Stroke Flashcards
(39 cards)
What are the features of lateral medullary syndrome?
AKA Wallenberg Syndrome
(1) Ipsilateral Horner Syndrome
(2) Ipsilateral Face & Contralateral Body Pain & Temperature Loss
(3) Ipsilateral Cerebellar Ataxia
(4) Ipsilateral dysphasia & dysarthria
(5) Hiccups, nausea, vomiting, vertigo
NO LIMB WEAKNESS!
What vessel is involved in a lateral medullary stroke syndrome?
PICA or vertebral artery
What are the signs and symptoms of a medial medullary syndrome?
(1) Ipsilateral tongue weakness
(2) Contralateral arm & leg weakness
(3) Contralateral loss of proprioception & vibration.
What vessel is involved in a medial medullary syndrome stoke?
Anterior Spinal Artery
What are the signs and symptoms of Weber syndrome?
A midbrain stroke, with:
(1) Ipsilateral CN 3 palsy (ptosis, mydriasis, diplopia (down & out).
(2) Contralateral hemiplegia of the face, arm and leg.
What features on exam would be present due to a stroke in the anterior cerebral artery?
(1) Contralateral Leg Weakness
(2) Contralateral Leg Numbness
(3) Contralateral Grasp Reflex (& other frontal signs.
What physical exam features would be present due to a stroke in the superior left MCA distribution?
(1) Broca’s (expressive, non-fluent) Aphasia
(2) Right weakness of the face and arm > leg.
(3) Gaze deviation to the left.
What would be the physical exam features of a left MCA inferior branch stroke?
(1) Wernicke’s Aphasia (receptive, fluent).
(2) Right cortical sensory loss
(3) Right homonymous superior quadrantonopsia.
What physical exam features would you seen in a stroke involving the superior branch of the right MCA?
(1) Left weakness face & arm > leg.
(2) Gaze deviation to the right.
What physical exam features would you see in a stoke involving the inferior branch of the right MCA?
(1) Left cortical sensory loss.
(2) Left hemineglect
(3) Left homonymous superior quandrantonopsia.
A stroke in which distribution would give a left homonymous hemianopia?
Posterior Cerebral Artery
What vessel supplies the majority of the midbrain?
The posterior cerebral artery.
What is the timeline cutoff for potential tPA in the setting of stroke?
Stroke symptoms < 4.5 hours
What is the timeline cutoff for consideration of endovascular therapy for stroke?
< 6 hours
Within 6-24 hours ECT could be considered based on results of a CT perfusion study
What are the relative exclusion criteria for giving tPA (8)?
(1) Major surgery within the last 14 d
(2) Arterial puncture within the last 7 days at a non-compressible site.
(3) History of intracranial hemorrhage.
(4) Stroke or serious head trauma within the last 3 months.
(5) On oral DOAC or VKA
(6) HTN (>180/105 mmHg) refractory to tax
(7) Imaging evidence of extensive infarction.
(8) Labs - BG < 2.7 or > 22.2, INR > 1.7 or platelets < 100
What are the absolute exclusion criteria for tPA?
(1) Any source of active hemorrhage or any condition that could increase the risk of major hemorrhage with tPA
(2) Hemorrhage on brain imaging.
What is considered a “disabling” neurological deficit warranting tPA therapy in the setting of stroke?
In general:
(1) NIHSS > or = 6
(2) Aphasia, hemianopia, weakness limiting sustained effort against gravity, visual/sensory extinction.
What are the inclusion criteria for EVT (4)?
(1) Disabling stroke AND functionally independent, with life expectancy > 3 months.
(2) < 6 hours from onset of stroke or last known well.
(3) CT head shows a small to moderate ischemic core with an ASPECTS score of 6 or higher.
(4) CT shows an occlusion in the anterior circulation of proximal large vessel
How long should you wait before starting antiplatelet therapy if a patient received tPA?
Wait 24 hours.
Only use ASA (single anti-platelet therapy).
What is your target blood pressure if a patient received tPA +/- EVT for their ischemic stroke?
< 180/105 mmHg for 24 hours
What is your target blood pressure post-stroke if a patient DID NOT receive tPA or EVT?
Permissive HTN < 220/120 mmHg x 24 hours
Which patients with stroke warrant dual antiplatelet therapy?
High risk TIA (ABCD2 score of 4 or more) OR minor stroke (NIHSS < or = 3) of non-cardioembolic origin.
What are the components of the ABCD2 score?
A - Age > or = 60 (Yes = 1 point)
B - SBP ≥ 140 mmHg or DBP ≥ 90 mmHg (Yes = 1 point)
C - Clinical Features: Unilateral weakness (+ 2 points) OR speech disturbance without weakness (+ 1 point)
D1 - Symptom Duration: < 10 minutes (0 points), 10-59 minutes (+ 1 point) OR ≥ 60 minutes (+ 2 points).
D2 - Diabetes Hx (Yes = 1 point)
0-3 Points = Low Risk
≥ 4 Points = High Risk
How would you manage a stroke or TIA due to severe intracranial atherosclerosis?
If a patient has had a stroke or TIA within the last 30 days and had evidence of 70-99% stenosis in a major intracranial vessel, consider dual anti-platelet therapy for 3 months, followed by single antiplatelet therapy.
Also requires aggressive management of all vascular risk factors.
