questions 5

Stroke

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Topic updated on 06/16/17 9:24am

Snapshot
  • A 60-year-old woman presents with acute onset of right facial weakness. Past medical history is significant for hypertension and type II diabetes mellitus. Non-contrast head CT is performed, which is negative for blood. (ischemic stroke)
Introduction
  • Acute onset of focal neurologic deficits resulting from
    • diminished blood flow (ischemic stroke)
    • hemorrhage (hemorrhagic stroke)
  • Risk factors include diabetes, smoking, atrial fibrillation, and cocaine
  • Etiology include
    • 35% - atherosclerosis of the extracranial vessels (carotid atheroma)
    • 30% -cardiac and fat emboli, endocarditis
    • 15% - lacunar
    • 10% - parenchymal hemorrhage
    • 10% - subarachnoid hemorrhage
  • Lacunar infarcts occur in areas supplied by small perforating vessels and result from
    • atherosclerosis
    • hypertension
    • diabetes
  • Watershed occurs at areas at border of two arterial supplies
    • often follow prolonged hypotension
  • TIA is charcaterized by transient neurologic deficits for less than 24 hours (usually less than 1 hr.)
Presentation
  • Edema occurs 2-4 days post-infarct.
  • Watch for symptoms
    • decorticate (cortical lesion): flexion of arms
    • decerebrate (midbrain or lower lesion): extension of arms 
    • cerebellar: ataxia, nystagmus, abnormal finger-nose and heel-shin 

      Carotid/Ophthalmic Amaurosis fugax (monocular blind)
      MCA Aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia.
      ACA Leg paresis, hemiplegia, urinary incontinence
      PCA homonynmous hemianopsia
      Basilar Art Coma, cranial nerve palsies, apnea, drop attach, vertigo
      Lacunar stroke

      Silent, pure motor or sensory stroke, "Dysarthria-Clumsy hand syndrome", ataxic hemiparesis.

  • Other stroke syndromes
    • lateral medullary infarct (Wallenburg syndrome)
      • loss of pain and temp on ipsilateral face and contralateral body, vestibulocerebellar impairment, Horner's syndrome
Evaluation
  • Labs
    • should include coagulation studies
    • lumbar puncture to r/o encephalitis
  • Echo to check for mural thrombus, rule out endocarditis
  • Imaging
    • CT without contrast for acute presentation 
      • important to diagnose as ischemic or hemorrhagic 
    • MRI for subacute
    • vascular studies of intra and extracranial vessels
  • EEG to rule out seizure
Differential
  • Brain tumor, epi / subdural bleeds, brain abscess, endocarditis, multiple sclerosis, metabolic (hypoglycemia), neurosyphillis
Treatment
  • For occlusive disease give IV tPA if within 3-4.5 hours 
  • Can consider intra-arterial thrombolysis in select patients (major MCA occlusion) up to 6 hours after onset of symptoms
  • Thrombectomy within 6 hours in an ischemic stroke with a proximal cerebral arterial occlusion, compared to alteplase alone, improved reperfusion, early neurological recovery, and functional outcome. 
  • For embolic disease and hypercoagulable states give warfarin / aspirin once the hemorrhagic stroke has been ruled out
  • Endarterectomy if corotid > 70% occluded
Prognosis, Prevention, and Complications
  • Less than 1/3 achieve full recovery
  • For embolic disease give warfarin / aspirin for prophylaxis
  • Carotid endarterectomy if stenosis is > 70%. Contraindicated if vessel is 100% occluded.
  • Manage hypertension


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Qbank (4 Questions)

TAG
(M3.NE.48) A 72-year-old female is brought in to the emergency department by ambulance after her husband noticed neurological changes. In particular, she reported a lack of pain and temperature on the right half of her face, as well as the same lack of sensation on the left side of her body. She reports feeling "unsteady" on her feet. On physical exam you note a slight ptosis on the right side. She is sent for an emergent head CT. Where is the most likely location of the neurological lesion? Topic Review Topic

1. Internal capsule
2. Midbrain
3. Pons
4. Medulla
5. Cervical spinal cord

PREFERRED RESPONSE ▶
TAG
(M2.NE.3) A 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable only for hypertension. On physical exam, vital signs are within normal limits except for a heart rate of 105 bpm. He is noted to have distinct right facial paralysis. Which of the following is the next best step in the management of this patient? Topic Review Topic

1. Administer IV tPA
2. Have the patient chew an aspirin
3. Send the patient for a non-contrast head CT scan
4. Send the patient for a contrast head CT scan
5. Send the patient for a diffusion weighted image (DWI) MR scan

PREFERRED RESPONSE ▶
TAG
(M2.NE.6) A 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable only for hypertension. On physical exam, vital signs are within normal limits except for a heart rate of 105 bpm. He is noted to have distinct right facial paralysis. A non-contrast head CT is performed and is shown in Figure A. What is the most likely diagnosis in this case? Topic Review Topic
FIGURES: A          

1. Acute hemorrhagic stroke
2. Acute ischemic stroke
3. Glioblastoma multiforme
4. Subdural hematoma
5. Partial seizure

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TAG
(M2.NE.27) A 65-year-old man with a past medical history of hypertension, diabetes mellitus type II, and hyperlipidemia, as well as a 30-pack-year smoking history presents to the emergency room with aphasia and right-sided hemiparesis. His wife reports that he was completely normal three hours ago at dinner. Vital signs are T 37C, HR 90, BP 142/91 mmHg, RR14, O2 99% on room air. On physical examination, he is unable to repeat a sentence. He is unable to express himself although he is able to follow commands. His right upper extremity and lower extremity are both weak but the weakness is more pronounced in his right arm than right leg. On examination of the head and neck, you note bilateral carotid bruits. Head CT is obtained (Figure A). Which of the following is true regarding the management of this patient?
Topic Review Topic
FIGURES: A          

1. The patient has a hemorrhagic stroke and should be treated with observation
2. The patient should be given thrombolytic therapy
3. The patient would benefit from thrombolysis, but its use is contraindicated because of his blood pressure at presentation
4. The patient's blood pressure should be lowered to the normal range with antihypertensive medications prior to treatment
5. The patient should receive MRI to confirm the stroke before receiving therapy

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