Neurology-Stroke And Tia

Front 1

How does an acephalgic migraine present,mimicking a stroke?

Back 1

A sensory disturbance is often prominent, and the sensory deficit, as well as any motor deficits, tends to migrate slowly across a limb over minutes rather than seconds as with stroke.

Diagnosis of migraine becomes more secure as the cortical disturbance begins to cross vascular boundaries or if typical visual symptoms are present, such as scintillating scotomata

Front 2

Name the two distinct pathway that causes focal cerebral infarction.

Back 2

1) necrotic pathway
2) apoptotic pathway

Front 3

What are the features that may suggest a hemorrhagic stroke?
(although not reliable)

Back 3

1) Depressed level of consciousness,
2) higher initial blood pressure,
3) worsening of symptoms after onset

Front 4

Name the 6 interventions that will improve clinical outcomes in stroke.

Back 4

(1) medical support
(2) intravenous thrombolysis
(3) endovascular techniques
(4) antithrombotic treatment
(5) neuroprotection
(6) stroke centers and rehabilitation.

Front 5

What are the medical support intervention?

Back 5

1) DVT prophylaxis
2) Lower BP if malignant HT or concomitant MI.
3) Treat fever with antipyretics and cooling measures.
4) Monitor BGL.Insulin infusion.
5) Hemicraniectomy.

Front 6

How do you define stroke onset?

Back 6

The time of stroke onset is defined as the time the patient's symptoms began or

The time the patient was last seen as normal or

Patients who awaken with stroke have the onset defined as when they went to bed.

Front 7

What is the time window for thrombolysis?

Back 7

Within 3 to 4.5hrs of stroke onset.

Front 8

What are the contraindications to TPA?

Back 8

1) Sustained BP >185/110 despite treatment

2) Platelets <100,000; HCT <25%; glucose <50 or >400 mg/dL

3) Use of heparin within 48 h and prolonged PTT, or elevated INR

4) Rapidly improving symptoms

5) Prior stroke or head injury within 3 months; prior intracranial hemorrhage

6) Major surgery in preceding 14 days

7) Minor stroke symptoms

8) Gastrointestinal bleeding in preceding 21 days

9) Recent myocardial infarction

10) Coma or stupor

Front 9

What are the indications for TPA?

Back 9

Clinical diagnosis of stroke

Onset of symptoms to time of drug administration 3 h

CT scan showing no hemorrhage or edema of >⅓ of the MCA territory

Age 18 years

Consent by patient or surrogate

Front 10

What is the alternative treatment for patients who is not eligible or failed TPA?

Back 10

Endovascular mechanical thrombectomy if patient within 8 h of symptom onset.

Based on the MERCI study.

Front 11

What is the only antiplatelet agent that has been proven effective for the acute treatment of ischemic stroke?

Back 11

Aspirin

Based on ICS and CAST study.

Front 12

Does heparin have any role in the primary treatment of atherothrombotic cerebral ischemia?

Back 12

No.no benefit over aspirin and increased bleeding rate

Based on TOAST study.

Front 13

Does stroke unit reduce mortality in stroke?

Back 13

Yes.Stroke units followed by rehabilitation services improves neurologic outcomes and reduces mortality.

Front 14

Name the common causes of ischaemic stroke

Back 14

thrombosis
embolic occlusion

Front 15

Name examples of thrombosis

Back 15

Lacunar stroke (small vessel)
Large vessel thrombosis
Dehydration

Front 16

Name examples of embolic occlusion

Back 16

Artery-to-artery:
Carotid bifurcation
Aortic arch
Arterial dissection

Cardioembolic:
Atrial fibrillation
Mural thrombus
Myocardial infarction
Dilated cardiomyopathy
Valvular lesions-
Paradoxical embolus
Atrial septal defect
Patent foramen ovale
Atrial septal aneurysm
Spontaneous echo contrast

Front 17

Name examples of valvular lesion causing ischemic stroke.

Back 17

Mitral stenosis,Mechanical valve, Bacterial endocarditis

Front 18

Name the hypercoagulable disorders that could cause ischemic stroke.

Back 18

Protein C deficiency
Protein S deficiency
Antithrombin III deficiency
Antiphospholipid syndrome
Factor V Leiden mutationa
Prothrombin G20210 mutationa
Systemic malignancy
Sickle cell anemia
-Thalassemia
Polycythemia vera
Systemic lupus erythematosus
Homocysteinemia
Thrombotic thrombocytopenic purpura
Disseminated intravascular coagulation
Dysproteinemias
Nephrotic syndrome
Inflammatory bowel disease
Oral contraceptives

Front 19

What is the most common cause of cerebral embolism?

Back 19

Nonrheumatic (non-valvular) atrial fibrillation is the most common cause of cerebral embolism overall.

Front 20

what is the annual risk of stroke in patients with AF?

Back 20

Patients with atrial fibrillation have an average annual risk of stroke of ~5%

Stroke risk depends on risk factors (CHADS).

If <65 and no risk factors.0.5%
With risk factors >15% per year.

Front 21

Is MI a risk factor for stroke?

Back 21

Yes.Recent MI may be a source of emboli, especially when transmural and involving the anteroapical ventricular wall,

Prophylactic anticoagulation following MI has been shown to reduce stroke risk.

Front 22

Which investigation to do if parodoxical embolization is suspected?

Back 22

Bubble-contrast echocardiography

This can demonstrate a right-to-left cardiac shunt, revealing the conduit for paradoxical embolization

Front 23

Name the 2 causes of paradoxical embolization.

Back 23

patent foramen ovale
atrial septal defect

Front 24

What is the most common source of artery-to-artery embolization?

Back 24

Carotid bifurcation atherosclerosis is the most common source of artery-to-artery embolus

Front 25

Name the risk factors for stroke/carotid disease?

Back 25

Male gender,
older age,
smoking,
hypertension,
diabetes, hypercholesterolemia

Front 26

What is the indication for a carotid endarterectomy?

Back 26

For symptomatic carotid stenosis: stenosis >70%.
17% ARR, 65%RRR

Based on NASCET and ECST study.

Front 27

When to perform a carotid endarterectomy?

Back 27

Within 2 weeks of symptom onset.

In addition, benefit is more pronounced in patients >75 years, and men appear to benefit more than women.

Based on NASCET study

Front 28

What is the recommendation for patients with asymptomatic carotid stenosis?

Back 28

Medical therapy for reduction of atherosclerosis risk factors, including cholesterol-lowering agents and antiplatelet medications, is generally recommended for patients with asymptomatic carotid stenosis

Front 29

Which type of dissection that causes SAH?

Back 29

Intracranial dissections.

Produce SAH because the adventitia of intracranial vessels is thin and pseudoaneurysms may form.

Front 30

Name the conditions that are associated with dissection.

Back 30

The cause of dissection is usually unknown and recurrence is rare.

Medical associations:
1) Ehlers-Danlos type IV,
2) Marfan's disease,
3) Dystic medial necrosis,
4) Fibromuscular dysplasia

Front 31

What is a common source of embolic stroke in younger patients?

Back 31

Dissection.

Common source of embolic stroke in young (age <60 years) patients.

Front 32

what are the main risk factors for lacunar infarct?

Back 32

Hypertension and age

Front 33

what are the most common lacunar syndromes?

Back 33

(1) Pure motor hemiparesis -posterior limb of the internal capsule or basis pontis; the face, arm, and leg are almost always involved;

(2) pure sensory stroke-ventral thalamus
(3) ataxic hemiparesis-ventral pons or internal capsule

(4) Dysarthria and a clumsy hand- ventral pons or in the genu of the internal capsule.

Front 34

What is a common cause of stroke in children?

Back 34

sickle cell anemia /disease

Risk predicted by documenting high-velocity blood flow within the MCAs

Treat with aggressive exchange transfusion.

Front 35

Fibromuscular dysplasia usually affects with artery?

Back 35

cervical arteries.
more common in women.

Front 36

How does drugs like cocaine or amphetamine cause stroke?

Back 36

On basis of acute hypertension or drug-induced vasculitis

Front 37

What is CADASIL?

Back 37

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)

An inherited disorder that presents as small-vessel strokes, progressive dementia, and extensive symmetric white matter changes visualized by MRI.

Front 38

How do CADASIL present?

Back 38

Presents with migraine with aura, often manifest as transient motor or sensory deficits.

Onset usually in the fourth or fifth decade of life.

Front 39

what causes amourosis fugax in TIA?

Back 39

Occurs from emboli to the central retinal artery of one eye.

Front 40

What is the role of statins in stroke?

Back 40

SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) trial showed benefit in secondary stroke reduction for patients with recent stroke or TIA who were prescribed atorvastatin, 80 mg/d

Front 41

How does aspirin work?

Back 41

Aspirin inhibits formation of thromboxane A2 ( a prostaglandin that causes platelet aggregation and vasoconstriction)

Paradoxically, also inhibits the formation of prostacyclin in endothelial cells (an antiaggregating and vasodilating prostaglandin)-transient effect.

But Aspirin in low doses given once daily inhibits the production of thromboxane A2 in platelets without substantially inhibiting prostacyclin formation.

Front 42

Which one is better.Aspirin, clopidogrel or both?

Back 42

CAPRIE study- clopidogrel only marginally better than aspirin

MATCH and CHARISMA study-
no benefit of clopidogrel combined with aspirin compared to aspirin alone.

Front 43

How does clopidogrel work?

Back 43

clopidogrel block the ADP receptor on platelets.

This prevents activation of glycoprotein IIb/IIIa receptor
that leads to fibrinogen binding to the platelet and consequent platelet aggregation.

Front 44

How does dipyridamole work?

Back 44

Dipyridamole is an antiplatelet agent that inhibits the uptake of adenosine by a variety of cells, including vascular endothelium.

The accumulated adenosine is an inhibitor of aggregation.

Also potentiates the antiaggregatory effects of prostacyclin and nitric oxide produced by the endothelium and acts by inhibiting platelet phosphodiesterase, which is responsible for the breakdown of cyclic AMP.

Elevation in cyclic AMP inhibits aggregation of platelets.

Front 45

Does a combination of aspirin
and dipyridamole work?

Back 45

Yes.ESPS II and ESPRIT study showed significantly better risk reduction when the two agents were combined.

Front 46

What is the most common side effect of dipyridamole?

Back 46

Headache.