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Neurology Clerkship > Stroke > Flashcards

Stroke Flashcards

1
Q

Gerstmann syndrome

A

Dominant parietal lobe infarction (specifically the angular gyrus)

  • Tetrad of:
    • Agraphia
    • Acalculia
    • Left-right confusion
    • Finger agnosia (inability to recognize one’s own fingers or the fingers of the examiner)
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2
Q

PICA stroke syndrome

A
  • aka Wallenburg syndrome or Lateral medullary infarction syndrome
  • Features:
    • Ipsilateral bulbar palsy (dysphagia, dysphonia, hiccups, decreased gag reflex)
    • Ipsilateral nystagmus and vertigo
    • Contralateral decrease in pain and temperature sensations in the trunk and limbs
    • Ipsilateral decrease in pain and temperature sensations in the face
    • Ipsilateral limb ataxia and dysmetria
    • Ipsilateral Horner syndrome
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3
Q

Stroke algorithm

A
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4
Q

TIA algorithm

A
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5
Q

Specific indication for TPA

A

Age > 18

Time from ischemic infarct within 3 hours

Non-contrast CT shows no evidence of hemorrhage

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6
Q

Only manage blood pressure in a patient with ischemic stroke if. . .

A

. . . blood pressure is >220 systolic, SEVERE

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7
Q

Deciding how to manage patients with TIA

A

ABCD2 score

Any patient with 3 or higher should be admitted for inpatient workup

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8
Q

Ischemic penumbra management

A

If a patient has a large proximal occlusion and a salvagable ischemic penumbra, there is evidence that endovascular treatment with embolectomy or intra-arterial tPA can save a significant amount of brain tissue

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9
Q

Todd’s paralysis

A

Brief period of paralysis folloing a seizure

On the ddx for acute stroke or TIA

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10
Q

Ischemic stroke is caused by ___, while hemorrhagic stroke is caused by ___.

A

Ischemic stroke is caused by vacsular insufficiency due to occlusion, while hemorrhagic stroke is caused by mass effect or cytotoxicity related to parenchymal hematoma.

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11
Q

Management of blood pressure in the ischemic stroke patient

A
  • ​Allow permissive hypertension acutely
  • Lower cautiously in days following acute event – abrupt lowering may exacerbate losses in the ischemic penumbra
  • Avoid extreme or accelerated hypertension, which may put the patient at risk for hemorrhagic converison
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12
Q

Lacunar stroke syndromes (six)

A
  • Pure motor
  • Pure sensory
  • Sensorimotor
  • Ataxia-hemiparesis
  • Dysarthria-Clumsy hand
  • Hemiballismus
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13
Q

Lesions of the visual field

A
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14
Q

What visual defect is Wernicke’s aphasia most commonly associated with?

A

Right superior quadrantanopia

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15
Q

Aphasia localization

A
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16
Q

Meyer’s loop

A
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17
Q

Left MCA stroke syndrome

A
  • Right-sided hemiparesis and sensory loss in the arm and lower face
  • Aphasia
  • Left gaze deviation (ipsilateral to infarct)
  • Homonymous hemianopia OR superior OR inferior quadrantanopia (rare)
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18
Q

Right MCA stroke syndrome

A
  • Left-sided hemiparesis and sensory loss in the arm and lower face
  • Left-sided neglect
  • Right gaze deviation (ipsilateral to infarct)
  • Homonymous hemianopia OR superior OR inferior quadrantanopia (rare)
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19
Q

ACA stroke syndrome

A
  • Contralateral hemiparesis and sensory loss in the lower limb
  • Abulia
  • Limb apraxia
  • Urinary incontinence
  • Dysarthria
  • Transcortical motor aphasia (nonfluent, but comprehension and repetition are intact)
  • Frontal release signs
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20
Q

Left PCA stroke syndrome

A
  • Contralateral homonymous hemianopia with macular sparing
  • Contralateral sensory loss (due to lateral thalamic involvement)
  • Memory deficits
  • Alexia without agraphia
  • Dysnomia/anomic aphasia (inability to name)
  • Agnosia (inability to recognize a sensory stimulus, usually visual)
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21
Q

Right PCA stroke syndrome

A
  • Contralateral homonymous hemianopia with macular sparing
  • Contralateral sensory loss (due to lateral thalamic involvement)
  • Memory deficits
  • Prosopagnosia (face blindness)
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22
Q

Features of thalamic injury

A
  • Decreased level of arousal
  • Variable sensory loss
  • Aphasia
  • Visual field losses
  • Apathy
  • Agitation
  • Personality change
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23
Q

Lenticulostriate artery strokes

A
  • aka Lacunar strokes or penetrating artery strokes
  • More often caused by lipohyalinosis in the setting of hypertension or diabetes than by embolic occlusion
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24
Q

Basilar artery strokes

A
  • Consciousness preserved if the reticular activating system is unaffected
  • Vertebrobasilar insufficiency:
    • Vertigo, drop attacks, tinnitus, hiccups, dysarthria, dysphagia
    • Ipsilateral cranial nerve deficits
    • Diplopia
    • Gait ataxia
    • Paresthesias
  • Pontine syndromes
  • Cerebellar syndromes
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25
Q

AICA stroke syndrome

A
  • aka the lateral pontine syndrome or Marie-Foix syndrome
  • Features:
    • Contralateral loss of pain and temperature sensation
    • Ipsilateral limb and gait ataxia
    • Ipsilateral loss of facial sensation to pain and temperature
    • Ipsilateral facial weakness, loss of lacrimation and salivation, loss of taste sensation on anterior 2/3 of tongue
    • Ipsilateral vertigo, nystagmus, hearing loss
    • Ipsilateral Horner’s syndrome
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26
Q

Internal carotid artery stroke syndrome

A
  • Ipsilateral amaurosis fugax or sudden onset blindness
  • Dysphagia
  • Ipsilateral tongue deviation
  • Contralateral hemiparesis, paresthesias, hemisensory loss, homonymous hemanopsia, etc etc
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27
Q

Common carotid artery stroke syndrome

A
  • Ipsilateral Horner’s syndrome
  • Ipsilateral MCA stroke syndrome
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28
Q

Pure sensory lacunar stroke syndrome

A
  • Most commonly involves the thalamus
  • Caused by occlusion of lenticulostriate/penetrating artery
  • Contralateral numbness and paresthesias of the arm, face, leg
29
Q

Pure motor lacunar stroke syndrome

A
  • Most commonly involves the posterior limb of the internal capsule
  • Caused by lenticulostriate/penetrating artery occlusion
  • Most common type of lacunar stroke
  • Features:
    • Contralateral hemiparesis of arm, face, leg
    • Dysarthria
    • No sensory impairment
30
Q

Sensorimotor lacunar stroke syndrome

A
  • Most commonly involves the posterior limb of the internal capsule
  • Caused by lenticulostriate/penetrating artery occlusion
  • Total contralateral hemiparesis and sensory impairment
31
Q

Ataxia hemiparesis lacunar stroke syndrome

A
  • Most commonly involves the posterior limb of the internal capsule
  • Caused by lenticulostriate/penetrating artery occlusion
  • Ipsilateral weakness and impaired coordination (ataxia, gait instability)
32
Q

Dysarthria-Clumsy Hand Lacunar stroke syndrome

A
  • Can involve the caudate, posterior limb of the internal capsule, putamen, or pontine base
  • Caused by lenticulostriate/penetrating artery occlusion
  • Dysarthria plus contralateral facial and hand weakness, but not leg weakness
33
Q

Hemiballismus lacunar stroke syndrome

A
  • May be caused by multiple locations of infarct, but NOT by the posterior limb of the internal capsule
  • Caused by lenticulostriate/penetrating artery occlusion
  • Contralateral, involuntary, large flinging movements of the arm or leg
34
Q

Most common site of lacunar stroke infarct

A

Posterior limb of the internal capsule

This can produce any lacunar stroke syndrome EXCEPT hemiballismus

35
Q

Ventral midbrain syndrome

A
  • aka Weber syndrome
  • Midbrain infarct syndrome
  • Caused by PCA obstruction
  • Affects occulomotor fibers + corticospinal tract
  • Ipsilateral occulomotor palsy and contralateral hemiparesis
36
Q

Claude syndrome

A
  • Midbrain infarct syndrome
  • Caused by PCA obstruction
  • Affects occulomotor fibers + superior cerebellar peduncles and red nucleus
  • Ipsilateral occulomotor palsy and contralateral ataxia
37
Q

Paramedian midbrain syndrome

A
  • Midbrain infarct syndrome
  • Caused by PCA obstruction
  • aka Benedikt syndrome
  • Affects occulomotor fibers and both the corticospinal tract and superior cerebellar peduncles
    • Basically a sum of Claude and Weber syndrome
  • Ipsilateral occulomotor palsy, contralateral hemiparesis, and contralateral rubral tremor
    • Rubral tremor: low frequency (< 4.5 Hz), large amplitude tremor that is present at rest and worsened by maintaining a posture, or by peforming specific activities (a combination of resting, postural, and intention tremor).
38
Q

Dorsal midbrain syndrome

A
  • aka Parinaud syndrome
  • Midbrain infarct syndrome
  • Caused by PCA obstruction. Also often results from compression, especially from pinealomas
  • Occular abnormalities:
    • Vertical gaze palsy
    • Eyelid retraction
    • Convergence-retraction nystagmus
    • Pseudo-Argyll Robertson pupils
39
Q

Nothnagel syndrome

A
  • Midbrain infarct syndrome
  • Caused by PCA obstruction. Also often results from compression, especially from pinealomas
  • Affects the superior colliculi and superior cerebellar peduncle
  • Ipsilateral or bilatreal occulomotor palsy and ipsilateral cerebellar ataxia
40
Q

Midbrain syndromes (five)

A
  • Weber syndrome
  • Claude syndrome
  • Benedikt syndrome
  • Parinaud syndrome*
  • Nothnagel syndrome*
    • All caused by PCA occlusion.
    • *Starred also caused by pinealomas
41
Q

Pontine syndromes (four)

A
  • Ventral pontine syndrome
  • Lateral pontine syndrome
  • Inferior medial pontine syndrome
  • Locked-in syndrome
    • Caused by different arteries depending upon level
42
Q

Ventral pontine syndrome

A
  • Pontine stroke syndrome
  • Caused by basilar artery occlusion
  • Ipsilateral facial nerve palsy
  • Ipsilateral abducens palsy
  • Contralateral hemiparesis
43
Q

Inferior medial pontine syndrome

A
  • Pontine stroke syndrome
  • Caused by paramedian-basilar artery branch occlusion
  • Contralateral hemiparesis, ipsilateral facial weakness, ipsilatreal abducens palsy, ipsilatreal internuclear ophthalmoplegia (aka injury to medial longitudinal fasciculus)
44
Q

Medial medullary syndrome

A
  • Caused by occlusion of branches of the anterior spinal artery or the vertebral arteries
  • Ipsilateral tongue palsy (with ipsilateral deviation), contralateral hemiparesis, contralateral loss of proprioception
45
Q

AMBOSS stroke pathway

A
46
Q

Signs that raise suspicion for hemorrhagic stroke over ischemic stroke

A
  • Headache
  • Depressed level of consciousness
  • Cushing’s triad
  • Extreme elevation in blood pressure
47
Q

Contraindications to tPA in the setting of stroke

A
  • Active bleeding
  • Recent history of stroke
  • History of intracerebral hemorrhage
48
Q

Secondary stroke prevention

A
  • If in setting of afib: anticoagulation
  • If no afib: antiplatelet regimen
    • aspirin + clopidogrel OR aspirin + dipyridamole
  • Screen for carotid stenosis
49
Q

tPA must be administered within ___ of a stroke in order to be effective

A

tPA must be administered within 4.5 hours of a stroke in order to be effective

50
Q

Endovascular/intra-arterial therapy must be performed within ___ of a stroke in order to be effective

A

Endovascular/intra-arterial therapy must be performed within 6 hours of a stroke in order to be effective

51
Q

For patients who are eligible, __ is the best possible treatment for stroke

A

For patients who are eligible, thrombectomy is the best possible treatment for stroke

But, they have to have an LVO and be within 6 hours of occlusion

52
Q

Patient has new onset R gaze preference, L sided neglect, L sided paralysis. Patient’s LKW time is 1 hour ago. CT is negative for hemorrhage. No contraindications to tPA or to contrast. What is the next step?

A

tPA, THEN angiography

After hemorrhage is ruled out, tPA should not be delayed for imaging

53
Q

Most sensitive imaging technique for suspected ischemic stroke

A

MRI with DWI and ADC

Hyperintense on DWI, hypointense on ADC

54
Q

Most sensitive imaging technique for small/micro hemorrhage

A

Gradient echo sequence-T2-weighted MRI

55
Q

Where does the blood supply to the medial temporal lobe come from?

A

The PCA

NOT the MCA

56
Q

Contraindicatinos to tPA

A
  • Active major bleed
  • Active anticoagulation
  • Major surgery or TBI within last 10 days
  • Non-disabling deficit (somewhat subjective)
  • SBP > 185 mmHg
57
Q

One lab that MUST be sent prior to administering tPA

A

Glucose

Since hypoglycemia can mimic stroke

58
Q

Imaging in stroke

A
  1. Non-con CT
  2. CTA head and neck
  3. Sometimes CT perfusion scan (6-24 hours if there is question of the benefit of late thrombectomy)
59
Q

Can you do thrombectomy after 6 hours from LKW?

A

Sometimes

It depends the results of the CT perfusion imaging. If there is a large ischemic penumbra, it is still worth doing.

60
Q

“High risk TIA” recurrence risk management

A
  • If carotid stenosis and not a candidate for endarterectomy by CTA, aspirin only as bridge to endarterectomy
  • If carotid stenosis and not a candidate for endarterectomy by CTA, DAPT for 21 days followed by monotherapy
  • If atrial fibrillation or DVT/paradoxical embolism, anticoagulation
  • If APLS or mechanical heart valves, warfarin +/- aspirin
61
Q

Brainstem vasculature

A

Note that the bottom artery is the anterior spinal artery, an important blood supply to the ventral medulla

62
Q

Collier’s sign

A

Unilateral or bilteral eyelid retraction

Caused by dorsal midbrain lesions, such as Parinaud syndrome, Miller-Fisher syndrome, dorsal midbrain infarct, or sometimes MS or encephalitis.

63
Q

INR cutoff for tPA eligibility

A

Must be < 1.7

64
Q

Where does this syndrome localize?

Ataxia, nystagmus, ophthalmoplegia, amnesia, confabulation

A

The mammillary bodies

Seen in Wernicke-Korsakoff syndrome

65
Q

Isolated vertical gaze paralysis

A

Likely a lesion to the superior colliculi

May suspect Parinaud syndrome

66
Q

Contralateral paralysis, tongue deviates ipsilateral? Artery?

A

Medial medullary syndrome

Anterior spinal artery

67
Q

Vomiting, nystagmus, vertigo, ↓ pain/temp from contralateral body and ipsilateral face, ipsilateral Horner, ataxia, dysmetria PLUS dysphagia, hoarseness, ↓ gag reflex? Artery?

A

Lateral medullary syndrome / Wallenburg syndrome

Posterior inferior cerebellar artery

68
Q

Paralysis of face, ↓ lacrimation/salivation, ↓ taste from anterior tongue? Artery?

A

Lateral pontine syndrome

Anterior inferior cerebellar artery

69
Q

Quadriplegia, loss of facial/mouth/tongue movement? Which artery?

Horizontal or vertical eye movements affected?

A

Locked-in syndrome

Basilar artery

Horizontal eye movements are affected, vertical are spared (superior colliculi)

Neurology Clerkship (60 decks)

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