Ch82 Special stroke conditions

Question 1

What are features of cerebellar strokes?

Answer 1

Ataxia Nystagmus Dysarthria Later patients develop hydrocephalus and brainstem compression

Question 2

How do you manage brainstem compression from a cerebellar stroke?

Answer 2

Suboccipital craniectomy and wide opening of the of the foramen magnum.

Question 3

What % of MCA strokes developed malignancy MCA syndrome?

Answer 3

10% (has an 80% mortality)

Question 4

What are the NICE guidelines for decompressive hemicraniectomy in stroke?

Answer 4

NICE guidelines 2018 based on HAMLET, DESTINY and DECIMAL: Within 48 hours of symptom onset NIHSS >15 with 1 point in the 1a critera (not alert) >50% of the MCA territory infarcted or >145cc stroked on MRI Benefit is greater if <60 years but DESTINY-2 showed sustained benefit >60 years (max age in the study was 82 years) Note: other territory involvement and dominant hemisphere does not change decision This reduces mortality and improves favorable functional outcome.

Question 5

How do you calculate the risk of stroke in AF?

Answer 5

CHADS2 CHF HTN Age>75 DM Systemic emboli Annual stroke risk is 3x the score e.g. 6 points = 18%/year

Question 6

What are the features of vertebro-basilar insufficiency?

Answer 6

Drop attacks Diplopia Dysarthria Defects in vision Dizziness May be due to craniocervical instability causing vertebral compression

Question 7

What is Bow hunter’s sign / stroke?

Answer 7

When head-turning causes VA occlusion and signs of vertebrobasilar insufficiency. Get a CT-A to see the bony anatomy. Treat with C1/2 fusion

Question 8

What are the 3 types of venous thrombosis?

Answer 8

Dural sinus thrombosis Cortical venous thrombosis Deep venous thrombosis

Question 9

What are the risk factors for cerebral venous thrombosis?

Answer 9

Infection Pregnancy OCP Sickle cell Hypercoagulable state (protein C & S deficiency and antithrombin 3 deficiency) Malignancy Diabetes

Question 10

What is the sign of SSS thrombosis on CTV?

Answer 10

Empty delta sign

Question 11

What is the treatment of cerebral venous thrombosis?

Answer 11

Anticoagulation with LMWH (even if ICH!) Thrombectomy if amenable Decompressive craniectomy/ EVD for ICP managment and if herniation

Question 12

What is Moya Moya?

Answer 12

Progressive bilateral spontaneous occlusion of the ICAs with compensatory capillary collaterals (puff of smoke). ICA shows intimal thickening histologically.

Question 13

How does Moya moya present?

Answer 13

Presents with TIA/Stroke is children and bleeds in adults.

Question 14

What factor is elevated in the dura and scalp of patients with moya moya?

Answer 14

FGF

Question 15

What are the age peaks for Moya Moya?

Answer 15

Juvenile <10 years and adult 30-40 years

Question 16

What layer of the scalp is the STA found?

Answer 16

Deep to the superficial temporalis fasia

Question 17

Which conditions cause secondary moya moya

Answer 17

Grave’s disease

Radiotherapy / Proton beam

TB meningitis

Retinitis pigmentosa

Fibromucular dysplasia

NF1 / Down syndrome / TS / Apert’s / SLE

Question 18

How is the diagnosis of Moya Moya made?

Answer 18

Bilateral stenosis of the terminal ICAs with the presence of dilated collateral supply

Question 19

What are the angiographic stages of Moya Moya?

Answer 19

1. Bilateral ICA stenosis
2. Development of collaterals at base of brain
3. Development of significant collaterals
4. Extracranial collaterals
5. Circle of willis and PCA occluded
6. Compete absence of major cerebral arteries

Question 20

What is the goal of EC/IC bypass for Moya Moya?

Answer 20

Prevent strokes (not TIAs)

Question 21

What are the direct and indirect surgical options for Moya Moya?

Answer 21

Direct = STA-MCA (can also use radial or saphenous grafts)

Indrect = Encephalomyosynangiosis = layering temporalis on the surface of the brain

Encephaloduralsynagiosis = suturing the STA to the pial surface