V A S C U L A R

Question 1

What kind of sx do you expect in a patient with a stroke affecting the basilar artery?

Answer 1

Coma, “locked in” syndrome, cranial nerve palsies, apnea, visual sx, drop attacks, dysphagia, dysarthria, vertigo, “crossed” weakness and sensory loss affecting ipsilateral face and contralateral body

Question 2

Immediate labs to get when pt presents with stroke

Answer 2

CBC with platelets, cardiac enzymes and troponin, electrolytes, BUN, creatinine, serum glucose, PTT, PT, INR, lipid profile, and O2 sat

Question 3

Most sensitive modality for diagnosing acute ischemic infarct

Answer 3

Diffusion weighted MRI

Question 4

If you suspect an embolic stroke, what tests should you order next

Answer 4

ECG, echo

Question 5

Contraindications to tPA tx

Answer 5

SAMPLE STAGES
Stroke or head trauma within last 3 most
Anticoag with INR >1.7 or prolonged PTT
MI (recent)
Prior intracranial hemorrhage
Low platelet count (185 OR diastolic>110
Surgery in the past 14 days
TIA
Age 400 mg/dL) or decreased (<50) blood glucose
Seizures at onset of stroke

Question 6

If anticoag is contraindicated in pt who just had a stroke, what meds can you give them instead?

Answer 6

ASA + clopidogrel.

Question 7

Target INR for pts with prosthetic valve

Answer 7

3-4. OR you can add anti-platelet agent.

Question 8

Thrombotic stroke is due to rupture of…?

Answer 8

Atherosclerotic plaque, which usually develops at branch points e.g. bifurcation of internal carotid and MCA in circle of Willis. It results in a PALE infarct at the periphery of the cortex.

Question 9

Embolic stroke is due to …?

Answer 9

Thromboemboli, usually 2/2 afib. Usually involves MCA. Results in HEMORRHAGIC infarct at periphery of cortex.

Question 10

Ischemic stroke – describe the pathology

Answer 10

Results in liquefactive necrosis*. Eosinophilic change in the cytoplasm of neurons (red neurons) is an early finding, 12 hours after. Necrosis occurs in 24, infiltration by neutrophils days 1-3, and microglial cells (days 4-7), and gloss (weeks 2-3) then ensue. This results in a formation of a fluid filled cystic space surrounded by gliosis.

Question 11

Which cranial nerve is associated with berry aneurysms?

Answer 11

CN III palsy with pupillary involvement

Question 12

What should you do if you suspect SAH but get a negative CT?

Answer 12

Immediate LP to look for RBCs, xanthochromia, increased protein (2/2 RBCs) and increased ICP. LP results can be falsely negative in first 6-12 hours bc xanthochromia not yet developed and after first 24-28 hours because its resolved.

Question 13

7 conditions associated with berry aneurysms (aka SAH)

Answer 13

MAKE SAH.
Marfans
Aortic coarctation
Kidney dz (ADPKD)
Ehlers danlos
Sickle cell anemia
Atherosclerosis
History (familial)

Additionally, being black has a higher risk.

Question 14

Intracerebral hemorrhage is classically due to rupture of?

Answer 14

Charcot Bouchard micro aneurysms of lenticulostriate vessels. Usually in BASAL GANGLIA.

Question 15

What feature of berry aneurysms make them more prone to rupture?

Answer 15

Lack of a media layer

Question 16

Pt presents with intractable vomiting, FEVER, occipital headache, blepharospasm, severe dizziness and inability to walk. Muscle strength is preserved and no sensory abnormalities noted. What is the most likely etiology?

Answer 16

Cerebellar hemorrhage. Fever is common in any intracranial hemorrhage.

Question 17

What kind of sx expected in MCA stroke

Answer 17

Aphasia if dominant (usually left) hemisphere or neglect if non dominant (right) hemisphere
CL paresis and sensory loss in face and arm
Gaze preference* toward side of lesion
Homonymous hemianopsia

Question 18

What kind of sx expected in ACA stroke

Answer 18

C/L paresis and sensory loss in log
Cognitive or personality changes –abulia, emotional disturbance, etc.
Dyspraxia
Urinary incontinence

Question 19

What kind of sx expected in PCA stroke

Answer 19

Homonymous hemianopsia
Memory deficits
Dyslexia/alexia
Dysphagia
Dysarthria

Question 20

What kind of sx expected in posterior limb of internal capsule stroke

Answer 20

Unilateral motor impairment with no sensory or cortical deficits
No visual field abnormalities

Question 21

Describe how homocysteinuria can cause CVA and what tx is.

Answer 21

CVA 2/2 pathologic changes in vessel walls and increased adhesiveness of the platelets usually involving cerebral vessels. Give Vit B6, folate, and B12 as well as anti-platelets or anti-coagulation. Don’t confuse with Marfans (same body habitus!)

Question 22

4 causes of craniocervical dissection

Answer 22

Trauma
FMD
Inflammatory/infectious diseases
Marfans

Question 23

Presentation of cingulate “subfalcine” herniation

Answer 23

Displacement of cingulate gyrus under fall cerebra; occurs 2/2 mass lesions of frontal lobes. Could compress ACA leading to infarction

Question 24

Presentation of transtentorial herniation

Answer 24

Pushes midbrain inferiorly
Presents with rapid change in mental status
B/L small and reactive pupils
Cheyne-Stokes respirations
Flexor or extensor posturing

Question 25

Presentation of uncal herniation

Answer 25

CN III becomes intrepid – leading to fixed and dilated IPSILATERAL pupil followed by eye that is deviated down and out.
Ipsilateral hemiparesis from compression of cerebral peduncle against tectorial edge
Compression of PCA
Rupture of paramedic artery leads to Duret (brainstem) hemorrhage

Question 26

Cerebellar tonsillar herniation into foramen magnum - signs and sx

Answer 26

Tonsillar herniation – > medullary compression –> respiratory arrest. Usually rapidly fatal.

Question 27

Which tracts affected in ASA stroke? Sx?

Answer 27

Infarct of paramedian branches of ASA and vertebral arteries (medial medullary syndrome): lateral corticospinal tract, medial lemniscus, caudal medulla –hypoglossal nerve.
Sx: contralateral hemiparesis of lower limbs, decreased contralateral proprioception, ipsilateral hypoglossal dysfunction (tongue deviates ipsilaterally).

Question 28

Which tracts affected in PICA stroke? Sx?

Answer 28

Lateral medullary (Wallenbergs) syndrome: lateral medulla affecting vestibular nuclei (vertigo, nystagmus, vomiting); lateral spinothalamic tract (decreased pain and temp sensation to limbs); spinal trigeminal nucleus (decreased pain and temp sensation to face); nucleus ambiguus (dysphagia, hoarseness, decreased gag reflex); sympathetic fibers (ipsilateral Horners); inferior cerebellar peduncle (ataxia, dysmetria).

Question 29

Which tracts affected n AICA syndrome? Sx?

Answer 29

Lateral pons–cranial nerve nuclei; vestibular nuclei (vomiting, vertigo, nystagmus); facial nucleus (paralysis of face, decreased lacrimation, salivation, decreased taste from anterior 2/3 of tongue, decreased corneal reflex); spinal trigeminal nucleus (Decreased pain and temp sensation); cochlear nuclei (ipsilateral decreased hearing); sympathetic fibers (ipsilateral Horners syndrome)

Question 30

Besides the lateral pons, what else does AICA supply?

Answer 30

Inferior and middle cerebellar peduncles.

Question 31

If a pt has a berry aneurysm with a CN III palsy, where is the lesion?

Answer 31

Posterior communicating artery

Question 32

Which kind of hematoma crosses suture lines?

Answer 32

Subdural hematoma

Question 33

Which kind of hematoma can cross falx, tentorium?

Answer 33

Epidural hematoma

Question 34

When does irreversible damage begin to the brain in hypoxia?

Answer 34

5 minutes

Question 35

4 most vulnerable areas of the brain to hypoxia

Answer 35

Hippocampus
Neocortex
Cerebellum
Watershed areas