC, electrolytes, creatinine, PTT/INR, ECG and urgent CT to rule out hemorrhage and assess infarct
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What mimics are important to rule out when stroke is suspected?
answer
seizure/post-ictal, hypoglycemia, migraine, conversion disorder
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What are the CT signs of acute stroke?
answer
• loss of cortical white-grey differentiation • sulcal effacement (i.e. mass effect decreases visualization of sulci) • hypodensity of parenchyma • insular ribbon sign • hyperdense MCA sign
question
Describe the appearance of T1, T2, and T2 flair MRI images
answer
T1 - anatomically correct: white matter is white, grey matter is grey T2 - backwards from T1, and CSF is white T2 flair - backwards from T1, CSF is dark
question
What are the antiplatelet therapy options for secondary prevention of stroke?
answer
Aspirin Clopidogrel (Plavix) Aspirin-extended release dipyridamole (Aggrenox)
question
Which antiplatelet therapies
are preferred for the secondary prevention of stroke?
answer
Clopidogrel (75 mg daily) or aspirin-extended release dipyridamole (25mg/200mg bid) over aspirin (although still an acceptable choice) 2A evidence
question
What dose of aspirin is acceptable to provide secondary prevention of ischemic stroke?
answer
50-100 mg daily (Grade 1B) Fewer GI side effects and bleeding using lower doses (<325 mg)
question
Should aspirin and clopidogrel be used in combination in the secondary prevention of ischemic stroke?
answer
No Lack of efficacy compared with clopidogrel alone and substantially increased risk of bleeding complications Some exceptions: recent MI, ACS, or arterial stent placement
question
Is it helpful to start antihypertensive therapy once a stroke has stabilized?
answer
antihypertensive therapy can reduce the rate of recurrent stroke, independent of the baseline blood pressure.
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What should the target blood pressure be for patients following a stroke?
answer
Uncertain Benefit associated with reduction of 10/5 mmHg (PROGRESS trial)
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What lifestyle modifications are beneficial in the treatment of hypertension?
answer
Weight loss Salt restriction DASH diet Physical activity Limited alcohol consumption
question
Which patients should be treated for hypertension long term following a ischemic stroke or TIA?
answer
Most patients, except normotensive patients whose stroke was cardioembolic, or patients whose initial BP is <120/70 mmHg.
question
Which antihypertensive agents should be used in the secondary prevention of stroke
answer
CHEP guidelines: ACEi + diuretic ACCOMPLISH trial: ACEi + long acting dihydropyridine calcium channel blocker
question
What are the different possible components of aphasia?
answer
1) fluency - sparse output, grammar mistakes, simplified, breakdown of speech praxis (any articular sounds) 2) content - paraphasias, neologisms 3) repetition 4) naming - can be specific or general 5) comprehension - difficulty understanding commands, appendicular vs. axial 6) reading 7) writing
question
A bright lesion on DWI and a matching dark lesion on ADC suggests what?
answer
acute stroke
question
A black lesion on SWI suggests what?
answer
hemosidirin
question
What are the common etiologies of cervical artery dissection?
answer
Spontaneous Traumatic (MVA, strangulation, direct blow, chiro, whiplash, etc.)
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How can a cervical artery dissection lead to stroke?
answer
Ischemic stroke: emboli from injured intima (>90%), hemodynamic compromise from reduced flow SAH (1%)
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What is the classic triad of carotid dissection? How often does this occur?
answer
<1/3 of patients 1) pain on one side of head, neck, or face 2) partial Horner's syndrome (miosis, ptosis) 3) cerebral or retinal ischemia (50-95%, may be delayed finding)
question
What are the presenting signs and symptoms for carotid dissection?
answer
Ischemic stroke TIA Retinal ischemia Local signs/symptoms (H/A, neck pain, Horner, CN palsy) Tinnitus
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How do you differentiate between a ptosis due to Horner's and a ptosis due to a CN III palsy?
answer
Horner's: not complete ptosis CN III: complete, down and outward eye deviation
question
What are the indications for rtPA in stroke?
answer
W/in 4.5 hrs of acute ischemic onset With no hemorrhage on CT, no large MCA infarct, clinical indication, no contraindications
question
What are the absolute contraindications to using rTPA in an ischemic stroke?
answer
Improving sx, minor sx, hemorrhage or mass on CT, high INR or aPTI, seizure at stroke onset, recent major surgery or trauma, recent Gl or urinary hemorrhage, recent LP or arterial puncture at noncompressible site, sBP > 185, dBP > 11 0, aggressive Rx to decrease BP. uncontrolled serum glucose, thrombocytopenia, PMHx ICH, sx of SAH/pericarditis/MI, pregnant.
question
When is anti-platelet therapy indicated in the setting of acute stroke?
answer
-Give at presentation of TIA or stroke if rTPA not received -If rtPA given at stroke onset, delay acute antiplatelet/anticoagulation treatment by 24 h.
question
Which patients should receive antihypertensive therapy in the acute phase on ischemic stroke?
answer
Only those with sBP >220 or dBP >120 OR pre-eclampsia/eclampsia, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or active ischemic heart disease
question
What are the treatment options for asymptomatic carotid stenosis?
answer
carotid endarterectomy is controversial - if stenosis >60%, risk of stroke is 2% per yr; carotid endarterectomy reduces the risk of stroke by 1% per yr (but 5% risk of complications)
question
What are the treatment options for carotid stenosis
answer
-carotid endarterectomy benefits those with symptomatic severe stenosis (70-99%); less beneficial for symptomatic moderate stenosis (50-69%) (NASCET trial) -endarterectomy and carotid stenting have similar benefits in a composite endpoint of reduction of stroke, MI and death (stenting results in higher rate of stroke periop, endart higher rate of MI) (CREST trial)
question
What are the anticoagulation options to prevent strokes in the setting of atrial fibrillation?
answer
CHADS2 score 0
(very low risk): antiplatelet 1 (low risk): anticoagulant or antiplatelet >2 (mod-high risk): anticoagulant (dabigatran or warfarin)
question
Is dabigatran or warfarin preferable for anticoagulation in high risk atrial fibrillation?
answer
RELY trial suggest dabigatran, but due to lack of reversible agent, practically warfarin is preferred
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