Stroke management

Question 1

Stroke causes

Answer 1

85% ischemic
(20% large artery atherosclerosis
25% small vessel lacunar stroke
20% cardioembolism
30% cryptogenic
5% others)

15% hemorrhagic

Question 2

Ischemic stroke mechanisms

Answer 2

intracranial atherosclerosis
small artery disease
carotid plaque with emboli
carotid stenosis
aortic arch plaque
a fib
valve disease
ventricular thrombi
cardiogenic emboli

Question 3

Cardioembolic sources

Answer 3

atrial septal aneurysm
patent foramen ovale
a fib
mitral stenosis mechanical vegetation
cardiomyopathy MI

Question 4

A fib and stroke

Answer 4

1% of population in NA and europe AF
5% of those over 65
2.5 mil Americans
1 of every 6 strokes due to AF

Question 5

CHADS2

Answer 5

1 point:
CHF
Hypertension
Age > 75
Diabetes

2 points:
stroke, TIA

Question 6

ACA stroke symptoms

Answer 6

Leg > arm weakness
Leg > arm numbness
Abulia

Question 7

MCA stroke symptoms

Answer 7

Hemiplegia --> affect motor strip
Cortical features:
- aphasia
- neglect
- visual field deficit
- gaze deviation

Question 8

Posterior circulation stroke symptoms

Answer 8

brainstem --> more nucleus/tract defects
Visual field defects
vertigo
Diplopia
Ataxia
Dysphagia
Weakness
Numbness

Question 9

Small vessel disease lacunar stroke syndrome

Answer 9

pure motor
pure sensory
mixed sensorimotor
dysarthria - clumsy
ataxia hemiparesis

Question 10

Hyperacute/acute stroke treatment

Answer 10

iv-tPA
endovascular mechanical thrombectomy
aspirin
stroke unit
hemicranectomy

Question 11

Secondary stroke prevention

Answer 11

antiplatelets (aspirin, clopidogrel, ASA and dipyridimole)
anticoagulants (warfarin, NOACs)
carotid revascularization (carotid endarterectomy, carotid stent)

Question 12

Tissue plasminogen activator

Answer 12

serine protease
converts plasminogen –> plasmin
fibrinolytic
only effective FDA approved treatment for acute ischemic stroke
10% bolus then infusion over 1 hour within 3 hours of symptom onset

Question 13

Antiplatelets for 2ndary stroke prevention (non-cardioembolic)

Answer 13

Aspirin
Clopidogrel slightly better than ASA
ASA + DP superior to ASA
Clopidogrel + ASA NOT indicated
ASA + DP NOT superior to clopidogrel
Do not combine anticoagulants + antiplatelets!!
Start tx as soon as possible
long-term treatment

Question 14

Hypertension control for stroke prevention

Answer 14

absolute target uncertain
benefits associated with overall reduction of 10/5 mmHg
optimal drug regimen uncertain - diuretic + ACEi?

Question 15

European guidelines for management of hypertension

Answer 15

General:

Question 16

TIA

Answer 16

episode of neurological deficit where symptoms resolve fully, noe vidence of loss of blood flow

Question 17

Infarction

Answer 17

injury permanent

Question 18

Penumbra

Answer 18

dysfunctional but salvageable tissue

Question 19

Carotid stenosis stroke risk

Answer 19

25% of disabling stroke within one year

Question 20

Carotid ischemic syndromes

Answer 20

unilateral weakness, numbness (contralateral)
Dysphasia if language dominant hemisphere
Amaurosis fugax: ophthalmic artery branch off carotid artery; transient monocular vision loss due to reduced blood flow to the retina

Question 21

Endarterectomy indications

Answer 21

symptomatic (strong indication)

asymptomatic - bruit detected (modest indication)

Question 22

Intra-arterial thrombolysis

Answer 22

direct local delivery of thrombolytic
lower dose/decreased systemic effects
increased rate of clot lysis
expanded time window (6 hours for MCA)
requires infrastructure/expertise

Question 23

Mechanical clot removal

Answer 23

time sensitive -

Question 24

Intracerebral hemorrhage sources

Answer 24

epidural, subdural: trauma
Subarachnoid: ruptured aneurysm
intraparenchymal - HTN
intraventricular

Question 25

Amyloid angiopathy

Answer 25

deposition of beta amyloid in vessel wall lobar hemorrhages typically in elderly Common in DOwn's syndrome characteristic histology - Congo Red (birefringent rings of amyloid deposition)

Question 26

Aneurysms

Answer 26

``` Saccular (berry) fusiform (sausage) arterial weakening typically at branch points: Circle of Willis common cause of subarachnoid hemorrhage ```

Question 27

Aneurysm risk factors

Answer 27

thinner intima/media lack external elastica medial defects

Question 28

Location of aneurysms

Answer 28

``` Ant communicating - 30% Post communicating - 25% MCA - 20% Carotid bifurcation - 8% Basilar bifurcation - 7% ```

Question 29

Clinical presentation of subarachnoid hemorrhage

Answer 29

``` Sudden, severe headache neck pain from increased ICP nausea - chemical irritation photophobia loss/alteration of LOC focal neurological deficits sudden death ```

Question 30

Pathological features of SAH

Answer 30

``` raised ICP, cerebral edema CN injury intracerebral hemorrhage intraventricular hemorrhage hydrocephalus ```

Question 31

Epidemiology of SAH

Answer 31

incidence of aneurysm in popn ~2% 10/100,000 per year most commonly age 40-60 modest female preponderance

Question 32

Hunt & Hess scale

Answer 32

1: asymptomatic/mild headache 2: severe headache/meningismus 3: drowsy, confused, mild deficit 4: stuporous, severe deficits 5: deep coma, moribund

Question 33

SAH management

Answer 33

``` neurosurgical ICU airway, ventilation BP control ICP control - ventriculostomy fluid/electrolyte monitoring early aneurysm repair ```

Question 34

SAH complications

Answer 34

recurrent bleeding from aneurysm - arterial pressure --> tamponade - clot stops intial bleed, then recurrent bleed can happen Vasospasm --> narrowing of blood vessels hydrocephalus seizures electrolyte abnormalities (commonly hyponatremia)

Question 35

Unruptured aneurysm/incidental aneurysms

Answer 35

risk of bleeding 1-3%/year risk increased with previous history of SAH, large size, HTN, smoking, posterior fossa location repair if >5 mm

Question 36

Cerebral A-V malformation

Answer 36

congenital 3 components: feeding arteries, nidus, draining veins High pressure from artery to vein with no arteriole or capillaries or venule in between Distended vein --> rupture

Question 37

Cerebral A-V malformation clinical features

Answer 37

hemorrhage seizures headache focal neurology

Question 38

Grading of cerebral A-V malformation

Answer 38

size location deep venous drainage

Question 39

Cerebral AV malformation treatment

Answer 39

``` none microsurgical removal stereotactic radiosurgery embolization combination/multidisciplinary ```

Question 40

Stroke mimics

Answer 40

``` DIIMMSSS Drug intoxication Infection Insanity conversion disorder Metabolic: hypoglycemia, renal failure, hepatic failure Migraines Syncope Seizure Structural: trauma, tumour, subdural hemorrhage ```