Neurology Clerkship > Stroke > Flashcards

Stroke Flashcards

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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
AICA stroke syndrome
* 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
26
Internal carotid artery stroke syndrome
* Ipsilateral amaurosis fugax or sudden onset blindness * Dysphagia * Ipsilateral tongue deviation * Contralateral hemiparesis, paresthesias, hemisensory loss, homonymous hemanopsia, etc etc
27
Common carotid artery stroke syndrome
* Ipsilateral Horner's syndrome * Ipsilateral MCA stroke syndrome
28
Pure sensory lacunar stroke syndrome
* Most commonly involves the thalamus * Caused by occlusion of lenticulostriate/penetrating artery * **Contralateral numbness and paresthesias of the arm, face, leg**
29
Pure motor lacunar stroke syndrome
* 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
Sensorimotor lacunar stroke syndrome
* Most commonly involves the posterior limb of the internal capsule * Caused by lenticulostriate/penetrating artery occlusion * **Total contralateral hemiparesis and sensory impairment**
31
Ataxia hemiparesis lacunar stroke syndrome
* 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
Dysarthria-Clumsy Hand Lacunar stroke syndrome
* 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
Hemiballismus lacunar stroke syndrome
* 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
Most common site of lacunar stroke infarct
**Posterior limb of the internal capsule** This can produce any lacunar stroke syndrome **EXCEPT hemiballismus**
35
Ventral midbrain syndrome
* aka Weber syndrome * Midbrain infarct syndrome * Caused by PCA obstruction * Affects occulomotor fibers + corticospinal tract * Ipsilateral occulomotor palsy and contralateral hemiparesis
36
Claude syndrome
* Midbrain infarct syndrome * Caused by PCA obstruction * Affects occulomotor fibers + superior cerebellar peduncles and red nucleus * Ipsilateral occulomotor palsy and contralateral ataxia
37
Paramedian midbrain syndrome
* 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
Dorsal midbrain syndrome
* 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
Nothnagel syndrome
* 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
Midbrain syndromes (five)
* Weber syndrome * Claude syndrome * Benedikt syndrome * Parinaud syndrome\* * Nothnagel syndrome\* * **All caused by PCA occlusion**. * \***Starred also caused by pinealomas**
41
Pontine syndromes (four)
* Ventral pontine syndrome * Lateral pontine syndrome * Inferior medial pontine syndrome * Locked-in syndrome * Caused by different arteries depending upon level
42
Ventral pontine syndrome
* Pontine stroke syndrome * Caused by basilar artery occlusion * **Ipsilateral facial nerve palsy** * **Ipsilateral abducens palsy** * **Contralateral hemiparesis**
43
Inferior medial pontine syndrome
* 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
Medial medullary syndrome
* 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
AMBOSS stroke pathway
46
Signs that raise suspicion for hemorrhagic stroke over ischemic stroke
* Headache * Depressed level of consciousness * Cushing's triad * Extreme elevation in blood pressure
47
Contraindications to tPA in the setting of stroke
* Active bleeding * Recent history of stroke * History of intracerebral hemorrhage
48
Secondary stroke prevention
* If in setting of afib: anticoagulation * If no afib: antiplatelet regimen * aspirin + clopidogrel OR aspirin + dipyridamole * Screen for carotid stenosis
49
tPA must be administered within ___ of a stroke in order to be effective
tPA must be administered within **4.5 hours** of a stroke in order to be effective
50
Endovascular/intra-arterial therapy must be performed within ___ of a stroke in order to be effective
Endovascular/intra-arterial therapy must be performed within **6 hours** of a stroke in order to be effective
51
For patients who are eligible, __ is the best possible treatment for stroke
For patients who are eligible, **thrombectomy** is the best possible treatment for stroke ## Footnote **But, they have to have an LVO and be within 6 hours of occlusion**
52
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?
tPA, THEN angiography After hemorrhage is ruled out, tPA should not be delayed for imaging
53
Most sensitive imaging technique for suspected ischemic stroke
MRI with DWI and ADC Hyperintense on DWI, hypointense on ADC
54
Most sensitive imaging technique for small/micro hemorrhage
Gradient echo sequence-T2-weighted MRI
55
Where does the blood supply to the *medial* temporal lobe come from?
The PCA NOT the MCA
56
Contraindicatinos to tPA
* Active major bleed * Active anticoagulation * Major surgery or TBI within last 10 days * Non-disabling deficit (somewhat subjective) * SBP \> 185 mmHg
57
One lab that *MUST* be sent prior to administering tPA
Glucose Since hypoglycemia can mimic stroke
58
Imaging in stroke
1. **Non-con CT** 2. **CTA head and neck** 3. *S**ometimes*** **CT perfusion scan** (6-24 hours if there is question of the benefit of late thrombectomy)
59
Can you do thrombectomy after 6 hours from LKW?
**Sometimes** It depends the results of the CT perfusion imaging. **If there is a large ischemic penumbra**, it is still worth doing.
60
"High risk TIA" recurrence risk management
* 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
Brainstem vasculature
Note that the bottom artery is the anterior spinal artery, an important blood supply to the ventral medulla
62
Collier's sign
**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.
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INR cutoff for tPA eligibility
Must be \< 1.7
64
Where does this syndrome localize? Ataxia, nystagmus, ophthalmoplegia, amnesia, confabulation
The mammillary bodies Seen in Wernicke-Korsakoff syndrome
65
Isolated vertical gaze paralysis
Likely a lesion to the superior colliculi May suspect Parinaud syndrome
66
Contralateral paralysis, tongue deviates ipsilateral? Artery?
Medial medullary syndrome Anterior spinal artery
67
Vomiting, nystagmus, vertigo, ↓ pain/temp from contralateral body and ipsilateral face, ipsilateral Horner, ataxia, dysmetria PLUS dysphagia, hoarseness, ↓ gag reflex? Artery?
Lateral medullary syndrome / Wallenburg syndrome Posterior inferior cerebellar artery
68
Paralysis of face, ↓ lacrimation/salivation, ↓ taste from anterior tongue? Artery?
Lateral pontine syndrome Anterior inferior cerebellar artery
69
Quadriplegia, loss of facial/mouth/tongue movement? Which artery? Horizontal or vertical eye movements affected?
Locked-in syndrome Basilar artery Horizontal eye movements are affected, vertical are spared (superior colliculi)
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