Stroke

Question 1

ABCD2 score

Answer 1

Age >60 (+1)
BP 140/90 (+1) 
Clinical features: unilateral weakness (+2), speech w/o weakness (+1)
Duration >60 min (+2)  or >10min (+1) 
Diabetes (+1) 

6-7 8.1% two day risk
4-5 4.1%
0-3 1%

Question 2

28 yo woman is 38 wks pregnant develops headache, lethargy, and then generalized seizure. Dx? Tx?

Answer 2

Venous Sinus Thrombosis,
In superior sagittal sinus thrombosis: focal signs and seizures.

Thought the lesion is frequently hemorrhagic, treatment is anticoagulation: heparin/warfarin.

Question 3

Agitation, quadrantanopsia, sensory neglect

Answer 3

nondominant parietotemporal (inferior branch mca) stroke. 
If dominant, will affect wernicke's area: word salad

Question 4

Factor V Leidon is the most common genetic risk factor for _______ and is associated with _________.

Answer 4

thrombophila, venous thrombosis. Stroke patients should be tested if they have a right to left shunt.

Question 5

Contraindications for tPA (3)

Answer 5

stroke or head trauma in past 3 mo.
major surgery in past 14 days
GI/U hemorrhage in past 21 days

Question 6

Distal symmetric polyneuropathy

Answer 6

Can be present in prediabetes.
Almost half of DM patients have. More common in TI
2hrGTT is more sensitive than Hgb A1c for detection of pre-diabetic glucose intolerance.
Thiazide diuretics?

Question 7

Indications for warfarin (6)

Answer 7

A fib
Decreased EF
mural thrombus
atrial clot
mechanical valves
DVT 

Give heparin for dissection

Question 8

Elderly lady suddenly becomes comatose.
location?
pathology?
sx?

Answer 8

likely brainstem disease
from pontine hemorrhage or basilar occlusion.
Will see pinpoint pupils, quadriparesis, ophthalmoplegia

Question 9

Manganese deposition

Answer 9

hepatocerebral degeneration in patients with chronic liver disease without neurologic signs. Will see TI hyperintesities in globus pallidus.

Question 10

hepatocerebral degeneration in patients with chronic liver disease without neurologic signs. Will see TI hyperintesities in globus pallidus.

Answer 10

Manganese deposition

Also think Copper for parkinson’s like neuro signs. check cu in urine and ceruloplasm.

Question 11

Heroin cns effects.

Answer 11

bradyphrenia (decreased speech output) cerebellar ataxia, quadriparesis, hemiparesis, myoclonus, pseudobulbar palsy, visual problems. due to spongiform white matter degeneration from toxin.

Question 12

cirrhosis and portal hypertension had mental status changes after esophageal variceal bleeding. Which of the following meds is most likely to improve his cognitive sx?

Answer 12

Rifaxim: abx confined to gut that eliminates bacterial flora leading to increased ammonia.

Question 13

flumazenil

Answer 13

benzo antagonist

Question 14

metronidazole

Answer 14

May treat: Trichomoniasis, Bacterial infection of the vagina, More

Question 15

n-acetylcysteine

Answer 15

acetylminophen overdose

Question 16

sulfoximine

Answer 16

?

Question 17

Infliximab

Answer 17

anti TNFalpha to counteract proinflammatory cytokine secreted by macrophages that contributes to granulomatous inflammation. Risk of reactivation of VZV.

Question 18

Chronic B6 deficiency

Answer 18

peripheral neuropathy with microcytic hypochromic anemia, hyperoxaluria, glossitis, and dermatitis.
Reduced pyridoxal phosphate (b6)

Question 19

Increased serum Methylmalonic acid

Answer 19

Assoc with B12 deficiency

Question 20

Reduced alpha tocopherol

Answer 20

Vit E deficiency

Question 21

Insulin neuritis (tx induced diabetic neuropathy)

Answer 21

Neuropathic sx can develop soon after initiation of insulin therapy and autonomic sx can occur as well. Spontaneous recover in 18 mo or later.

Question 22

2 days of confusion, diplopia, and ataxia after gastric bypass 2 weeks ago

Answer 22

Wiernicke’s encephalopathy

Give thiamine, don’t wait for lab tests.

Question 23

Deficiencies that can cause ataxia

Answer 23

Thiamine

Question 24

Things that can cause microcytic anemia

Answer 24

B6

Iron deficiency

Question 25

Spinocerebellar syndrome with some peripheral n involvement

romberg, dysmetria in arms and legs, absent jp and vibration to wrists and ankles, areflexia

Answer 25

Looks like Friedreich ataxia:
Vit E deficiency
why not b12?

Question 26

Stroke Mimics

Answer 26

Migraine
Seizure - post ictal paralysis, 
TIA
structural lesions
metabolic derangements
recrudescence
psychiatric disease (conversion, malingering)

Question 27

ACA Infarct

Answer 27

Isolated contralateral leg weakness or contralateral leg weakness.
Contralateral leg numbness
Ipsilateral gaze preference
Urge Incontinence

Question 28

MCA Infarct

Answer 28

Contralateral arm/face weakness and numbness
Complete homonymous hemianopia (quadrantonopsia if superior/inferior division)
Gaze preference
Aphasia (if dominant), Neglect (if non-dominant.)