Stroke

Question 1

Two main etiologies of stroke

Answer 1

Ischemic (80%) and hemorrhagic (20%)

Question 2

What are the main causes of local arterial obstruction that lead to focal cerebral ischemia?

Answer 2

Atherosclerosis (e.g. rupture)
Fibromuscular dysplasia
Arteritis
Dissection of arterial wall
Coagulopathies
Lipohyalinosis 2/2 HTN
Migraine (?)

Question 3

What can cause ischemic stroke secondary to impaired venous drainage?

Answer 3

Thrombosis of a cerebral sinus or vein, usually in patients with coagulopathy or who are severely dehydrated

Question 4

What is hemorrhagic transformation?

Answer 4

After an ischemic stroke, the blood vessels in the area are more likely to rupture upon reperfusion, leading to hemorrhage

Question 5

What usually causes parenchymal hemorrhages?

Answer 5

Rupture of small dilatations of penetrating arteries 2/2 chronic hypertension

Question 6

What is the most common etiology of subarachnoid hemorrhage?

Answer 6

Ruptured berry aneurysm

Question 7

What usually causes ischemic stroke?

Answer 7

Obstruction of an artery

Question 8

What are the key presenting clinical features of stroke?

Answer 8

Acute, focal symptoms and signs

Question 9

Clinical features of stroke in the MCA territory

Answer 9

Weakness in contralateral face, arm>leg
Sensory loss in contralateral face, arm>leg
Visual deficit in contralateral hemifield
Impaired gaze in contralateral direction
Aphasia if dominant hemisphere
Visuospatial impairment and neglect if non-dominant

Question 10

Clinical features of stroke in the ACA territory

Answer 10

Weakness in contralateral leg>arm
Sensory loss in contralateral leg>arm
Deficits in attention and/or motivation

Question 11

Clinical features of stroke in the PCA territory

Answer 11

Visual deficit in contralateral hemifield

If dominant hemisphere, alexia without agraphia

Question 12

Clinical features of stroke in territory of the lateral medullary artery (e.g. Wallenberg’s syndrome)

Answer 12

Sensory loss in ipsilateral face and contralateral arm, leg, trunk
Ipsilateral Horner's syndrome
Ipsilateral ataxia
Dysarthria and dysphagia
Nystagmus
Vertigo

Question 13

Clinical features of stroke in territory of the medial medullary artery

Answer 13

Weakness of contralateral arm, leg
Sensory loss of contralateral arm, leg
Ipsilateral tongue weakness

Question 14

Clinical features of pontine stroke

Answer 14

Weakness of ipsilateral face and contralateral leg and arm
Sensory loss of contralateral arm, leg, trunk and ipsilateral face
Impaired gaze in ipsilateral direction
Nystagmus
Ipsilateral Horner’s syndrome
Ataxia (ipsi or contra)

Question 15

Clinical features of midbrain stroke

Answer 15

Contralateral hemiparesis
Ipsilateral CNIII palsy
+/- contralateral ataxia

Question 16

Wallenberg’s syndrome?

Answer 16

1. IPSI face reduced pain and temp
2. Contra limbs and trunk reduced pain and temp
3. IPSI Horner’s syndrome
4. Dysarthria, dysphagia, ataxia, vertigo and nystagmus

Question 17

Most common locations for lacunar infarcts?

Answer 17

Basal ganglia, thalamus, pons, or internal capsule

Question 18

Presentation of subarachnoid hemorrhage

Answer 18

Acute severe headache

Meningeal signs

Question 19

Management of acute stroke

Answer 19

1. tPA within 4.5 hours of symptom onset
   Other options:
2. Catheter-directed thrombolytics
3. Thrombectomy

Question 20

Most significant complication of acute stroke?

Answer 20

Increased ICP

Question 21

Other complications of stroke?

Answer 21

Seizures
SIADH
Depression

Question 22

Primary prevention of stroke

Answer 22

1. Control BP in pts with HTN (ACEs and ARBs, man)
2. Quit smoking
3. Control diabetes, consider adding statin even if pt doesn’t have dyslipidemia
4. Control lipids (STATINS!)
5. Warfarin (or DOACs) for pts with AFib or mechanical heart valves
6. CEA for pts with bad carotid disease
7. Screen sickle cell patients using transcranial doppler, and transfuse if high risk of stroke

Question 23

Secondary prevention of stroke in patients who have had a TIA or stroke

Answer 23

1. Warfarin/DOAC if cardioembolic source
2. CEA if carotid source
3. Anti-platelet agents for everybody
4. Statin if LDL-C >100 mg/dL
5. See all the primary prevention stuff, which still applies to these patients

Question 24

Secondary prevention of stroke caused by arterial dissection

Answer 24

Anti-coagulate for 3-6 months after stroke

Question 25

Lenticulostriate artery supplies what structure? What would a lesion here show?

Answer 25

Striatum and internal capsule. Stroke —> contralateral hemiparesis/plegia

Question 26

Medial medullary syndrome

Answer 26

Stroke of anterior spinal artery
Damage to lateral corticospinal tract –> contralateral hemiparesis in limbs
Damage to medial lemniscus –> loss of proprioception contralaterally
Damage to caudal medulla/CNXII –> tongue deviates toward lesion

Question 27

Lateral medullary syndrome

Answer 27

Stroke of PICA
Lesions to CNVIII nucleus, spinal trigeminal nucleus, lateral spinothalamic tract, nucleus ambiguus, sympathetics, and inferior cerebellar peduncle –> vertigo, decreased pain and temp ipsi face and contra body, dysphagia, ipsilateral Horner’s syndrome, ataxia

Question 28

Lateral pontine syndrome

Answer 28

Stroke of AICA
Lesions to CNVIII nucleus, CNVII nucleus, CNV nucleus, sympathetics, and middle and inferior cerebellar peduncles –> Vertigo, nystagmus, facial paralysis, decreased lacrimation/salivation, ipsilateral loss of pain and temp of face, contralateral loss of pain and temp of body, ataxia and dysmetria

Question 29

Most common site of saccular (berry) aneurysm

Answer 29

Anterior communicating artery and anterior cerebral artery. Associated with ADPKD, Ehlers-Danlos