- stroke - MCA
2 the SINGLE most important treatable risk factor for both the primary and secondary prevention of stroke.
- middle cerebral artery (more than 90%)
2. Hypertension
stroke in MCA - manifestation
- Weakness or sensory loss on the opposite side (face + upper limb)
- homonymous hemoanopsia (loss of visual field on the opposite side
- aphasia: if in the speech center (left side on 90%)
stroke in ACA - manifestation
- Weakness or sensory loss on the opposite side (lower ext and trunk
- urinary incontinence
- personality/cognitive defects (such as confusion)
stroke in PCA manifestation
- ipsilateral loss of the face, 9th and 10th CNs
- Limb ataxia
- Contralateral sensory loss of the limbs
- contralateral hemianopia with macular sparing
stroke - best initial test / Most accurate (explain)
- best initial: CT without contrast
- most accurate: MRI
- CT first to exclude hemorrhage
- CT needs 5 days to reache greater than 95% sensitivity. MRI 48h
the best initial therapy for nonhemorrhagic stroke
- less than 3 hours since osnet of stroke (some places 4.5): thrombolysis
- more than 3 hours: aspirin: if the patient already on aspirin: add dipyridamole or switch to clopidogrel
- hemorrhagic: nothing, reversal anticoagulationm control BP and control ICP (mannitol, hyperventilation, nanesthesia)
if the patient already on aspirin: add dipyridamole or switch to clopidogrel
hemorrhagic stroke - surgery
it will not help outside the posterior fossa
prevention of stroke
- either aspirin or clopidogrel (started on the first 48h)
- not combine them –> combination only adds bleeding
- you can combine dipyrodamole with aspirin
statin - stroke
every patient with stroke should be started on statins regardless of LDL
goal: 70 or less than 100
test to evaluate the cause of stroke
- EKG (for AF)
- Echo (damaged valves, thrombi, patent foramen ovale)
- Holter
Carotid duplex US
Carotid endarterectomy (CEA) is indicated in
symptomatic patients with >70% carotid artery stenosis or asymptomatic patients with >60% stenosis. CEA should be performed within 2 weeks to reduce the risk of stroke
NO point to operate 100%
TIA - definition / management
symptoms last less than 24h, then resolve
aspirin: if the patient already on aspirin: add dipyridamole or switch to clopidogrel
3. hemorrhagic: nothing
stroke - hypertenion treatment
do not treat it immediately unless it is extreme (more than 220/120) or the patient has CAD in order to maintain cerebral perfusion
(nicardipine or labetolol)
Headache - MCC, how to diagnose
Tension headache
diagnosis of exclusion
exclude migraine, .cluster, giant, pseudotumor
Pseudotumor cereberi - associated with, mimics brain tumor, physical findings
- obesity, venous sinus thrombosis, OCPs, vit A toxicity
- mimics brain tumor with nausea, vomiting, visual disturbances
- papilledema with diplopia from from 6th CN palsy
pseudotumor cerebri - diagnosic test
cannot be made without CT (or MRI) to exclude an intracranial mass lesion and a LP showing increased pressure (the CSF itself is normal)
- cluster headache - treatment
2. migraine - treatment
- triptans, ergotamine, 100% O2, predinosone, lithium as abortive therapy
- triptans or ergotamine as adorptive therapy
pseudotumor cerebri - treatment
weight loss, acetazolamide (decreases CSF production), steroid help, repeated LP rapidly, ventriculoperitoneal shunt or fenestrate into optic nerve if medical therpay does not control)
- differences in treatment between cluster and migraines
- verapamil
2. cluster –> 02 100%, prednisone, lithium
preventive therapy for migraine + cluster
- migraine: patients experiencing 3 or more per mounth
- -> medication. the vest is propranolol. Other: CCB, amitriptyline, SSRI, topiramate, Botulinum toxin injections, sodium valproate - not as clear: verapamil, sodium valproate
Trigeminal Neuralgia - treatment
- oxcarbazepine or carbamazepine
- Baclofen and lamotrigine olaso effective
- if meds do not control –> gamma knife or surgical decompression
how to reduce the incidence of postherpetetic neuraligia
- treatment of vesicular lesions with acyclovir, famciclovir or valganciclovir seems to reduce the incidence of posthherpetic neuralgia (steroids do not)
- prevention Zoster vaccine indicated in all above 60. Similar to the varicella (much higher dose)
postherpetetic neuraligia - treatment of pain
- TCA, gabapentin, pregabalin, carbamazepine, phenytoin
2. topical capsaicin is helpful
Willis aneyrisms are more frequent in those with
how to determine the site
- PKD 2. tobacco 3. HTN 4. hyperlipidemia
5. alcohol 6. coartraction
