[10.07a] Common Adult Neurological Diseases and Emergencies Part 1 V2.pdf

Acute clinical syndrome affecting a focal area of the brain

What is the definition of a stroke?

Ischemic and Hemorrhagic

What are the two primary categories of stroke?

65 percent

What percentage of strokes are classified as ischemic?

29 percent

What percentage of strokes are intracerebral hemorrhages?

5 percent

What percentage of strokes are subarachnoid hemorrhages?

Clot or occlusion of major vessels

What is the primary cause of an ischemic stroke?

Rupture of vessels or trauma

What are the two primary causes of a hemorrhagic stroke?

Embolism

What term describes a blood clot that forms in an artery and later travels to the brain?

Thrombosis

What term describes an atheromatous plaque formed in the vessels that later ruptures?

Embolic stroke

Which type of ischemic stroke peaks in neurologic deficit right away and then plateaus?

Thrombotic stroke

Which type of ischemic stroke presents with a stepwise progression of neurological deficits?

Age, Sex, Race, Family history, and Prior stroke/TIA/MI

What are five non-modifiable risk factors for stroke?

More than 60 years old

At what age are individuals more commonly affected by stroke?

Males

Which gender is more commonly affected by stroke?

African-Americans

Which race is more commonly affected by stroke?

Hypertension, Atrial fibrillation, Diabetes, Smoking, Hyperlipidemia, Obesity, and OSA

What are seven modifiable risk factors for stroke?

Hypertension

What is the most important modifiable risk factor for stroke?

Diabetes mellitus

Which risk factor accelerates atherosclerosis?

Cigarette smoking

Which risk factor increases the risk of carotid plaque formation?

TOAST Classification

What system classifies ischemic stroke based on the underlying pathophysiologic mechanism?

Cardioembolism

What is the most common cause of ischemic stroke according to the TOAST classification?

LA/LV thrombus, atrial fibrillation, and heart failure with EF less than 30 percent

What are three potential sources of a cardioembolism?

Stasis of blood

Why does a thrombus form in a heart with atrial fibrillation or low ejection fraction?

Large-Artery Atherosclerosis

What is the second most common cause of ischemic stroke?

Branching points or curves

At what specific anatomical locations do atheromatous plaques preferentially form?

Repetitive stereotyped transient ischemic attacks

Large-Artery Atherosclerosis is often heralded by what events?

Chronic hypertension

Lacunar infarctions are caused by vascular changes resulting from what condition?

Small lake

What is the meaning of the term lacune?

Lipohyalinosis

What is another name for local fibrous and hyalinoid arteriolar sclerosis found in small vessel occlusion?

Dissection, vasculitis, and hypercoagulable states

What are three examples of stroke of other determined etiology?

Stroke of Undetermined Etiology

What classification is used if two or more potential causes are identified or if the evaluation is negative?

Absence of glucose and oxygen

What is the immediate result of the absence of blood flow in a part of the brain?

Failure of Na-K ATPase pump

What energy-dependent process fails during a stroke to disrupt cellular homeostasis?

Infarct core

What is the term for the area of the brain that is already destroyed during a stroke?

Penumbra

What is the term for the salvageable area around the infarct core?

55 mL/100 g/min

What is the normal cerebral blood flow?

23 mL/100 g/min

What is the critical level of cerebral blood flow for infarction where impairment can be reversed if flow is restored?

Less than 10 to 12 mL/100 g/min

What level of cerebral blood flow causes infarction regardless of duration?

Circle of Willis

What anatomical structure provides collateral circulation to the brain?

Carotids, ACA, AComm, PComm, PCA, and Basilar artery

What are the six components of the Circle of Willis?

Anterior Circulation

Which circulation is composed of branches of the internal carotid artery, including the ACA and MCA?

Posterior Circulation

Which circulation is composed of the vertebral arteries, basilar artery, and PCA?

MCA (Middle Cerebral Artery)

Which artery supplies the lateral part of the brain and major language areas?

ACA (Anterior Cerebral Artery)

Which artery supplies the medial portion of the brain?

PCA (Posterior Cerebral Artery)

Which artery supplies the occipital lobe and inferior/medial temporal lobes?

MCA

Contralateral weakness of the face and arm more than the leg suggests an occlusion in which artery?

ACA

Contralateral weakness of the lower more than the upper extremities suggests an occlusion in which artery?

Apathy and abulia

What two prefrontal signs are associated with an ACA stroke?

Lenticulostriate arteries

Which branches of the proximal MCA supply the internal capsule?

Away from the weakness

In an MCA stroke, in which direction does the preferential gaze usually look?

PCA

Homonymous hemianopia with macular sparing and contralateral achromatopsia are signs of which artery involvement?

Anton syndrome

What syndrome is defined by bilateral visual loss with denial of blindness and confabulations?

Bilateral occipital lobes

What is the anatomical location of the lesion in Anton syndrome?

Weber syndrome

What syndrome presents with contralateral extremity weakness and ipsilateral oculomotor palsy?

Balint syndrome

What syndrome involves optic ataxia, oculomotor apraxia, and simultagnosia?

Bilateral occipital-parietal border zones

What is the anatomical location involved in Balint syndrome?

AICA (Anterior Inferior Cerebellar Artery)

Which artery occlusion causes Lateral Pontine Syndrome?

SCA (Superior Cerebellar Artery)

Which artery occlusion causes ipsilateral limb ataxia, dysarthria, and vertigo?

PICA (Posterior Inferior Cerebellar Artery)

Which artery is involved in Wallenberg syndrome?

Lateral medulla

What is the anatomical location of the lesion in Wallenberg syndrome?

Severe vertigo, ipsilateral facial numbness, and contralateral body numbness

What are three clinical features of Wallenberg syndrome?

Basilar artery

Which artery occlusion causes Locked-in syndrome?

Awareness and vertical eye movement

In Locked-in syndrome, awareness is spared, but what movement is the only one typically preserved?

Dejerine syndrome

What syndrome presents with contralateral weakness of the leg and arm and ipsilateral tongue paralysis?

Medulla and cervical spinal cord

What is the anatomical location of Dejerine syndrome?

Anterior spinal artery

Which vascular territory involvement causes quadriparesis and bilateral pain/temperature loss while sparing proprioception?

Timely restoration of blood flow

What is the most effective maneuver for salvaging ischemic brain tissue?

Time of ictus

What term refers to the time symptoms started?

Last known well

If a patient wakes up with symptoms, what time is established to determine eligibility for treatment?

Todd paralysis

What is the term for paralysis of a limb after a focal seizure?

Hyperglycemia, hypoglycemia, hemiplegic migraine, and panic disorder

What are four common stroke mimickers?

CBG

What is the only important test that must be taken in the acute phase in the ER to rule out a stroke mimic?

Within 25 minutes

Within how many minutes should emergent neuroimaging be obtained for a suspected stroke?

Thrombolysis and mechanical thrombectomy

What are the two primary acute interventions to decide upon after imaging?

NIHSS

What standardized scale quantifies the degree of neurological deficit and predicts mortality?

Score of 15 to 24

What NIHSS score range indicates a moderately severe stroke?

Score of 25 to 42

What NIHSS score range indicates a severe stroke?

Score of 0 to 4

What NIHSS score range indicates a mild stroke?

Rule out a hemorrhage

What is the primary use of a cranial CT scan in the acute stroke phase?

Hypodense

How does an infarct usually appear on a CT scan?

Sulcal effacement

Which hyperacute CT sign involves the obliteration of sulci on the affected side?

Hyperdense artery sign

Which CT sign signifies acute thrombosis of a major vessel like the MCA?

Loss of grey-white matter differentiation, loss of insular ribbon, and obscuration of lentiform nucleus

What are three other hyperacute CT signs of stroke?

DWI sequence

What is the most sensitive MRI sequence for the detection of acute infarcts?

SWI or GRE

Which MRI sequences can detect hemorrhage?

Chronic lacunar infarct

Small ischemic lesions appearing as white areas on a DWI sequence signify what?

CTA or MRA

What imaging is done if a large blood vessel occlusion is suspected?

CT/MR Perfusion

What modality measures cerebral blood volume and flow to detect salvageable penumbra?

4.5 hours

What is the golden time period for administering IV thrombolysis?

IV TPA

What medicine breaks down fibrin to dissolve a clot?

0.9 mg/kg

What is the dose for Alteplase?

90 mg

What is the maximum dose for Alteplase?

0.25 mg/kg

What is the dose for Tenecteplase?

Tenecteplase

Which thrombolytic is more fibrin-specific and has a longer half-life than Alteplase?

6 percent

What is the risk of symptomatic cerebral hemorrhage after thrombolysis?

CT with hemorrhage or extensive hypodensity

What are two absolute neuroimaging contraindications for thrombolysis?

Pregnancy

Which condition is listed as a relative contraindication for thrombolysis?

Within 6 to 24 hours

What is the time window for performing endovascular mechanical thrombectomy?

Large-vessel occlusion with NIHSS score of 6 or more

Which patients are candidates for mechanical thrombectomy?

Maintain glucose between 140 to 180 mg/dL

What is the target glucose range for general medical management of stroke?