Term
| How do you tell the difference between a Stroke and a Transient Ischemic Attack (TIA) in terms of clinical presentation? |
|
Definition
1) A stroke persists beyond 24 hours
2) TIA is brief episode of neurological dysfunction (20-30 minutes usually) caused by focal brain or retinal ischemia |
|
|
Term
| What are the 4 causes of Sudden neurological deficit? |
|
Definition
1) Stroke
2) Seizure
3) Migrane
4) Factitious disorder (conversion, malingering) |
|
|
Term
| What are the most common symptoms of a stroke? |
|
Definition
1) Weakness
2) Numbness
3) Tingling
4) Loss of vision and ability to speak
5) Slurred speech |
|
|
Term
A patient presents with the "worst headache of their life."
What is the most likely diagnosis until proven otherwise? |
|
Definition
| Subarachnoid Hemorrhagic (SAH) stroke. |
|
|
Term
A patient presents with Unilateral weakness, numbness and tingling, as well as Monocular loss of vision in the right eye and Gaze deviation to the left side.
They are having difficulty speaking or understanding speech and when asked to draw a picture of a clock, they only draw the left side.
What is your diagnosis? |
|
Definition
Infarction of left anterior circulation.
Unilateral weakness, numbness and tingling are suggesting of stroke.
Monocular vision loss is characteristic of an Anterior infarction, but does not confirm it for sure.
However, their is broca's and wernicke's aphasia, suggesting a left-side lesion, and therefore the left-side Gaze is diagnostic for an Anterior Circulation infarction on the left side. Furthermore, the Non-dominant hemisphere neglect also suggests anterior infarction. |
|
|
Term
A patient presents with Unilateral weakness, numbness and tingling, and his gaze is biased toward the left. His gaze is also disconjugate. However, there is no evidence of aphasia or sensory neglect.
What is your diagnosis? |
|
Definition
Right side Posterior Infarction.
Disconjugate gaze and absence of sensory neglect and aphasia is suggesting of posterior circulation, and if this is the case, the gaze will drift AWAY from the lesion. |
|
|
Term
A patient presents with hemineglect of their left side.
You perform an angiogram, inserting contrast into the right internal carotid artery. What do you see? |
|
Definition
Contralateral hemineglect is characteristic of an MCA infarction in the areas supplying the Parietal Lobe in the NON-DOMINANT hemisphere.
You might see an embolism that has blocked the MCA where is branches to supply the Parietal lobe on the right side. |
|
|
Term
A patient presents with a left-hand gaze preference and expressive aphasia
You perform an angiogram, inserting contrast into the left internal carotid artery. What do you see? |
|
Definition
An embolism blocking the MCA where it supplies the frontal lobe on the left side (dominant hemisphere for language with Broca's area)
**Ipsilateral gaze preference is characteristic of infarctions in the MCA supplying the frontal lobes in both dominant and non-dominant hemispheres. Broca's aphasia tells you left |
|
|
Term
A patient presents with Hemianopsia of the left visual field.
What type of stroke might have taken place? |
|
Definition
Infarction of Right PCA.
PCA supplies the occipital lobe and infarction causes Contralateral Hemianopsia. |
|
|
Term
| When do you see contralateral gaze preference vs. ipsilateral gaze preference? |
|
Definition
1) Ipsilateral is seen in MCA infarctions supplying the frontal lobe.
2) Contralateral is seen Paramedian Pontine RF infarctions. |
|
|
Term
A patient comes in and she is in a deep coma.
What brainstem syndrome could be giving rise to this coma? |
|
Definition
| Syndrome in the RF of the Pons and Midbrain |
|
|
Term
| What are the different types and causes of Stroke? |
|
Definition
1) Ischemic: occlusion of vessel/speed depends upon collateral circulation (TIA occurs without actual infarction)
- Caused by Atherosclerosis, Cardioembolism (A-fib) and Small vessel disease (Lipohyalinosis and local thrombosis of arterioles)
2) Intracerebral Hemorrhage: Cerebral artery within parenchyma ruptures and blood is toxic to neurons (Hematoma may actually Tamponade the ruptured artery, and limit hemorrhage)
- Caused by Hypertension (Charcot-Bouchard aneurism), Amyloid angiopathy in vessels, Arteriovenous malformation
3) Subarachnoid Hemorrhage: bleeding occurs between arachnoid and pia surrounding brain (worst headache of life)
- Caused by Trauma, Berry aneurysm (congenital) and Arterial dissection. |
|
|
Term
| What type of strokes are caused by Berry Aneurisms? What abut Arteriovenous Malformations? |
|
Definition
Both are congenital condiions.
1) Berry Aneurisms are found in Circle of Willis and cause Subarachnoid Hemorrhagic stroke
2) Arteriovenous Malformations cause Intracerebral Hemorrhagic stroke and blood/neuron toxicity. |
|
|
Term
What type of stroke is a patient with Hypertension especially prone to?
What about a patient with small vessel disease or Amyloid Angiopathy? |
|
Definition
1) Hypertension and Amyloid Angiopathy of arterioles predispose patients to Intracerebral Hemorrhage.
2) Small Vessel Disease (Lipohyalinosis and local thrombosis of arterioles) predisposes for Ischemic Stroke. |
|
|
Term
| A patient in A-fib presents with Hemianopsia of the left visual field. What happened? |
|
Definition
A-fib causes embolic events and Ischemic stroke.
The left visual field suggests Right PCA infarction. |
|
|
Term
What do you do first when you suspect a stroke?
What if CT is negative, but the patient suffered trauma and you know that they have a Berry Aneurism? |
|
Definition
Get a CT to look for blood in brain or sub-A space!
If you don't see blood on CT, but suspect SAH, get a Lumbar puncture, which is more sensitive! |
|
|
Term
| What do you order if your patient is hypertensive, atherosclerotic and presents with tingling and numbness? |
|
Definition
| Probably an ischemic stroke, but CT WILL NOT catch early ischemic strokes, so order an MRI! |
|
|
Term
| What acute treatment measures for Ischemic, SAH and intracerebral strokes should be taken? |
|
Definition
1) Ischemic means you need to get rid of the occlusion with thrombolytics (if within 3 hours) and then keep neuronal environment healthy.
2) In SAH, you need to PREVENT RE-BLEEDING through surgical means and then prevent blood-induced vessel vasospasms.
3) In Intracerebral Hemorrhages, you need to STOP BLEEDING by controlling BP |
|
|
Term
| What are some Secondary Preventative measures that should be taken for re-occurence of Ischemic, Intracerebral and SAH strokes? |
|
Definition
1) Ischemic- Control high BP, Smoking, Diabetes, Carotid artery atherosclerosis, A-fib (anti-coagulation with Coumadin), and Cholesterol
2) For Hemorrhagic strokes you need to control high BP (MOST IMPORTANT), and for AV malformation, you can get endovascular surgery. |
|
|
Term
| What occurs during Uncal Herniation? |
|
Definition
Also "transtentorial herniation," Cerebral Edema causes the medial temporal lobe across the tentorium cerebelli leading to compression of the
1) 3rd cranial nerve (MYDRIASIS-blown pupil)
2) Posterior cerebral artery (medial temporal/occipital lobe infarction and VISUAL FIELD DEFECT)
3) Contralateral cerebral peduncle (Paresis contralateral to peduncle but Ipsilateral to lesion) |
|
|
Term
A patient presents with a left visual field defect, a blown left pupil and muscle weakness on the left side.
What is wrong and how do you respond? |
|
Definition
Sounds like Uncal herniation with compression of CN III, PCA and Contralateral Crux Cerebri.
You need to place a shunt to reduce the Edema and pressure causing the herniation. |
|
|
Term
| What is the difference between Fusiform and Mycotic aneurisms? |
|
Definition
1) Fusiform is caused by atherosclerotic disease in the Basilar Artery
2) Mycotic is caused by infection of the distal branches of the MCA. |
|
|
Term
| What are the major predisposing factors for Intraparenchymal hemorrhages (IH) and where do you find each kind of hemorrhage? |
|
Definition
1) Hypertension (50s)
- frequently affecting penetrating arteries and arterioles of deep gray matter structures (Basal ganglia, thalamus, pontine tegmentum) in patients in their 50s
2) Arteriovenous malformation (50% in 20s-40s)
- Found mostly in supratentorial compartment in cerebral arteries (most often MCA) of YOUNG patients (20-40)
- Often also involve Subarachnoid space (SAH)
3) Amyloid angiopathy (Elderly)
- Produce large hemorrhages affecting cortex and subcortical white matter (stain with Congo Red) |
|
|
Term
| What is the difference between Global and Focal Ischemia? What cells do you worry about? |
|
Definition
1) Global
- Systemic perfusion issue (Hypovolemic shock in sepsis or Cardiopulmonary arrest)
- Purkinje cells, Layer III/V cells and CA1 cells are most susceptible to transient global ischemia
2) Focal (Acute, Subacute with macrophages and Chronic with cyst)
- Vascular occlusion from atherosclerosis leading to thrombosis (emboli tend to appear red and involve gray-white junction)
- Acute (48h) has soft, edematous appearance
- Subacute (2-14d) has liquifactive necrosis with dead/viable border (macrophages are active)
- Chronic (weeks-months) involves Cystic Cavity formation lined by reactive astrocytes |
|
|
