Stroke (made in med school)

Question 1

ACA Anterior cerebral artery

Answer 1

Contralateral leg weakness

Question 2

MCA Middle cerebral artery

Answer 2

Contralateral face and arm weakness greater than leg weakness; sensory loss, field cut, aphasia, or neglect (depending on side)

Question 3

PCA Posterior cerebral artery

Answer 3

Contralateral field cut

Question 4

Deep penetrating arteries

Answer 4

Contralateral motor or sensory deficit WITHOUT cortical signs (eg. aphasia, apraxia, neglect, normal higher cognitive functions)

Question 5

Basilar artery (ventral pons)

Answer 5

Quadriplegia and speechlessness due to severe dysarthria with preserved consciousness; able to move eyes and wink

Question 6

Vertebral artery

Answer 6

Lower cranial nerve deficits (eg. dysphagia, dysarthria, tongue or palate deviation) and/or ataxia with crossed sensory deficits

Question 7

CBC

Answer 7

To ensure adequate oxygen carrying capacity

Question 8

PT and PTT

Answer 8

Baselines studies before possible anticoagulation

Question 9

Lupus anticoagulant, anticardiolipin antibody, factor V leiden, protein C, protein S, AT III

Answer 9

Screening for hypercoagulable states

Question 10

Blood glucose, creatinine, lipid profile

Answer 10

Risk factors screening

Question 11

Blood cultures

Answer 11

If patient is febrile, ESP IF ENDOCARDITIS is suspected

Question 12

Hemoglobin electrophoresis

Answer 12

Hemoglobinopathies can cause stroke

Question 13

SPE

Answer 13

Lymphoproliferative diseases can predispose to brain hemorrhage

Question 14

ANA, ESR

Answer 14

If vasculitis suspected

Question 15

RPR or VDRL

Answer 15

NEUROSYPHILIS CAN PRESENT AS ACUTE STROKE

Question 16

TOAST classifications

Answer 16

• Large vessel atherosclerosis (embolus/thrombosis)
• Cardioaortic embolism
• Small vessel occlusion (lacunae)
• Stroke of other determined etiology*
• Stroke of undetermined etiology

*Dissection, vasculitis, vasospasm, venous infarct, hypercoagulability, hyperviscosity

Question 17

Modifiable risk factors

Answer 17

Htn, DM, HLD
Cardiac disease
Afib
Smoking, obesity, inactivity, ETOH or drugs
Elevated homocysteine
Hypercoagulable states eg. pregnancy
OSA

Question 18

Non-modifiable risk factors

Answer 18

Age, race, sex, family history

Question 19

More likely to have ICH than ischemic stroke?

Answer 19

• Younger patients
• Happened when awake
• Headache
• Elevated BP (SBP >200)
• Reduced level of consciousness
• Vomiting (posterior fossa ICH)
• Seizures (lobar ICH)

Question 20

Normal CBF?

Answer 20

Whole brain is 46mL/100g/min

Grey is 80mL/100g/min
White matter is 20mL/100g/min

Question 21

CBF in ischemia? in infarction?

Answer 21

Ischemia <20mL/100g/min

Infarction 8-10mL/100g/min

Question 22

CHADS2

Answer 22

Prediction tool for estimating risk of stroke in patients with afib.

CHF, HTN, Age >75, DM, Stroke previously +2

Question 23

When to treat HTN in stroke acute setting?

Answer 23

If BP >220/120
ACS
Heart failure
Aortic dissection
Hypertensive encephalopathy
AKI

Question 24

Protocol for lowering BP in stroke?

Answer 24

Cautious lowering over 1st 24 hrs with IV labetalol 10-20mg over 1-2 min
IV nicardipine 5mg/hr (titrate up by 0.25mg/h…max is 15mg/hr)

Question 25

Thrombolysis contraindicated if

Answer 25

MAP >130mmHg | BP >185/110 (need to lower this BP before starting then maintain it at 180/105)

Question 26

If candidate for thrombolytic therapy, what do you do with BP? What do you hold for first 24 hours after thrombolytic therapy?

Answer 26

Lower to 185/110 before initiation then maintain at 180/105 Aspirin & anticoagulants held to prevent bleeding

Question 27

If outside the 3 hr window for thrombolytics?

Answer 27

Antiplatelet therapy (aspirin or clopidrogel)

Question 28

Hypoglycemia in setting of acute stroke?

Answer 28

BAD- inc acidosis in penumbra

Question 29

Hyperglycemia in acute stroke?

Answer 29

Common even in patients without DM. | BAD- inc infarct volume, inc hemorrhagic conversion. LOWER IT to 60-160mg/dL.

Question 30

Why is fever bad in acute ischemic stroke? Goal?

Answer 30

Increases metabolic demands, enhances release of NTs, inc free radical production We want temp < 99 or 37.2 C

Question 31

ECG changes 2/2 stroke?

Answer 31

ST depression, QT dispersion, inverted T waves, prominent U waves

Question 32

tPA exclusions?

Answer 32

- CT head demonstrates hemorrhage or intracerebral mass lesion - Hx of previous intracranial hemorrhage - Head trauma or prior stroke in previous 3 months - SAH sx - Evidence of active bleeding or acute trauma (fracture) on exam - BP >185/110 (lower it...) - Platelet count < 100k - PTT outside normal range if receiving heparin in last 48 hours - INR > 1.7 if on warfarin (target INR for ppl with hx of DVT, prosthetic heart valves, hypercoagulable states, etc. is 2-3!!!)

Question 33

tPA "warning" situations

Answer 33

- Sx onset > 4.5 hrs - Neurologic signs clearing spontaneously - Glucose < 50 - MI in past 3 months - Major surgery in past 14 days - Arterial puncture at noncompressible site in past 7 days - GI or GU hemorrhage in past 21 days - Seizures with postictal residual neuro impairments - Multilobar infarction (hypodensity >1/3 cerebral hemisphere CT)

Question 34

non-traumatic intracerebral hematoma MCC? Others?

Answer 34

hypertensive hemorrhage. Other causes include amyloid angiopathy, a ruptured vascular malformation, coagulopathy, hemorrhage into a tumor, venous infarction, and drug abuse.

Question 35

Where does hypertensive hemorrhage hit?

Answer 35

Hypertensive hemorrhage has a predilection for deep structures including the thalamus, pons, cerebellum, and basal ganglia, particularly the putamen and external capsule

Question 36

Thrombotic ischemic strokes

Answer 36

53% of all ischemic. May be preceded by a transient ischemic attack and often occurs at night or in the morning when blood pressure is low.

Question 37

Hypoperfusion infarctions occur under two circumstances.

Answer 37

Global anoxia may occur from cardiac or respiratory failure and presents an ischemic challenge to the brain.

Question 38

What causes the MASS EFFECT in ischemic stroke?

Answer 38

Brain edema!