Stroke and Neurocritical Care Flashcards by Jose Danilo Diestro

Embolic strokes most commonly affect which artery.

MCA

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Headaches associated with MCA strokes are usually localized to ___; while they occur in the ___ in PCA strokes.

MCA: temporal
PCA: retro-ocular

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Lesions to NONDOMINANT parietal lobe cause:

Isolated agitated delirium

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This direct branch of the ICA supplies the internal segment of the globus pallidus and posterior limb of the internal capsule and optic tract. Occlusion leads to which symptoms.

Anterior choroidal artery

Hemiplegia, hemisensory loss, homonymous hemianopia, sparing cognition and language

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Components of Gerstmann syndrome.

Where is the lesion?

Finger agnosia
Acalculia
Right/left confusion
Agraphia

Dominant inferior parietal lobule / angular gyrus

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APRAXIA QUIZ

Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia

Where is the lesion?

Inability to perform complex learned movements with preserved understanding of intended movement

Ideomotor

Dominant parietal lobe

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APRAXIA QUIZ

Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia

Where is the lesion?

Inability to perform complex learned movements with impaited understanding of intended movement

Ideational

Dominant parietal lobe

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APRAXIA QUIZ

Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia

Where is the lesion?

Inability to construct a whole from its parts

Constructional apraxia.

Nondominant parietal lobe

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APRAXIA QUIZ

Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia

Clumsiness of skilled acts with preserved understanding of intended movement

Limb-kinetic

Premotor or dominant parietal lobe

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APRAXIA QUIZ

Choose which term is described:
(A) Ideomotor, (B) ideational, (C) dressing, (D) constructional, (E) dressing apraxia or (F) limb-kinetic apraxia

Loss of topographical orientation resulting in inability to dress in an organized manner

Dressing apraxia

Nondominant parietal lobe

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NAME THAT SYNDROME

Bilateral cortical blindness with normal-appearing optic disks and preserved pupillary light reflexes, with denial of blindness and visual hallucinations

Anton’s syndrome

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NAME THAT SYNDROME

Simultagnosia (Inability to synthesize disparate images within the visual field into a coherent whole)

Optic ataxia (Inability to reach targets under visual guidance)

Gaze apraxia (Inability to direct gaze at a target)

Where is the lesion?

Balint’s syndrome

Bilateral occipitoparietal border zone strokes

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Patient presents with purely visual hallucinations that are well formed, complex, and appear cartoonish and nonthreatening, and are perceived as unreal by the patient. If due to a stroke, where is the lesion?

Peduncular hallucinosis

Stroke of the MIDBRAIN in the vicinity of the cerebral peduncles related to PCA occlusion

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Inability to recognize and identify familiar faces, interpret facial expressions or judge age or gender based on facial features. If due to a stroke, where is the lesion?

Prosopagnosia

Bilateral ventromesial occipitotemporal stroke

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Name that syndrome.

Ipsilateral CN III lesion +
Contralateral hemiparesis

Weber’s syndrome

Midbrain stroke due to PCA thrombus

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Name that syndrome.

Ipsilateral CN III lesion +
Contralateral ataxia / tremor

Claude’s syndrome

Midbrain stroke due to PCA thrombus

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Name that syndrome.

Ipsilateral CN III lesion +
Contralateral hemiparesis +
Contralateral ataxia / tremor

Benedikt’s syndrome

Midbrain stroke due to PCA thrombus

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Name that syndrome.

Ipsilateral CN V, IX, X and XI palsy +
Horner syndrome +
Cerebellar ataxia +
Contralateral pain and temperature loss +
Vertigo, nausea, hiccups

Wallenberg’s syndrome

Lateral medullary stroke due to vertebral or PICA thrombus

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Palatal tremor that persists during sleep and is audible to the patient. If due to stroke, where is the lesion?

Palatal myoclonus

Stroke in the dentato-rubro-olivary triangle of Guillan-Molere (usually pontine tegmentum)

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Name that syndrome.

Hemisensory loss +
Painful paresthesias

Where is the lesion?

Thalamic syndrome of Dejerine and Roussy

VPL/VPM stroke

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All CN nuclei are ipsilateral to the nerve except ____ and the ____ subnucleus of ____, which cross contralaterally.

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CN IV

2. Superior rectus subnucleus of CN III

As a rule of thumb, sensory nuclei are located laterally/medially within the brainstem; while motor nuclei are located laterally/medially.

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Sensory nuclei are lateral while motor nuclei are medial.

Normal cerebral blood flow (in mL/100g/min).

What is the critical threshold for functional impairment? Infarction?

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Normal: 55
Functional impairment: 23
Infarction: 12

Autoregulation occurs within this range of mean arterial pressures.

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50 - 150 mmHg

CT signs of stroke

Cortical effacement Loss of grey-white distinction Spontaneous HYPERdensity along an occluded proximal MCA (hyperdense MCA sign) or MCA branches within the Sylvian fissure (MCA dot sign)

What is the gold standard for imaging stroke?

MRI | Hyperintensity on DWI and hypointensity on apparent diffusion coefficient maps present within 30 minutes

Trials have demonstrated the superiority of this anticoagulant for primary and secondary prevention of stroke in patients with AF (SPAF II trial)

Warfarin

Indication for elective carotid endarterectomy for low-risk patients

>70% SYMPTOMATIC carotid stenosis (stroke or TIA) (NA-SCET Trial) >60% ASYMPTOMATIC (ACAS trial)

For patients with dilated cardiomyopathy, warfarin is recommended as prophylaxis if EF is < ___.

20%

Syndrome of episodic migraine-like headache and cyclic vomiting with focal neurologic deficits and seizure. May have sensorineural hearing loss, pigmentary retinopathy and myopathy.

Mitochondrial myopathy, encephalopathy, lactic acidosis and strokes (MELAS)

Renovascular hypertension, renal artery stenosis, and internal carotid stenosis associated with aneurysm formation and dissection. Angiogram shows "chain-of-lakes" pattern

Fibromuscular dysplasia

Indications for use of tPA in ischemic stroke

1. Ischemic stroke within 3 hours of onset 2. NIHSS > 3 3. No hemorrhage on head CT 4. Clear time of onset

Contraindications for use of tPA

1. Rapidly resolving deficits 2. Seizure at onset 3. Prior stroke or head trauma 14 days 5. Prior ICH 6. SBP >185 7. DBP > 110 8. GI or GU tract hemorrhage 400

Most common site of an ICH

Putamen

Indications for neurosurgical consultation re: ICH

Posterior fossa hemorrhage >3cm in maximal diameter; or significant mass effect on the 4th ventricle or rapidly expanding superficial supratentorial ICH in a young patient with a rapidly declining neuro exam

Recommendations for clipping or coiling unruptured aneurysm

Anterior circulation aneurysms >7mm Posterior circulation aneurysms >3mm Remote aneurysm in a patient with prior rupture Rapidly enlarging aneurysm

CSF Physiology 1. Normal volume 2. Rate of CSF production 3. Normal ICP

1. 150 mL 2. 20mL/h (450 - 500 mL) 3. <15 mmHg

In hyperosmolar therapy for patients with increased ICP, what is the target serum osmolarity? What is the risk of higher serum osmolarity?

Target: 300 - 310 mOsm/L | Acute tubular necrosis if serum osmolarity is higher

Target PCO2 range in patients with increased ICP

28 - 32 mmHg

Goal ICP in patients with increased ICP

<20 mmHg

Describe grading of concussions.

Grade 1: No LOC, sx (ex. confusion) 15 mins | Grade 3: (+) LOC

Patient with severe brain injury is comatose; CT is normal. Diagnosis?

Diffuse axonal injury

Most common locations of punctate hemorrhages in diffuse axonal injury

Gray-white junction Corpus callosum Middle cerebral peduncles

How many percent of TBI patients have C-spine injuries?

5 - 10%

In DAI, what is the goal CPP and goal ICP?

CPP > 60 | ICP < 20

Is seizure prophylaxis recommended for brain trauma patients?

YES. For 1 week in setting of moderate to severe

Total caloric needs of patients with severe TBI

140%

Criteria for intubation in GBS

1. VC < 15 mL/kg 2. Negative inspiratory force < -25 mL/kg 3. 30% decrement in forced vital capacity or NIF over 24h 4. Severe uncompensated respiratory acidosis 5. Severe bulbar involvement with inability to control secretions

Tetrad of neuroleptic malignant syndrome

Fever Rigidity Autonomic instability Mental status changes

Serotonin syndrome antidote

Cyproheptadine

Name that syndrome. Action myoclonus occurring in chronic survivors of cardiac arrest

Lance-Adams syndrome | Postanoxic myoclonus

Stroke and Neurocritical Care Flashcards

(51 cards)