NEURO-STROKE/TUMOR Flashcards
(264 cards)
1
Q
What is a stroke?
A
A stroke, or cerebrovascular accident, is an acute neurologic deficit due to damage to the brain tissue from a vascular cause.
2
Q
What are the two different causes of stroke?
A
Ischemic = blockage of vessel causing ischemia; Hemorrhagic = bleeding (aneurysm, HTN).
3
Q
What are the risk factors for stroke?
A
Primary and secondary prevention involves modifying risk factors.
4
Q
What is a TIA?
A
Transient Ischemic Attacks (TIAs) involve acute neurologic deficits that resolve without evidence of brain tissue damage.
5
Q
How long do TIA symptoms normally last?
A
Typically symptoms last < 1 hr, up to 24 hrs, and symptoms will oftentimes be relieved prior to their arrival to the emergency room.
6
Q
What is the epidemiology for stroke nationally?
A
5th leading cause of death; Estimated 7+ million people have had a stroke; Annual rate ~ 795,000 (>1/min)~ 600,000 are 1st occurrence.
7
Q
What are the medical risk factors for ischemic stroke?
A
Atherosclerosis, Heart disease (afib, HFrEF), Diabetes mellitus, Hyperlipidemia, Sickle cell disease, Hypercoagulable disorder, Obesity.
8
Q
What specific heart diseases put patients at higher risk of stroke?
A
Atrial fibrillation – 5x risk of stroke; Mechanical heart valve; Calcified heart valve; Coronary artery disease; CHF with EF < 25%.
9
Q
What are the medical risk factors for hemorrhagic stroke?
A
Vascular malformations and Amyloid angiopathy.
10
Q
What is the estimated percent of primary stroke prevention?
A
80% of first strokes are preventable.
11
Q
What are the non-modifiable risk factors for stroke?
A
Age, gender, race, genetic.
12
Q
What are the lifestyle risk factors for stroke?
A
Smoking (>50% increased risk), Alcohol abuse, Drugs (Illicit & prescribed), Diet, Exercise.
13
Q
What type of stroke do blood thinners increase the risk for?
A
Hemorrhagic.
14
Q
What are the medical risk factors for both ischemic and hemorrhagic stroke?
A
Poorly controlled hypertension; Hypertension increases risk of stroke by 50%.
15
Q
What are the two different types of strokes?
A
Ischemic and Hemorrhage.
16
Q
What is an ischemic stroke?
A
Damage to brain tissue occurs because of reduced blood flow to brain tissue. ~85-90% of all strokes in US.
17
Q
What is a hemorrhagic stroke?
A
Intracranial hemorrhage causes damage to brain tissue due to toxic effects of blood or mass effect due to increased pressure. ~10-15%.
18
Q
What are the functional areas of the cerebrum?
A
Cerebrum:
Frontal lobe (motor, personality, decision making)
Parietal lobe (somatosensory)
Temporal lobe (hearing, balance, some speech functioning-speech selection, long term memory formation)
Occipital lobe (vision)
Insula lobe (taste, dopamine system and risky behavior, addiction, time keeping)
19
Q
What is the primary motor and sensory cortex?
A
Upside down person. So damage to the top of the head causes issues with the lower limbs and extremities, while damage to the side of the head would cause issues with the face and upper extremities.
20
Q
What is the function of the spinocerebellum?
A
Coordination of motor signals out to muscles.
Medial portion = vermis; control of axial muscles. Lateral sides control arm and leg muscles.
21
Q
What is the role of the cerebrocerebellum?
A
Interacts with the motor cortex of the cerebrum to plan muscle movements.
22
Q
What does the vestibulocerebellum (flocculonodular lobe) control?
A
Balance and eye movements.
Receives signals from vestibulocochlear nerve and sends signals to muscles involved with posture.
23
Q
What are the functions of the cerebellum?
A
Motor coordination, proprioception, eye movement control.
Cerebellum receives signals from the contralateral cerebrum and sends signals to ipsilateral body.
24
Q
Which cranial nerves are associated with the midbrain?
A
Cranial nerves I-IV.
25
Which cranial nerves are associated with the pons?
Cranial nerves V-VIII.
26
Which cranial nerves are associated with the medulla?
Cranial nerves IX-XII.
27
What are the functions of the medulla?
Reticular activating systems, cardio functions, respiratory functions.
28
Basal ganglia influences
the output of the upper motor cortex neurons to help regulate movement and reduce unwanted muscle movements; no direct connection to cerebellum, but have complementary functions
29
Thalamus
Information processing and gate keeps what sensations get your focus. This structure is why we can dissociate while driving
30
What portions of the basal ganglia deal with movement?
Globus pallidus, putamen, caudate nucleus
31
White matter tracts carrying
signals from cerebrum to contralateral cerebellum and spinal cord. Damage to this causes decreased motor effects.
Damage here is going to give us weakness on the entire side of the body (face, arm, and legs, but no sensory problems). The issue is within the internal capsule, that is where the stroke is.
32
What is the vasculature anatomy of the brain?
Anterior circulation
- Common carotids (aortic arch)
- Internal carotids
- Anterior and middle cerebral arteries (ACA, MCA)
Posterior circulation
- Vertebral arteries
- Basilar artery
- Posterior cerebral arteries (PCA)
33
What arteries connect the circle of willis?
Anterior and posterior communicating arteries
34
Anatomy of the circle of willis
35
Common Carotids →
internal and external carotids
Internal carotids → Anterior cerebral artery (ACA) and Middle cerebral artery (MCA)
36
Subclavian arteries →
vertebral arteries → basilar artery → Posterior cerebral artery (PCA)
Cranial nerves I and II are around this area in addition to the pituitary
37
What does the anterior cerebral artery supply?
Supplies the anteromedial portion of the frontal, parietal lobes.
Feeds the top of the head
38
MCA Lenticulostriate arteries (“penetrating arteries”) supply
Basal ganglia and internal capsule
39
What are the vertebral arteries?
40
Aneurysms typically come off what?
The circle of Willis
41
What are the internal carotid arteries?
Ophthalmic a., Middle cerebral a. (MCA), Anterior cerebral a. (ACA)
42
If there was a clot of the ophthalmic artery, what kind of symptoms could we expect to see?
Loss of vision, curtain coming down over my vision, loss of peripheral vision, anything having to do with sudden onset vision impairment.
43
What structures lie in the middle of the circle of Willis?
The optic chiasm with CN I and II, the hypothalamus, and pituitary gland. Inflammation of these structures can lead to compression of the vessels within the circle of Willis; it can cause major problems.
44
Where is the most likely location for aneurysms to occur?
Circle of Willis
45
What symptoms are expected with a blockage of the anterior cerebral artery?
Leg weakness, leg impaired motor movement, and sudden personality changes.
46
What does the middle cerebral artery supply?
The superior division and inferior division supply the inferolateral frontal and parietal, superolateral temporal, and insula lobes.
## Footnote
WE DO NOT TEND TO SEE HEARING CHANGES when blockage of this artery occurs.
47
Where is the language center typically located?
For most people, it's on the left side of the brain because that's the dominant side.
48
What do lenticulostriate arteries supply?
They supply the deep structures of the brain, including the internal capsule and basal ganglia.
49
What symptoms result from damage to the internal capsule?
Hemiparesis, Hemiparesis sensory loss
50
What supplies the posterior circulation?
Vertebral arteries, Basilar artery, Posterior cerebral artery
51
What does the vertebral arteries supply?
The medial medulla forms the basilar artery. Major branch: posterior inferior cerebellar artery.
52
What does the basilar artery supply?
The medial pons. Major branches: superior cerebellar and anterior inferior cerebellar arteries.
53
What does the posterior cerebral artery supply?
Supplies the thalamus (sensory loss), occipital lobe (vision loss), and inferior temporal lobe.
54
What is the pathophysiology of stroke?
1. Thrombosis (~ 50% of all strokes)
2. Embolus (most likely from A Fib and heart conditions)
3. Systemic hypoperfusion (watershed stroke)
55
How does thrombosis stroke occur?
Clot formation in a vessel leads to stenosis or occlusion. Clot formation is promoted by: Atherosclerosis, Lipohyalinosis.
56
What are less common causes of thrombosis stroke?
Infection (COVID!), Vasculitis, Dissection, Vasoconstriction, Coagulation disorders, Inflammatory disorders.
57
What is lipohyalinosis?
Thickening and narrowing of smaller blood vessels of the brain, likely due to hypertension and/or inflammation. This is more likely to occur in the Lenticulostriate arteries.
## Footnote
May also be called lacunar stroke.
58
Large vessel thrombosis
Large vessel thrombosis usually due to stenosis from atherosclerosis
Usually affect the cerebrum
Due to middle cerebral, posterior cerebral
The image is most likely due to middle cerebral stroke
59
Small vessel thrombosis
Small vessel thrombus usually due to narrowing from lipohyalinosis
Usually affect deep internal structures (basal ganglia, internal capsule, thalamus)
“lacunar” strokes
60
Stroke causes necrosis of tissue and leaves behind
Gapping holes of fluid (encephalomalacia)
61
Embolus stroke pathophysiology
Material from another site travels and occludes a vessel
Thrombus/ plaque debris (most common): Cardiogenic, Arterial (usually aortic or carotid), Cryptogenic (unknown)
Infection (endocarditis-vegetation of the heart valves)
Cholesterol, fat (bone fracture)
Air or other gas
62
What cardiogenic factors are associated with embolism stroke?
Atrial fibrillation
63
What cardiogenic factors are associated with embolism stroke?
Mechanical heart valves
64
What cardiogenic factors are associated with embolism stroke?
Patent foramen ovale (PFO)
## Footnote
DVT that normally would have gone from the right side and to the lungs, but now it can crossover and travel to the brain.
65
What cardiogenic factors are associated with embolism stroke?
Rheumatic aortic valves
66
What cardiogenic factors are associated with embolism stroke?
HFrEF with EF < 30%
67
What cardiogenic factors are associated with embolism stroke?
Dilated cardiomyopathy
## Footnote
HTN is the most common reason, alcohol.
68
What cardiogenic factors are associated with embolism stroke?
CABG surgery
69
What cardiogenic factors are associated with embolism stroke?
Left atrial myxoma (tumor)
70
What cardiogenic factors are associated with embolism stroke?
Endocarditis
71
How do we look for a PFO?
On echo and see if there are bubbles
72
What is the pathophysiology of systemic hypoperfusion (watershed)
Areas between arterial systems are vulnerable to poor perfusion if BP drops too low
Causes: Low cardiac EF / Myocardial infarction
73
What are the symptoms of systemic hypoperfusion (watershed)?
Bilateral weakness, especially in proximal upper extremities (a 'man-in-the-barrel' syndrome – arm > leg weakness). Sometimes also lower extremities, but less prominently.
74
What are some overall causes of Ischemic stroke/TIA?
Large vessel atherosclerosis (30%), Cardioembolic (20%), Small vessel occlusion (15%), Stroke of other determined etiology (10%).
75
When stroke etiology is unknown, what do we think?
Stroke of unknown etiology (25%): Two or more possible causes, No workup or Incomplete workup, Complete workup without definitive cause (Cryptogenic).
76
What are the presenting symptoms associated with stroke?
Symptoms are related to specific vessel(s) affected and underlying pathophysiology. Thrombosis fluctuating course, often more gradual; Embolus → sudden onset, severity of symptoms steady; Watershed → fluctuating course.
77
What may be included in a patient's history when presenting with a stroke?
Specific symptoms, Course of symptoms, Time of onset (last known normal), Activity at onset, Associated symptoms, Hx of prior CVA/TIA, Hx of prior CAD/PVD, Hx of heart disease, Risk factors, Medications.
78
What may be on a differential diagnosis for stroke?
Migraine, Seizure, Metabolic issue (hypoglycemia), Venous sinus thrombus, Conversion disorder, Hypertensive encephalopathy, Encephalitis/Meningitis, Bell palsy, Tumor, Abscess, Multiple sclerosis, Myocardial infarction, Spinal cord issue.
79
What do new murmurs indicate?
Endocarditis until proven otherwise.
80
What may be included in a patient's PE when presenting with a stroke?
General assessment (ABCs), Vital signs, Cardiovascular: Neck bruits, Murmurs, Irregular HR, Pulses, Neurologic – thorough! BP often elevated in CVA.
81
What symptoms may occur with a blocker anterior cerebral artery?
Contralateral Leg paresis &/or sensory deficits, Less common to have face/arm paresis, behavioral changes.
82
What symptoms may occur with a blocker middle cerebral artery?
Contralateral Arm/lower face paresis &/or sensory deficits, homonymous hemianopsia, Ipsilateral eye deviation, Dominant hemisphere: language deficits (Broca’s vs Wernicke’s), Nondominant hemisphere: contralateral neglect and confusion.
83
What is the symptom acronym for stroke?
Weakness, Numbness/tingling, Visual field loss, Vertigo, Nausea/vomiting, Loss of coordination, Language issues, Gaze preference, Neglect, Behavioral changes, Cranial nerve deficits, Confusion, Coma
84
What is Homonymous hemianopsia?
Facial nerve controls muscles in upper and lower face; receives contralateral and ipsilateral input so forehead movement is preserved bilaterally in a cerebral infarct
85
What happens if only one branch of the middle cerebral artery is occluded?
Will have symptoms associated with just the lobe affected.
86
If the Lenticulostriate arteries only are occluded, what happens?
Mainly basal ganglia / internal capsule.
## Footnote
Pure motor issues → contralateral lower face/arm/leg (all 3).
87
If the internal carotid artery is blocked, what symptoms would there be?
Mixed MCA and ACA symptoms.
## Footnote
Amaurosis fugax (Ophthalmic a.).
88
If the posterior cerebral artery is blocked, what symptoms would there be?
Homonymous hemianopsia with central sparing. Other vision issues, memory issues, sensory loss → contralateral face/arm/leg.
89
If the vertebral artery is blocked, what symptoms would there be?
Ipsilateral hemiparesis, ipsilateral hemisensory loss arm/leg, ipsilateral tongue deviation (stroke occurred on the same side the tongue is pointing).
90
If the basilar artery is blocked, what symptoms would there be?
Locked in syndrome → quadriplegia except eyes. Coma.
91
If the cerebellar artery is blocked, what symptoms would there be?
Ipsilateral ataxia, 'crossed body' – ipsilateral face/contralateral body sensory loss.
## Footnote
Ipsilateral upper AND lower face hemiparesis, Ipsilateral Horner’s syndrome, Vertigo, Nystagmus, Nausea/vomiting, Dysphagia, Dysarthria (issues with speech), Dysphonia (voice changes), Hiccups (unrelenting hiccups).
92
What is Homonymous hemianopsia with central sparing (5)?
93
When each specific artery is occluded, what are the implications?
94
What cranial nerves are associated with the Pons?
CN V, VI, VII, VIII
95
What cranial nerves are associated with the Medulla?
CN IX, X, XII
96
What are the symptoms of Horner’s syndrome?
Ipsilateral miosis, ptosis, anhidrosis
97
What are the symptoms of Wallenburg stroke?
Vertigo, nausea/vomiting, UNRELENTING hiccups that don’t stop for days
98
What symptoms are associated with Internal Carotid issues?
Amaurosis fugax; MCA & ACA symptoms
99
What are the symptoms of Anterior Cerebral artery issues?
Contralateral Leg paresis &/or sensory deficits; behavioral changes
100
What are the symptoms of Middle Cerebral artery (main) issues?
Contralateral Arm/lower face paresis &/or sensory deficits, homonymous hemianopsia, ipsilateral eye deviation, language deficits (dominant hemisphere), contralateral neglect (non-dominant), confusion (non-dominant)
101
What are the symptoms of Middle Cerebral artery (lenticulostriate) issues?
Contralateral hemiparesis (lower face/arm/leg)
102
What are the symptoms of Posterior Cerebral artery issues?
Homonymous hemianopia with central sparing; other vision issues; memory issues; sensory loss – face/arm/leg
103
What are the symptoms of Vertebral artery issues?
Hemiparesis/hemisensory loss arm/leg; ipsilateral tongue deviation
104
What are the symptoms of Basilar artery issues?
Locked in syndrome – quadriplegia except eyes; coma
105
What are the symptoms of Cerebellar artery issues?
Gait imbalance; ipsilateral limb ataxia; dysarthria; vertigo; nystagmus; nausea/vomiting; dysphagia; dysarthria; dysphonia; hiccups
106
What is affected in the cerebral motor cortex stroke?
Only lower face affected, can still raise eyebrows
107
What is affected in a facial nerve stroke?
Lower and upper face affected
108
What is the initial evaluation of Stroke?
NIH Stroke Scale (NIHSS): 11 standardized tests, in order. Anything above 6 is a really high score.
109
What is the initial workup for stroke in the ER?
If stroke is suspected, “Code Stroke” is called. Labs: blood glucose, CBC, BMP, PT/INR, PTT, troponin. If female – pregnancy test.
110
What imaging is done for stroke in the ER?
EKG, CT head non-contrast (goal: door-to-imaging time <25 min) - FIRST DECISION
111
What should be evaluated besides ischemia in stroke?
Evaluate for causes besides ischemia & rule out hemorrhage, mass, abscess. Most common finding = nothing abnormal (85% of the time)
112
What is the criteria for reperfusion therapies?
If yes: has to be within 4 hours of last known normal. Will patients need to be transferred? Will additional imaging studies be needed?
113
What is option 1 for treatment of acute thrombolysis stroke?
IV tPA (tissue plasminogen activator or alteplase)
114
What is the criteria to use alteplase?
Persistent measurable neurologic deficit (NIHSS = 6+). Can be administered within 4.5 hrs of last known normal.
115
What is the administration method for alteplase?
Administered as 60 min infusion: Dose is weight-based. Given first as bolus and is then continued as a 60 min infusion.
116
What are the complications of alteplase?
Intracranial hemorrhage, other bleeding (GI, etc), angioedema
117
What is an alternative to alteplase?
Tenecteplase - engineered variant of alteplase with longer half-life and higher specificity for fibrin.
118
What is option 2 for the treatment of acute stroke?
Mechanical thrombectomy removes thrombus: Highly specialized procedure; only a few centers do this -> transfer may be needed.
119
What is the criteria for doing a mechanical thrombectomy?
Within 24 hrs of symptom onset, no evidence of hemorrhage or extensive infarct on CT, persistent significant neurologic deficit(s), large vessel thrombus in ANTERIOR CIRCULATION ONLY confirmed on imaging.
120
What symptoms are associated with middle cerebral artery defects?
Opposite side face and arm, language affected on one side, forehead not affected, gaze deviation and neglect on the opposite side.
121
What are the complications for mechanical thrombectomy?
Vessel perforation/dissection, embolization of the thrombus
122
What is a mechanical thrombectomy?
Goes past the clot and pulls back to grab it and the relief and changes are immediate.
123
Additional imaging studies needed before possible reperfusion tx done immediately after CT head if needed
CT angiography or MR angiography
visualize presence of thrombus
CT perfusion or MRI perfusion study
Assesses extent of infarct versus surrounding penumbra (green area is tissue that can still be saved) – risks/benefit analysis. Is there viable brain tissue? Can we save some of it?
124
What is the focus of further workup for inpatient admission for stroke?
Evaluating underlying cause(s) for ischemic stroke and identifying risks amenable to modification for secondary stroke prevention.
125
What type of monitoring is required for stroke patients during inpatient admission?
Telemetry monitoring for 24-48 hours in the hospital, possibly after discharge as well.
126
What arrhythmias are monitored during telemetry for stroke patients?
Looking for arrhythmias, including atrial fibrillation (a fib).
127
What laboratory tests are standard for stroke workup?
Hemoglobin A1C and a lipid panel, specifically looking for LDL levels.
128
Why is the lipid panel considered standard of care for stroke patients?
Diabetics are at higher risk of stroke; obtaining LDL levels is crucial.
129
What additional tests may be indicated for stroke patients?
TSH (if a fib, jumpy, tremors) and hypercoagulable workup (consider if age < 55).
130
What is the most common cause of cardioembolic strokes?
Atrial fibrillation (a fib).
131
Where do patients go if they received TPA for a stroke?
ICU for 24 hours, and the next step is to determine the cause of the stroke.
132
What imaging is used to visualize infarction in stroke patients?
MRI.
133
What should be done if MRI is contraindicated for a stroke patient?
Follow up with a non-contrast CT head 24-48 hours after the initial CT to assess damage from the stroke.
134
What test for stroke is most sensitive at detecting early edema?
MRI.
T2 image is with the bright CSF and so in FLAIR they took it out, so the stroke shows up better.
In FLAIR and DWI stroke shows up bright= bad=stroke
135
What does FLAIR stand for?
Processed T2 images that reduce brightness of CSF to illuminate edema.
136
What does DWI show?
Areas of restricted diffusion; often the earliest images to show an ischemic stroke.
137
What is ADW used for?
Helps confirm areas of brightest on DWI images are due to stroke – edema will be dark.
138
What is the next step to work up a stroke?
Evaluation of extracranial and intracranial vessels (if not already done).
139
What should you look for in stroke evaluation?
Atherosclerosis, stenosis, AVM.
140
What are the options for looking for atherosclerosis?
CT Angiography (CTA head and neck), MR Angiography (MRA head and neck), Carotid doppler (only evaluates extracranial vessels - carotids), Transcranial doppler (only evaluates limited portions of intracranial vessels).
141
What is the differences in CT over time in stroke?
Right middle cerebral artery stroke with weird limp and gait
Ischemic area appears dark after several days.
142
Case courtesy of Hugo Neves (RT)
Chronic stroke – “encephalomalacia” – area of density similar to CSF
That dead tissue has been cleaned out by the microglia and fluid replaces it. That portion of the brain is gone
143
CTA neck
144
ALL STROKE PTS NEED
MRI, Imaging of the vessels, and we need to assess the heart
145
CTA neck 3D rendering
146
MRA Head
147
Carotid Doppler
148
What is the third step to work up a stroke?
Evaluation of cardioembolic source
149
What is Transthoracic Echocardiogram (TTE) used for?
Evaluate for intracardiac thrombus, valvular vegetations, valvular calcifications
## Footnote
With bubble study to evaluate for PFO (patent foramen ovale).
150
What is the standard for all stroke patients regarding echocardiograms?
Patients may get TTE or Transcranial Doppler in addition.
151
What is the purpose of cardiac event monitoring in stroke patients?
~ 30% of people with cryptogenic stroke after workup will have paroxysmal atrial fib with longer monitoring.
152
What are the types of cardiac event monitors?
Holter monitor vs mobile external monitor vs implantable loop monitor.
153
What does Transcranial Doppler (TCD) detect?
Emboli make distinctive sound moving past the probe.
154
What are some inpatient management options for stroke treatment?
NPO until swallowing evaluation done by RN. Neurologic monitoring. BP management.
155
What is the BP management guideline for stroke patients?
Permissive hypertension for 24-48 hrs. Only treat if BP > 220/120 mmHg.
156
Who else do stroke patients need to see?
Evaluation by Physical Therapy, Occupational Therapy, Speech Therapy.
157
Who gets rehab after a stroke?
Patients who are younger, can tolerate it, and have insurance.
158
What do stroke patients need after discharge?
Assessment for Rehab, secondary prevention strategies, DVT prophylaxis.
159
How many therapy groups must a stroke patient see?
At least 2.
160
What are additional inpatient/outpatient options for stroke help?
Physical Therapy, Occupational Therapy, Speech and Language Pathology.
161
What are some secondary prevention strategies for stroke patients?
Statins, blood glucose control, BP control, lifestyle modifications, antithrombotic medications.
162
What is included in the immediate workup for stroke?
Call stroke, glucose, CT non-contrast head, MRI, CTA/MRA.
163
What are the treatment options for stroke?
Thrombectomy within 24 hours, TPA within 4 hours.
164
What is the NIHSS used for?
Neuro checks and therapy evaluations.
165
How is TIA evaluation and workup similar to ischemic stroke?
Similar imaging and labs, same management.
166
What is the risk assessment for possible subsequent stroke based on?
ABCD2 scale: Age, blood pressure, clinical features, duration, and diabetes.
167
Holter monitor
wear for 48 hours
168
Mobile monitor (Zio)
2 weeks- a month
169
Implantable Loop Monitor
170
ABCD2
171
What is the diagnosis if symptoms resolve in 24 hrs and there is nothing on the MRI?
TIA
172
What are the prevention strategies for ischemic stroke and TIA?
Antithrombotic meds: antiplatelet or anticoagulation. Most patients will get antiplatelet treatment.
173
When should antiplatelet therapy be given?
When the cause of stroke is large or small vessel occlusion or unknown etiology.
174
What are the options for antiplatelet therapy?
Aspirin, Plavix (clopidogrel), Aspirin+dipyridamole (Aggrenox), Cilostazol (Asian population).
175
What kind of antithrombotic treatment do most people receive?
Antiplatelet.
176
What is the antiplatelet treatment if the patient has TIA?
If on anticoagulation, give that. If no reason for anticoagulation, evaluate ABCD2.
177
What is the antiplatelet treatment for ABCD2 < 4?
Aspirin 325 mg daily.
178
What is the antiplatelet treatment for ABCD2 >= 4?
Dual antiplatelet therapy (DAPT) -- loading doses of aspirin and clopidogrel, then aspirin 81 mg + clopidogrel 75 mg for 21 days, then monotherapy (usually aspirin).
179
What is the antiplatelet treatment if the patient has an ischemic stroke?
If on anticoagulation, hold initially and give antiplatelet for a few weeks based on NIHSS score.
180
What is the antiplatelet treatment for NIHSS <= 5?
DAPT -- loading doses of aspirin and clopidogrel, then aspirin 81 mg + clopidogrel 75 mg for 21 days, then monotherapy.
181
What is the antiplatelet treatment for NIHSS > 5?
Aspirin 325 mg daily, if able. For patients with large vessel atherosclerosis on imaging, do DAPT for 90 days, then aspirin.
182
Where is the language center typically located?
Usually the left side.
183
When should anticoagulation be used?
When the cause of stroke is cardioembolic (afib), arterial dissection, venous thrombus, or hypercoagulable state.
184
What are the options for anticoagulation therapies?
Warfarin or DOAC (apixaban, rivaroxaban).
185
When should anticoagulation be initiated or restarted for a minor stroke?
48 hrs after stroke or at discharge.
186
When should anticoagulation be initiated or restarted for a larger stroke?
Wait 1-2 weeks prior to starting/restarting. Give aspirin 325 mg in the interim.
187
What are the two ways to treat carotid artery stenosis:
Carotid endarterectomy
Carotid artery stenting: Percutaneous stent placed
188
What is carotid endarterectomy (CEA)?
A surgical procedure to remove plaque from the carotid artery to restore blood flow.
189
When should CEA be performed?
Only if there is still some blood flow throughout the carotid artery and stenosis is 70-99%.
190
What is the risk of performing CEA?
Risk of embolism and stroke from plaque during removal, which can break off and travel to the brain.
191
What are common causes of stroke/TIA in children?
Genetic disorders, trauma with arterial dissection, congenital heart disease, and low blood sugar.
192
What does a new seizure in a child indicate?
Possible stroke.
193
What is the prognosis after stroke occurrence?
Recovery of function is greatest during the first 3 months, with maximum recovery typically at 6 months.
194
What factors can limit recovery after a stroke?
Depressive symptoms and higher NIHSS scores at discharge.
195
What is the risk of death after stroke occurrence?
Higher risk of death compared to the general population.
196
What type of stroke has a higher risk?
Hemorrhagic stroke has a higher risk than ischemic stroke.
197
What is predictive of long-term survival after a stroke?
Functional status at 6 months post-CVA.
198
What are significant risk factors for stroke?
Diabetes, smoking, atrial fibrillation, and the onset and last known normal.
199
What is the first scan performed for stroke assessment?
CT of the head, which may show nothing initially.
200
What are the majority of brain and spinal cord tumors?
The majority are secondary tumors from metastatic spread.
201
From which cells do most primary nervous system tumors arise?
Most arise from glial cells or meningeal cells, not neurons.
202
How do tumors in adults and children vary?
They vary in terms of common types, lethality, and location.
203
What are common symptoms of nervous system tumors?
Symptoms include headache, seizures, and focal neurologic deficits.
204
What is the primary method for diagnosing nervous system tumors?
Diagnosis is based on imaging, usually MRI with contrast, and biopsy.
205
What does treatment for most types of tumors involve?
Treatment involves surgical resection, radiation, and/or chemotherapy.
206
What medications are included in the treatment for tumors?
Medications include steroids, seizure medications, and pain medicines.
207
What genetic syndromes are linked to increased incidence of nervous system tumors?
Genetic syndromes include Neurofibromatosis, von Hippel-Lindau syndrome, Li-Fraumeni syndrome, Lynch syndrome, and basal cell nevus syndrome.
208
What percentage of patients report headache as a symptom?
25% report headache.
209
What are concerning symptoms associated with headaches?
Concerning symptoms include waking from sleep, bifrontal tension-type, worsening with position change, and a new headache in patients over 55 years.
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What are some neurologic symptoms that may indicate a tumor?
Neurologic symptoms include impaired cognition, behavioral changes, language difficulties, and vision changes.
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What pediatric symptoms may indicate a nervous system tumor?
Pediatric symptoms include lethargy, macrocephaly, behavioral changes, irritability, and poor growth.
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What is included in the history assessment for suspected tumors?
History includes progression and duration of symptoms, prior cancer, and family history of autoimmune disorders.
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What are some differential diagnoses for nervous system tumors?
Differential diagnoses include stroke, hemorrhage, abscess, encephalitis, and autoimmune disorders.
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What imaging is typically used for diagnosis?
MRI with contrast is typically used; CT with contrast if MRI is not possible.
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What factors influence the treatment plan for nervous system tumors?
Factors include benign vs malignant, single vs multiple lesions, and severity of deficits.
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What is the role of surgery in treating primary brain cancer?
Surgical resection aims for maximum possible removal.
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What is the recommended seizure prophylaxis after surgery?
Levetiracetam is recommended for seizure prophylaxis after surgery.
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What are the side effects of radiation therapy?
Side effects include toxicity to healthy brain tissue and increased intracranial pressure.
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What is the treatment for edema in brain tumors?
Dexamethasone is used to reduce edema.
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What should be considered when choosing anti-epileptic medications?
Drug interactions need to be considered when making choices for anti-epileptic medications.
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What is the approach to treating metastatic cancer?
Treat the primary cancer and consider surgery/radiation as needed.
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How many types of primary nervous system tumors are there according to the 2016 WHO classification?
120+ different types of primary nervous system tumors.
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What are the main types of CNS tumors?
Gliomas, Meningeal, CNS lymphoma, Embryonal, Neuronal, Sellar region, Pituitary, Other.
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What are examples of gliomas?
Astrocytoma, oligodendroglioma, ependymoma.
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What is required to diagnose CNS lymphoma?
Need 10 ml of CSF to be able to diagnose.
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What are examples of embryonal tumors?
Medulloblastoma, retinoblastoma.
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What are the types of PNS tumors?
Neurofibromas, Schwannomas, Perineuromas, Paragangliomas / Pheochromocytomas, Malignant peripheral nerve sheath tumors.
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What are benign, non-neoplastic peripheral nerve growths?
Neuromas, Ganglion cysts, Sarcoid granulomas.
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How many grades are there in the WHO classification for tumor grading?
4 grades based on rate of growth and prognosis.
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What characterizes Grade I tumors?
Slow growing, often benign.
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What characterizes Grade II tumors?
Relatively slow growing, infiltrative.
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What characterizes Grade III tumors?
Malignant, infiltrative, fast growing ('anaplastic').
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What characterizes Grade IV tumors?
Malignant, highly infiltrative, rapid growth, rapid recurrence, necrotic ('-blastoma').
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Are nervous system tumors rated on the TNM system?
No, nervous system tumors are not rated on the TNM system.
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What percentage of primary CNS tumors are gliomas?
40% of primary CNS tumors; 80% of malignant tumors.
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What are the main types of nervous system cells?
Neurons, Glial cells.
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What do astrocytes do?
Form the blood-brain barrier.
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What do ependymal cells produce?
Make CSF fluid.
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What is the role of oligodendrocytes / Schwann cells?
Wrap around axons to form myelin sheaths.
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What do microglia do?
We lose 10,000 neurons every day.
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What is the most common type of glial tumor?
Astrocytomas.
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What is an example of a Grade I astrocytoma?
Pilocytic astrocytoma - most common in kids.
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What is an example of a Grade II astrocytoma?
Diffuse astrocytoma - grows very fast.
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What is an example of a Grade III astrocytoma?
Anaplastic astrocytoma - grows very fast.
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What is an example of a Grade IV astrocytoma?
Glioblastoma - most common of astrocytoma, life expectancy is usually a year and a half.
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What are the common symptoms of Grade I astrocytoma?
Usually benign and slow-growing, issues with balance, nausea/vomiting/lethargy.
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What is the treatment for Grade I astrocytoma?
Surgery/radiation - good chance of being treated completely.
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What is Glioblastoma (GBM)?
Most common malignant CNS tumor, accounting for ~15% of all primary CNS tumors. Typically occurs in individuals over 60 years old and is aggressive and fast-growing. 5-year survival rate is 10%.
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What are the treatment options for Glioblastoma?
Treatment depends on age, comorbidities, and functional status. Options include surgical resection, adjuvant radiation therapy and chemotherapy, Temozolomide, and newer treatment Optune, which generates alternating electrical fields to disrupt fast-growing tumor cells.
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What are Oligodendrogliomas?
Tumors that arise from oligodendrocytes, representing ~5% of CNS tumors. They can be Grade II or Grade III, with a median survival of over 10 years.
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What are Ependymomas?
Tumors that arise from ependymal cells, often found along the CSF pathway. More common in children, they account for 5% of pediatric CNS tumors and are more common in the spine.
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What are Meningiomas?
Tumors that arise from the dura mater, making up ~35% of CNS tumors. They are more common in women, grow slowly, and are often monitored rather than surgically removed.
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What is Schwannoma?
Tumors that arise from Schwann cells along cranial, spinal, or peripheral nerves. They account for ~8% of CNS tumors and can cause unilateral loss of hearing in adults until proven otherwise.
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What is Medulloblastoma?
A type of embryonal tumor, usually Grade IV, more common in children, and accounts for ~20% of pediatric CNS tumors. It often starts in the cerebellum.
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What is Primary Central Nervous System Lymphoma (PCNSL)?
A rare form of Non-Hodgkin’s Lymphoma characterized by uncontrolled growth of mature B or T cells. It is more common in immunocompromised individuals and is treated with high-dose methotrexate chemotherapy.
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What percentage of brain tumors are primary versus metastatic?
85-90% of all primary nervous system tumors are primary, while ~65% are metastatic.
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What are the most common types of brain tumors in adults?
In adults, 70% of brain tumors are supratentorial, with the most common types being metastases, meningiomas, glioblastomas, schwannomas, and pituitary tumors.
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What are the most common types of brain tumors in children?
In children, brain tumors are the 2nd most common type of cancer (15%), with 70% being infratentorial, including astrocytomas, medulloblastomas, brainstem gliomas, and ependymomas.
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What are the types of spinal cord tumors?
Spinal cord tumors can be extradural (55%), intradural extramedullary (40%), or intramedullary (5%). Extradural tumors often include metastases, while intradural tumors include meningiomas and neurofibromas.
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What is Neurofibromatosis?
A rare genetic disorder characterized by the formation of benign tumors in multiple locations. There are three types: NF 1, NF 2, and Schwannomatosis.
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What are the characteristics of NF 1?
NF 1 typically presents in birth or early childhood with café-au-lait spots, growths under the skin (neurofibromas), freckling at skin folds, and scoliosis.
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What are the characteristics of NF 2?
NF 2 usually presents in older children or early adulthood with bilateral acoustic neuromas and CNS tumors such as meningiomas and ependymomas.
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What is Schwannomatosis?
A very rare form of Neurofibromatosis characterized by multiple schwannomas and associated pain.
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Typical Ages and Populations associated
