Stroke/Neuro HY

Question 1

Biggest risk factor for strokes?

Answer 1

HTN

Question 2

Elderly with asymmetric motor and/or sensory deficits
Stroke is suspected, NBSIM?

Answer 2

NC-CT Head

(differentiates between ischemic & hemorrhagic)

Question 3

Pt has Transient ischemic attack (TIA) a temporary, focal cerebral ischemic event that results in neurological symptoms which self resolve

It is not associated with a ____ on neuroimaging.

List the 2 mcc of TIA

Answer 3

visible acute infarct

Cardioembolic (atrial fibrillation, recent MI)
Atherosclerosis (carotid artery stenosis)

Question 4

Pt with hx of Atrial Fibrillation (or recent MI) presents after a TIA/Stroke.
NCCT → pharmacotherapy?

Answer 4

Anticoagulation
Warfarin

(not antiplatelet drug like the other pts if the cause of stroke was cardioembolic use anti coagulant)

Question 5

60M smoker with a history of HTN and DM
presents after transient, painless vision loss (or a recent TIA)
NBSID?

Answer 5

Carotid duplex U/S

Question 6

Recent TIA
carotid duplex u/s shows >50% stenosis
NBSIM?

Answer 6

Carotid Endarterectomy

Question 7

Asymptomatic with carotid bruit
found to have less than 80% carotid stenosis of duplex u/s
NBSIM?

Answer 7

Wait for pt to become symptomatic or have ≥ 80% stenosis
then do Carotid Endarterectomy
Until then, statin, smoking cessation, Aspirin
━━
Symptomatic means pt has:
contralateral motor/sensory deficits (TIA/Stroke)
ipsilateral transient blindness (Amaurosis fugax)

Question 8

Patient found to have ischemic stroke on head CT.
What is the next best step in diagnosis?

Answer 8

Carotid duplex Ultrasound

Question 9

Pt found to have carotid stenosis.
What medication do you start (1st-3rd line)?

Answer 9

Aspirin (1st line) antiplatelet
Clopidogrel (2nd line) antiplatelet
Dipyridamole (3rd line)

Question 10

Pt found to have 100% stenosis on carotid duplex u/s
NBSIM?

Answer 10

No carotid endarterectomy
━
Start Aspirin (2nd line Clopidogrel), Statin (high intensity), Manage risk factors (smoking cessation, HTN, DM)
━
pt’s body has developed collateral circulation → no surgery

Question 11

Pt is elderly/smoker/ and/or hx of HTN
presents with sudden and severe headache, nausea & vomiting
FMH (+) renal dz, brain bleeds (AVMs/Aneurysms)
± nuchal rigidity or AMS
NCCT Head negative
Suspected Dx/NBSIM?

Answer 11

Lumbar Puncture (xanthochromia: RBCs in CSF)
Subarachnoid Hemorrhage (still suspected despite negative imaging)

NCCTH (+) hyperdensities in the subarachnoid space

Question 12

Once SAH is confirmed, ____ is always necessary in order to identify the source of bleeding (aneurysms or AVMs) and plan definitive treatment.

Answer 12

angiography

Question 13

Recent DVT now has a stroke.
Dx/Dxt?

Answer 13

PFO (Patent Foramen Ovale)
Cryptogenic Stroke
TEE with a Bubble Study
(bubbles travel to left side heart)

Question 14

Management of hemorrhagic stroke focuses on

Answer 14

1st: Secure ABCs (posturing = herniation = intubate)
───
Then preventing further bleeding
1st: BP control (Nicardipine, Labetalol)
2nd: AC Reversal (Warfarin: PCC or Heparin: Protamine)
3rd: Lowering ICP (HOB, Sedation, Mannitol)

Question 15

Pure motor (Upper & Lower Extremity) stroke
Dx/location/artery/Patho

Answer 15

Lacunar Stroke
Internal Capsule
microatheroma–lipohyalinosis
thrombotic small-vessel occlusion of lenticular striate a

Question 16

Left side FACE sensory sxs
Right Side BODY sensory sxs
Tongue deviates left
Localize Lesion. List arteries involved.

Answer 16

Lateral set up (Face and Body Opposite)
Left face sxs = ipsilateral to lesion
CN12 (medulla)
Lateral Left Medulla
PICA
(Vertebral artery if s/t next extension)

Question 17

Pure sensory (Upper & Lower Extremity) stroke
Contralateral numbness & paresthesia of the face & L/UE
dx/location

Answer 17

Lacunar stroke
Thalamus VPL (ventral posterolateral )

Question 18

Pt with Ischemic stroke develops worsening stroke sxs and AMS the next day? NBSIM?

Answer 18

Repeat CT Head
(hemorrhagic transformation)

FYI: Putaminal hemorrhage always involves the internal capsule (Hemiparesis)

Question 19

Elderly woman
R sided Headache + ↑ ESR
NBSIM (2)?

Answer 19

Start Prednisone
& get Temporal Artery Biopsy

Giant cell arteritis

Question 20

Negative CT Head
LP: elevated opening pressure, and elevated red blood cell count that does not decline with successive samples.
Dx?

Answer 20

Subarachnoid Hemorrhage

Question 21

Depending on the time of presentation (<__ hr for thrombolysis, <__ hr for mechanical thrombectomy) tx considered independently
Mind Contraindications before tx

Answer 21

<4.5hr → TpA
<24hr → Embolectomy

Question 22

Pt with mechanical valves and suspected TIA NBSIM (aside from NCCT Head)

Answer 22

Echocardiography

Question 23

Brain Stem Blood supply (Medial to lateral)
Midbrain →
Pons →
Medulla →

Answer 23

Midbrain → PCA/SCA
Pons → Basilar/AICA
Medulla → Vertebral/ PICA

Question 24

Brainstem CN locations
Midbrain →
Pons →
Medulla →

Answer 24

Midbrain → CN 3,4
Pons → CN 5,6
Pontine medullary Jxn → CN 7, 8
Medulla → CN 9, 10 & 12

Question 25

CT scan of the head: **biconvex (lens-shaped)** hyperdensity that does not cross suture lines

Answer 25

Epidural Hematoma

Question 26

CT scan of the head: **Concave (Crescent-shaped)** hyperdensity that crosses suture lines (Banana-shaped)

Answer 26

Subdural Hematoma

Question 27

Rupture of Bridging veins

Answer 27

Subdural Hematoma

Question 28

Trauma to sphenoid bone with tearing of middle **meningeal artery**

Answer 28

Epidural Hematoma

Question 29

BRF for Subdural Hematoma (3)

Answer 29

Age (Old) Alcoholism (Chronic) AntiCoagulant use

Question 30

Elderly with * Fluctuating Cognition * Visual hallucinations (before motor sxs) * Parkinsonism ± REM sleep behavior disorder dx?

Answer 30

dementia with Lewy bodies

Question 31

Medication C/I in lewy body dementia?

Answer 31

Severe sensitivity to antipsychotics

Question 32

50+ y.o. Patient with Executive dysfunction + Behavior changes: Disinhibition (sexual/ Rude comments) Apathy (unconcerned/uninterested) Compulsions or ritualistic behaviors Hyperorality (chewing, sucking) Executive dysfunction (low MOCA score)

Answer 32

frontotemporal dementia (Frontal lobe atrophy)

Question 33

Pt with h/o HTN Sudden **or** stepwise decline in **executive function + memory** ± FND Imaging: multiple small cortical and subcortical infarctions.

Answer 33

Vascular dementia BRF: HTN

Question 34

Presents with shuffling gait with quick, short steps Bradykinesia Muscle Rigidity Resting Tremor (improves w/ voluntary movement)

Answer 34

Parkinson's **Dopaminergic** neurons degeneration in the **substantia nigra pars compacta**

Question 35

rapidly progressive dementia + Executive dysfunction startle myoclonus/hyperreflexia/babinski mood symptoms **sleep disturbances** Dx?

Answer 35

CJD Enhancement of putamen & caudate head (hockey stick sign) not atrophy like HD

Question 36

Executive dysfunction Mood symptoms (rude) Repeated abrupt, involuntary movements in the upper extremities, Head, or Neck. Dx? Disorder? Patho: Neuro imaging:

Answer 36

Huntington disease (AD) CAG trinucleotide repeat expansion disorder Loss of **GABA-ergic** neurons **Caudate & putamen** atrophy

Question 37

Presents with progressive cognitive decline that impairs activities of daily living (bathing, dressing, preparing meals) and eventually leads to mood sxs (apathy, withdrawal) Dx/Mcc?

Answer 37

Dementia MCC: Alzheimer's *Cognitive decline precedes mood sxs*

Question 38

Early on presents with isolated impairments in memory. Then progresses to **apathy, social withdrawal**, and ± Hallucinations Can *mimic* depression. Dx/Tx?

Answer 38

Alzheimer's Dementia Donepezil, Rivastigmine, and galantamine **Cholinesterase inhibitors** (Donna & Riva going to the Gala)

Question 39

Subacute (>1 week) back pain + radiating down leg + impaired motor/sensory/reflex activity in the BLE (**LMN** sxs) bowel/bladder/sexual dysfunction and/or saddle anesthesia.

Answer 39

Cauda equina syndrome

Question 40

Classic triad Fever + Focal/severe back pain + Neurologic findings (motor/sensory change, bowel/bladder dysfunction) ↑ ESR Dx? Dxt (2)? Mcc?

Answer 40

Spinal Epidural Abscess MRI Spine + Blood cx mcc: Staph a.