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46 Cards in this Set

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How does an acephalgic migraine present,mimicking a stroke?
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
Name the two distinct pathway that causes focal cerebral infarction.
1) necrotic pathway
2) apoptotic pathway
What are the features that may suggest a hemorrhagic stroke?
(although not reliable)
1) Depressed level of consciousness,
2) higher initial blood pressure,
3) worsening of symptoms after onset
Name the 6 interventions that will improve clinical outcomes in stroke.
(1) medical support
(2) intravenous thrombolysis
(3) endovascular techniques
(4) antithrombotic treatment
(5) neuroprotection
(6) stroke centers and rehabilitation.
What are the medical support intervention?
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.
How do you define stroke onset?
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.
What is the time window for thrombolysis?
Within 3 to 4.5hrs of stroke onset.
What are the contraindications to TPA?
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
What are the indications for TPA?
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
What is the alternative treatment for patients who is not eligible or failed TPA?
Endovascular mechanical thrombectomy if patient within 8 h of symptom onset.

Based on the MERCI study.
What is the only antiplatelet agent that has been proven effective for the acute treatment of ischemic stroke?
Aspirin

Based on ICS and CAST study.
Does heparin have any role in the primary treatment of atherothrombotic cerebral ischemia?
No.no benefit over aspirin and increased bleeding rate

Based on TOAST study.
Does stroke unit reduce mortality in stroke?
Yes.Stroke units followed by rehabilitation services improves neurologic outcomes and reduces mortality.
Name the common causes of ischaemic stroke
thrombosis
embolic occlusion
Name examples of thrombosis
Lacunar stroke (small vessel)
Large vessel thrombosis
Dehydration
Name examples of embolic occlusion
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
Name examples of valvular lesion causing ischemic stroke.
Mitral stenosis,Mechanical valve, Bacterial endocarditis
Name the hypercoagulable disorders that could cause ischemic stroke.
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
What is the most common cause of cerebral embolism?
Nonrheumatic (non-valvular) atrial fibrillation is the most common cause of cerebral embolism overall.
what is the annual risk of stroke in patients with AF?
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.
Is MI a risk factor for stroke?
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.
Which investigation to do if parodoxical embolization is suspected?
Bubble-contrast echocardiography

This can demonstrate a right-to-left cardiac shunt, revealing the conduit for paradoxical embolization
Name the 2 causes of paradoxical embolization.
patent foramen ovale
atrial septal defect
What is the most common source of artery-to-artery embolization?
Carotid bifurcation atherosclerosis is the most common source of artery-to-artery embolus
Name the risk factors for stroke/carotid disease?
Male gender,
older age,
smoking,
hypertension,
diabetes, hypercholesterolemia
What is the indication for a carotid endarterectomy?
For symptomatic carotid stenosis: stenosis >70%.
17% ARR, 65%RRR

Based on NASCET and ECST study.
When to perform a carotid endarterectomy?
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
What is the recommendation for patients with asymptomatic carotid stenosis?
Medical therapy for reduction of atherosclerosis risk factors, including cholesterol-lowering agents and antiplatelet medications, is generally recommended for patients with asymptomatic carotid stenosis
Which type of dissection that causes SAH?
Intracranial dissections.

Produce SAH because the adventitia of intracranial vessels is thin and pseudoaneurysms may form.
Name the conditions that are associated with dissection.
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
What is a common source of embolic stroke in younger patients?
Dissection.

Common source of embolic stroke in young (age <60 years) patients.
what are the main risk factors for lacunar infarct?
Hypertension and age
what are the most common lacunar syndromes?
(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.
What is a common cause of stroke in children?
sickle cell anemia /disease

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

Treat with aggressive exchange transfusion.
Fibromuscular dysplasia usually affects with artery?
cervical arteries.
more common in women.
How does drugs like cocaine or amphetamine cause stroke?
On basis of acute hypertension or drug-induced vasculitis
What is CADASIL?
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.
How do CADASIL present?
Presents with migraine with aura, often manifest as transient motor or sensory deficits.

Onset usually in the fourth or fifth decade of life.
what causes amourosis fugax in TIA?
Occurs from emboli to the central retinal artery of one eye.
What is the role of statins in stroke?
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
How does aspirin work?
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.
Which one is better.Aspirin, clopidogrel or both?
CAPRIE study- clopidogrel only marginally better than aspirin

MATCH and CHARISMA study-
no benefit of clopidogrel combined with aspirin compared to aspirin alone.
How does clopidogrel work?
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.
How does dipyridamole work?
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.
Does a combination of aspirin
and dipyridamole work?
Yes.ESPS II and ESPRIT study showed significantly better risk reduction when the two agents were combined.
What is the most common side effect of dipyridamole?
Headache.