Vascular Neurology Flashcards
(35 cards)
ABCD2 Score What is it for? Components and points?
Predicts stroke after TIA Age > 60 (1pt) BP of 140/90 or > (1 pt) Clinical Symptoms (1pt speech w/o weakness, 2 pts focal weakness) Duration (1 pt 10-59min, 2pt 60+min) Diabetes (1pt) 2 day risk of stroke: 0% for 0-1, 1.3% for 2-3, 4.1% for 4-5, 8.1% for 6-7
NIHSS components
Wallenberg Syndrome
What region affected?
Vessel?
Structures and corresponding symptoms?
Lateral Medulla
PICA off of vertebral artery
- Vestibular n. = Vertigo, nystagmus, nausea, vomiting
- Descending tract and n. of CN V = ipsilateral facial sensation loss
- Spinothalamic tract = pain and temp to contralateral body
- 1st order sympathetics = ipsilateral Horner’s (meiosis, anhidrosis, ptosis)
- CN IX and X fibers = hoarseness, decreased gag, ipsilateral palate and vocal cord paralysis, dysphagia
- Cerebellum and cerebellar tracts = ipsilateral ataxia and lateropulsion
- Nucleus solitarius = ipsilateral taste
tPA exclusion criteria
Absolute contraindications
- Any prior ICH
- Severe head trauma last 3 months
- Known intracranial malformation or neoplasm
- Ischemic stroke < 3 months ago
- Aortic arch dissection
- Acute internal bleeding or bleeding at a noncompressible site in last 7 days
- Diatheses: Platelets < 100K, heparin w/i 48 hours, elevated aPPT, INR >1.7, PT >15
- DOAC in last 48 hours - BP > 185 sys or >110 dia - glucose < - INR After 3 hours: - Age >80 - Any AC at all - Hx of diabetes AND stroke - NIHSS >25
Relative Contraindications
- Intracranial/spinal surgery last 14 days
- Rapidly improving or minor symptoms
- Pregnancy
- GI or UT hemorrhage w/i 21 days
- Seizure at onset
- MI w/i 3 months
Thalamic blood supply
Vessels?
Symptoms?
- Tuberothalamic artery (branch of PCOM) = Anterior thalamus (VA n.)
- Thalamoperforating/paramedian artery (PI segment of PCA) = Medial thalamus (DM n.)
Artery of Percheron = normal variant. Single branch off unilateral P1 supplying bilateral medial thalami - Thalamogeniculate artery (branch of P2 of PCA) = Lateral Thalamus (VL n.)
- Posterior choroidal artery (branch of P2 off PCA) = Posterior thalamus (Pulvinar)
Can be effected by CSVT of deep veins as well
Recurrent Artery of Heubner
Origin? Supplies? Risks? Clinical symptoms?
- Deep Branch off ACA
- Supplies anterior limb of internal capsule, inferior head of the caudate, anterior globus pallidus
- AT risk w/ ACA aneurysm or clipping
- Symptoms =
unilateral = weakness contralateral arm & face. dysarthria. hemichorea.
bilateral = akinetic mutism.
ACA
Origin?
Supplies?
Infarct Symptoms?
Origin: ICA
Supplies:
Pre-and post ACA -> recurrent artery of huebner, deep branches = anterior limb of IC, inferior head of caudate and anterior globus pallidus
- Infarct =
unilateral = weakness contralateral arm & face. dysarthria. hemichorea.
bilateral = akinetic mutism.
Post ACA = anterior 3 quarters of the medial frontal lobe
- Infarct = leg weakness, urinary incontinence (medial micturition center)
MCA
Origin and branches?
Supplies?
Infarct Symptoms?
Origin: ICA
Branches:
Superior MCA division supplies lateral and inferior frontal gyri, parietal lobe
- Broca’s, arm and face weakness, eye deviation (FEFs), sensory loss
Inferior MCA division supplies superior temporal lobe, insula
- Wernicke’s
- Sensory loss in face and arm
- Visual defects in contralateral hemifield (optic radiations)
Lenticulostriate branches supply putamen, part of head and body of caudate, external globus pallidus, posterior limb of IC, and corona radiata
- Lacunar infarcts yielding pure sensory or motor syndromes
Parinaud Syndrome
Lesion of dorsal midbrain aka quadrigeminal plates (Pineal tumors, midbrain infarcts)
- Supranuclear paralysis of eye elevation
- convergence-retraction nystagmus
- light-near dissociation
- lid retraction
- Skew deviation
Anterior Choroidal artery
Origin and branches?
Supplies?
Infarct Symptoms?
Origin: ICA just after PCOM
Supplies; Internal segment of globus pallidus, part of posterior limb of internal capsule, part of geniculocalcarine tract, choroid plexus
Symptoms:
hemiplegia
hemianaesthesia and
contralateral hemianopia
Medial Medullary Syndrome
Vessel?
Structures and corresponding symptoms?
Vertebral artery or 1+ of its medial branches
- Pyramid - contralateral arm and leg
- Medial Lemniscus - contralateral sensation/vibration
- Hypoglossal fibers - ipsilateral tongue
Millard-Gubler Syndrome
Foville Syndrome
MG (AKA Ventral Pontine Syndrome)
- Corticospinal tracts (pre-decusation) = contralateral arma dn leg hemiparesis
- Facial n. = ipsilateral facial weakness
Foville Syndrome
- MG syndrome symptoms
- Abducens n. = ipsilateral horizontal gaze palsy
Weber vs Benedikt’s Syndrome vs Claude Syndrome
What region infarcted? What structures? Symptoms?
Weber
Ventral Midbrain
1. Cerebral Peduncle = Contralateral hemiweakness
2. CNIII Fascicle = CNIII palsy
Benedikt’s:
Ventral mesencephalic tegmentum
1. Ventral red nucleus = contralateral involuntary movements (tremor, choreathetosis)
2. Fascicle of CN III = CNIII palsy
Claude:
Dorsal mesencephalic tegmentum
1. Dorsal red nucleus = Ataxia and tremor (NO chorea)
2. Fascicle of CN III = CNIII palsy
Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Trial
More adverse events but no additional benefit treating severe intracranial stenosis with Warfarin over aspirin.
CHADS2 or CHA2DS2VASc
Use?
Components?
Risk Stratification to determine if AC should be used in the setting of Atrial Fibrillation
CHF, HTN, Age >75 (2pts), Diabetes, Stroke/TIA/TE Hx (2 pts), Vascular disease, Age 65-74, Sex category (Female) = Max 9 points
Does not account for chronic kidney disease risk.
Score 0 = Can defer AC. Score 1 = +/- antithrombotics, AC depending. Score > 2 = Offer AC.
SAMPRIS Trial
Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial
Management of symptomatic intracranial stenosis:
- ASA indefinitely and clopidogrel x 90 days
- BP control < 140 (130 in diabetics)
- high dose statin (LDL < 70)
- Glucose control
- exercise, stop smoking
ASPECTS
Alberta Stroke Program Early CT score
Look at CT, subtract 1 point for each area with early changes:
- 4 deep: Caudate, internal capsule, lentiform nucleus, insular region
- 6 cortical
10 = normal HCT. 0 = Entire MCA territory. >7 is very bad
North American Symptomatic Carotid Endarterectomy Trial
Asymptomatic Carotid Surgery Trial, Asymptomatic Carotid Atherosclerosis Study
NASCET (Symptomatic)
Occlusion → Medical management
70-99% symptomatic stenosis → CEA
50-69% → CEA if men, previous strokes, hemispheric symptoms
<50% → Medical management
ACST/ACAS (asymptomatic)
>60% → CEA better than medical management but very high NNT
CADASIL
Symptoms
Cause
Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy
- Multiple strokes w/o risk factors, hx of migraines, dementia, family hx
- Missesense mutation of NOTCH3
Gertsmann’s Syndrome
Left (Dominant) Parietal Lobe near Angular Gyrus
- Finger Agnosia
- Right-left confusion
- Agraphia
- Acalculia
- +/- aphasia
Lacunar Syndromes
- Pure Sensory
Pure Motor
Clumsy-Hand Dysarthria
Ataxic hemiparesis
Cause? Where?
Caused by lipohyalinosis of small vessels due to HTN
Pure Sensory → Thalamus, Contralateral sensory
Pure Motor → Posterior limb of IC or ventral pons, contralateral motor
Clumsy Hand Dysarthria → Paramedian Pons, contralateral hand weakness, dysarthria
Ataxic Hemiparesis → Pons, midbrain, or internal capsule, Ataxia out of proportion to weakness
Dilated thin-walled vessels, no normal brain tissue, “popcorn” appearance
Name? Cause? Risk?
Cavernous malformation
Congenital
Usually incidental, may bleed
Thin-walled venous structure, normal brain tissue intervening
Name? Cause? Risk?
Venous Angioma
Congenital
Usually benign
Abnormally dilated capillaries, normal brain tissue intervening
Name? Cause? Risk?
Capillary telangiectasias
Congenital
Usually benign
