Stroke

Question 1

What do you if think a patient has stroke?

Answer 1

FOCUSED history -Time of onset (last known well) -Basic risk factors ( HTN, HDL,DM,TOB, CAD, hx cardiac surgery) -taking antithrombotics

Question 2

Patient presents with right sided facial drop, right sided arm weakness and difficulty speaking, but able to understand commands. What part of the brain is effected? What is the next step?

Answer 2

*Left sided MCA occluded or hemorrhage-broca aphasia *Need non- contrasted head CT STAT - if non-hemorrhagic, give tPA and get STAT CT angiogram if onset less than 4.5hrs

Question 3

tPA how does it work? Risks?

Answer 3

-Bind to fibrin and dissolve clot NNT = 7 -Risk: ICH (intracranial bleed) 6.4%

Question 4

Patient has an mca occlusion what interventional treatment can you do after obtain CT angiogram?

Answer 4

Endovascular therapy (mechanical thrombectomy within 6hrs) after tPA

Question 5

Ischemic stroke etiology

Answer 5

-Large arteriosclerosis *-cardioembolism* -small vessel occlusion -other determined etiology (dissection) -undetermined

Question 6

After thrombotic stroke event what should the patient take?

Answer 6

Aspirin daily (antithrombotic) Risk factor modification -diet to decrease HTN -stop alcohol -exercise -stop smoking

Question 7

When give dual antiplatlet therapy? Aspirin + extended release dipyridamole

Answer 7

-post small vessel occlusion -intercranial atherosclerosis

Question 8

What give someone with a-fib to prevent strokes?

Answer 8

Warfarin 68% efficacy (anticoagulation) ASA 20% efficacy

Question 9

40 yr old patient with history of uncontrolled HTN, develops sudden HA with gait instability, weakness and altered mental status. Last known well 4hr. BP 220/120 left lower sided facial droop, no movement LUE or LLE. Right side moves against gravity. Decrease consciousness. Diagnosis and treatment?

Answer 9

Hemorrhagic stroke - stop bleeding –reverse anticoagulation

Question 10

Layers of meninges?

Answer 10

DAP Dura Arachnoid Pia

Question 11

36 yr old patient hits left side head while skiing. Brief LOC and then responsive, within 20 minutes got slurred speech and appeared confused. Half hour later LOC. Diagnosis? Work up?

Answer 11

-Head CT without contrast -Epidural hematoma (lucid interval after trauma) -middle meningeal artery rupture -cannot cross midline

Question 12

Family brings elderly patient to ER with mentation problems and disorientation. Questionable minor ball several months ago. Work up? What could this be?

Answer 12

-subdural hematoma -tearing bridging veins (build up over time) CT noncontrast head -can cross midline

Question 13

Middle aged patient complains about sudden onset of worst headache of their life 10 out of 10. What is your differential? What do you want to do?

Answer 13

Non-contrast CT head -Subarachnoid hemorrhage -causes: congenital aneurysms, septic aneurysms, arterial venous malformation

Question 14

Intracerebral hemorrhage causes?

Answer 14

Cerebral amyloid angiopathy, germinal matrix hemorrhage (prenatal)

Question 15

How tell difference between adult brain and baby brain grossly?

Answer 15

Baby brain smooth

Question 16

Grey matter vs white matter vulnerability

Answer 16

Grey: Neurons > oligodendrocytes >astrocytes > vessels White: oligodendrocytes>astrocytes> vessels

Question 19

Infant and adult brain vulnerability?

Answer 19

-CA1 (Sommer’s sector) of hippocampus -purkinje cells of cerebellum

Question 20

1 day post stroke micro findings histology?

Answer 20

Red neurons (coagulative)

Question 21

1 day-2 weeks post stroke finding micro and macro

Answer 21

Micro: transient neutrophils, massive macrophages Macro: adematous liquefactive

Question 22

Beyond 2 weeks post stroke micro and macro changes?

Answer 22

Micro: rim of Astrogliosis

Macro: progressive cavitation

Question 23

Diagnosis

Answer 23

Epidural Hemorrage

Question 24

Diagnosis?

Answer 24

Subdural Hemorrage

Question 25

What could have caused this and where is this located

Answer 25

DM or HTN could have caused, weakening of small vasculature in the basal ganglia caused this hemorrage.

Question 26

What is this?

Answer 26

germinal matrix hemorrage (prenatal)

Question 27

What is this?

Answer 27

1 day post stroke- red neurons

Question 28

What is this?

Answer 28

1 day- 2 weeks post stroke -transient neutrophils, massive macrophages

Question 29

What is this?

Answer 29

More than 2 weeks post stroke rim of astrogliosis

Question 30

How old is this this stroke?

Answer 30

1 day-2 weeks. Right side is macrophages

Question 31

How old is this stroke?

Answer 31

1 day old

Question 32

How old is this stroke?

Answer 32

greater than 2 weeks (cavatation)

Question 33

This is a 28 year-old female who has 5 days of **left leg numbness.****Four years ago**she had**blurry vision**in the right eye for**2 weeks**.**One year ago**she had**numbness**of the**right face**for**4 weeks**. There are no motor abnormalities. Fatigue is present. The exam confirms **decreased pinprick** in the **left leg** and a mild right afferent **pupillary defect** (optic nerve finding). Diagnosis?

Answer 33

MS

Question 34

Diagnosis

Answer 34

MS (disease CNS) ## Footnote **Dawson Fingers**

Question 35

MS signs

Answer 35

- optic neuritis (blurry vision, painful eye movement, color desaturation) - weakness, spasticity - sensory - ataxia, tremor - cognitive - Lhermitte's sign - fatigue - heat and exercise intolerance - Bladder - sexual dysfunction

Question 36

How test for MS?

Answer 36

MRI CSF (oligoclonal bands) **Evoked potential** (longer time to get sensory information to brain using CNS)

Question 37

58 year-old hypertensive man was admitted to the hospital for sudden onset of **dizziness, vomiting, dysarthria, and numbness.** The exam revealed **pinprick sensory loss on the _right face_** and **left body**, but proprioception was fine; nystagmus to the left; miosis, ptosis and decreased facial sweating on the right; ataxia of the right arm/leg; hoarseness; and the soft palate moved to the left when saying "aaah".

Answer 37

Right face sensory loss and left body loss= brainstem problem Wallenberg Syndrome (stroke of posterior lateral medulla, blood supply PICA and vertebral)

Question 38

loss of pinprick sensation means damage to what part of pathway?

Answer 38

spinothalamic

Question 39

loss of proprioception means damage to what part of pathway?

Answer 39

posterior columns

Question 40

53 year-old female who has 1 day of bilateral leg weakness, urinary retention and numbness from the waist down. One week ago she had a cold. The exam confirms decreased pinprick at T8 and below, reduced proprioception in the feet, bilateral leg weakness, absent leg reflexes, upgoing toes, and reduced rectal tone.

Answer 40

Transverse myelitis (whole spine cord damage)

Question 41

This is a 21 year-old male s/p an MVA today. He is on a stretcher with severe mid back pain. He has trouble with feeling in both legs and moving the right one. The exam confirms **decreased pinprick** and temperature in the _left leg_, **decreased proprioception** and vibration in the _right leg_, and **weakness** with upgoing toe in the _right_ leg.

Answer 41

Brown Sequard Syndrome loss pinprick _left_ leg= **spinothalamic** damage _right_ side decrease proprioception _right_ side= damage **posterior columns** _right_ side right sided weakness = cortico spinal tract damage _right_ side

Question 42

This is a 72 year-old female who had **surgery to repair an aortic aneurysm** 2 days ago. Now that she is waking up it is clear she can’t move her legs. The exam confirms paraplegia, and **decreased pinprick** in both legs while **proprioception and vibration are intact**. There is a sensory level at T10

Answer 42

Anterior Spinal Artery Syndrome

Question 43

This is a 42 year-old male who has 3 weeks of progressive bilateral leg and arm numbness, and gait trouble. The exam confirms **decreased proprioception and vibration** in the **LE**, and spastic weakness in the legs with **increased reflexes** and upgoing toes. **Pinprick is normal**.

Answer 43

B12 deficiency

Question 44

Nerve conduction studies: Axon damage vs. demyelinating damage

Answer 44

Axon damage (90%): DM * amplitude decreased * CV normal Demyelinating damage (10%): GBS * amplitude normal * CV decreased