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Neurology – Stroke Essay Example

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Pages: 6 (1544 words)
Published: April 17, 2018

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question

What are the major types of stroke?

answer

Ischemic, hemorrhagic, (hemorrhagic transformation from ischemic)

question

What are the primary sources of ischemic stroke?

answer

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?

answer

Migraine, postictal paresis, hypoglycemia, conversion disorder, subdural hematoma, and brain tumors

question

what are the most common causes of ischemic stroke?

answer

Atherosclerosis and cardioembolism

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question

Define the term stroke

answer

sudden onset of neuro deficits of a vascular basis with infarction of CNS tissue

question

Define the term transient ischemic attack

answer

sudden onset of neuro deficits of a vascular basis without infarction

question

What are the main ischemic causes of stroke?

answer

-large vessel disease (atherosclerotic) -cardioembolic -lacunar/small artery occlusion -other -undetermined

question

What are the main causes of hemorrhagic stroke?

class="lbl">answer

-intracerebral hemorrhage (ICH) -subarachnoid hemorrhage

question

What deficits might an ACA stroke produce?

answer

Contralateral leg paresis and sensory loss

question

What deficits might a MCA stroke produce?

answer

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

question

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

question

What deficits might a basilar artery stroke produce?

answer

Locked in syndrome 1. Quadriparesis or quadriplegia 2. Anarthria or dysarthria 3. Impaired horizontal eye movements 4. Spared vertical eye movements

question

What deficits would a medial medullary infarct produce?

answer

Anterior spinal artery Contralateral hemiparesis (facial sparing), contralateral impaired proprioception and vibration sensation, ipsilateral tongue weakness

question

What deficits would a PICA stroke produce?

answer

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

question

Describe a large vessel stroke

answer

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

question

Describe the primary mechanism of small vessel/lacunar strokes

answer

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

question

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%

question

What are the possible mechanisms for ICH?

answer

Hypertensive Trauma, amyloid angiopathy, vascular malformation, vasculitis, drug use

question

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

question

What mimics are important to rule out when stroke is suspected?

answer

seizure/post-ictal, hypoglycemia, migraine, conversion disorder

question

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.

question

What should the target blood pressure be for patients following a stroke?

answer

Uncertain Benefit associated with reduction of 10/5 mmHg (PROGRESS trial)

question

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.)

question

How can a cervical artery dissection lead to stroke?

answer

Ischemic stroke: emboli from injured intima (>90%), hemodynamic compromise from reduced flow SAH (1%)

question

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

question

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

Neurology – Stroke Essay Example

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