Stroke

Question 1

Sub-categorisation of Ischaemic strokes by aetiology

Answer 1

Atherosclerotic (in-situ)
* Large vessel
* Small vessel

Artery to artery embolism
* Extracranial vessel stenosis
* Dissection

Cardioembolic

Paroxysmal Embolism

Other

Question 2

RFs Haemorrhagic stroke

Answer 2

• HTN
• Hypocholesterolemia
• Heavy EtOH use
• Cerebral amyloid angiopathy
• Antithrombotic therapy
• Underlying structural pathology

Question 3

Where does ASA come off of

Answer 3

Vertebral arteries

Question 4

Where does PICA come off of

Answer 4

Vertebral arteries

Question 5

Order of cerebellar arteries (post/inf to sup/ ant)

Answer 5

PICA
AICA
SCA

Question 6

Where does AICA come off of

Answer 6

Basilar artery

Question 7

Anterior Cerebral artery syndrome

Answer 7

• Leg>Arm/Face
• Motor»_space;sensory
• Dysexecutive, abulia, urinary incontinence
• Dysphasia (dominant)

Question 8

Posterior Cerebral Artery syndrome

Answer 8

• Homonymous Haemianopia
• Behavioural change, memory issues

Question 9

Middle cerebral artery syndrome

Answer 9

• Face/Arm > Leg
• Dysphasia (dominant)
• Dyspraxia/Neglect (non-dominant)
• Homonymous Haemianopia
• Motor and Sensory

Question 10

Basilar Artery/vertebral artery syndrome

Answer 10

• Locked in syndrome (sparing EOM)
• Initially vertigo, ataxia, diplopia, isolated limb symptoms

Question 11

Small vessel/ lacunar stroke syndromes (5)

Answer 11

Question 12

Gerstmann syndrome brain area

Answer 12

Inferior parietal lobule of dominant hemisphere

Angular and supramarginal gyri (Brodman area 39 and 40) near the temporal and parietal junction

Question 13

Gerstman syndrome Sx

Answer 13

• Dysgraphia/agraphia
• Dyscalculia/acalculia
• Finger agnosia
• Left-right disorientation
• +/- aphasia
• +/- apraxia

Question 14

Lateral Medullary syndrome synonyms

Answer 14

• Wallenberg Syndrome
• PICA syndrome
• Vertebral artery syndrome - misnomer really as can cause other issues

Question 15

Lateral Medullary syndrome Sx

Answer 15

Contralateral
* trunk/limb numbness (pain/temp)

Ipsilateral
* Facial numbness (pain/temp)
* Skew deviation/room tilt
* Dysphagia/hoarseness/gag
* Horner’s syndrome
* Limb ataxia

• Palatal myoclonus
• Vertigo/nystagmus

Question 16

Top of the Basilar Syndrome

Answer 16

• Ptosis
• Dilated pupils
• Ocular motor deficits
• Somnolence (thalamic infarction), hallucinations, dreamlike behaviour
• Motor function otherwise preserved

Can cause full basilar thrombosis -> locked in

Question 17

Balint syndrome

Answer 17

• B/L parietal/occipital junction lesions e.g. watershed
• Simultagnosia
• Oculomotor apraxia
• Optic ataxia

Question 18

Anton syndrome

Answer 18

• Bilateral occipital lesions
• Cortical blindness

Question 19

Benedikt syndrome,

Webber syndrome

Answer 19

• Midbrain stroke
• Posterior cerebral artery or penetrating branches of basilar artery
• CN III palsy
• Ataxia/choreoathetosis

Webber syndrome
* Similar to Benedikt except more hemiplegia than limb ataxia

Question 20

Anterior spinal artery syndrome

Answer 20

• Loss of power distally
• +/- Loss of temp/pain
• Posterior column unaffected

Question 21

Spinal cord syndrome with syringomyelia

Answer 21

Central cord syndrome

Question 22

Location of haemorrhage in cerebral amyloid angiopathy

Answer 22

Lobar Haemorrhage

Question 23

Location of haemorrhages in deep haemorrhages

Answer 23

B: Basal Ganglia
C: Thalamus
D: Pons
E: Cerebellum

(A is a lobar haemorrhage)

Question 24

Main RF for lobar cerebral haemorrhage

Answer 24

Cerebral amyloid angiopathy

Question 25

Main RF for deep cerebral haemorrhage

Answer 25

HTN

Question 26

ICH treatment

Answer 26

Lower blood pressure to ~140 systolic Reverse anticoagulation Surgical interventions * Posterior-fossa – most evidence of benefit * Supratentorial – no clear benefit unless declining; primarily reduces mortality * New microsurgeries hold some promise – ongoing clinical trials Determine underlying cause

Question 27

Mian Ros for SAH

Answer 27

aneurysm, smoking, hypertension, female, methamphetamines, cocaine

Question 28

SAH Px

Answer 28

* Thunderclap Headache * Photophobia, neck stiffness, confusion, focal neurology, seizures

Question 29

Ix for SAH

Answer 29

* Head CT ideally with CTA (rarely conventional angiogram now) – 98.7% sensitive <6 hrs * Lumbar puncture for xanthrochromia (develops 12 hours post HA) (+ RBCs in the 100s to 1000s in 3% of people with normal CT) * MRI with SWI - maybe better than LP even really

Question 30

SAH treatment

Answer 30

* ABC * Lower BP (SBP <140) to prevent rebleeding * Clip/coil aneurysm to fix the underlying problem * Oral Nimodipne to prevent vasospasm

Question 31

Occlusion areas amenable to ECR

Answer 31

Question 32

CI to thrombolysis (Bleeding risk)

Answer 32

*Known history of ICH *Prior stroke or serious head injury within 3months *Sustained Blood Pressure >185/110 *Dabigatran within 48 hrs/high TT/unable to give idarucizumab *Heparin within the last 48hrs with elevated PTT *PT >15seconds *Platelet count <100,000 uL *Major surgery within past 14days *Gastrointestinal or urinary tract hemorrhage within 21d *Arterial puncture at noncompressible site <7days

Question 33

Strongest modifiable RF for stroke?

Answer 33

HTN

Question 34

Anti-paltelets after stroke

Answer 34

DAPT for 21 days then SAPT

Question 35

Stein with best evidence for stroke prevention?

Answer 35

atorvastatin

Question 36

PSK9i in stroke prevention

Answer 36

Evolocumab good

Question 37

Dose reduction criteria dabigatran

Answer 37

Use reduced dose of 110mg dose if * >80 years of age * CrCl 30-50 mL/min and HAS-BLED score is щ3, * between 75-80 years of age with a low CHA2 DS2 -VAS c score and HAS-BLED щ2, If CrCl <30ml/min DO NOT USE

Question 38

Dabigatran reversal

Answer 38

Idarucizumab (praxbind)

Question 39

CEA indication post stroke

Answer 39

CEA if symptomatic (<3/12) and * Ipsilateral 70-99% stenosis * Ipsilateral 50-69% stenosis in highly selected cases and low surgical risk (<3%)

Question 40

PFO closure indications

Answer 40

Cryptogenic stroke/ TIA PFO on bubble study in 6-9 months Preferably young (<60)

Question 41

Left atrial appendage occlusion

Answer 41

* May be considered in high stroke risk with genuine contraindication to anticoagulants