Stroke: phantom menace
You have a 65 year old female who presents to the ED with a 1 hour sudden onset of monocular vision loss in the right eye. She denies any weakness, headache, nausea, and is talking normally to you. In addition to an eye exam, what else should you do?
A) Test vision in other eye via Snellen chart
B) Listen for Carotid Bruits
C) CT Head non-contrast
D) Prescribe Corticosteroid
How do we treat high risk vs. low risk?
Differentiate thrombotic/lacunar/embolic/hemorrhagic strokes. In which one would you find papilledema on exam?
Thrombotic = occlusion of large/medium size vessels due to atherosclerotic plaques. Can be intra or extracranial occlusion. neuro deficits can fluctuate if clot breaks/gets re-lodged.
Lacunar = occlusion of small vessels (penetrating arteries) due to plaques, chronic HTN (-> vessel wall hypertrophy = smaller lumen). Lacuna = small spots of necrosis. symptoms progressively worsen.
Embolic = clot lodges in cerebral vasculature from a distant site (eg. cardiogenic) common with arrhythmias. onset of symptoms is abrupt, maximal at start.
Hemorrhagic = rupture of vessel. will see papilledema! may cause HA, N/V, AMS, Vision change, CN palsy, Brain herniation.
What is the best emergent imaging technique for stroke management?
MRI Brain
CT Head Non-Contrast
CT Head with IV Contrast
PET scan
Radionuclide testing
CT head non-contrast.
What is the most common type of headache? How does this present?
tension headache. Episodic, constant when present. can be unilateral or BIL, often with neck pain. NO neuro symptoms or N/V.
What is the most common malignant brain tumor in pediatric patients? Where does it occur?
Medulloblastoma - most often occuring in cerebellum.
Presentation: Increased ICP, cerebellar dysfunction -> motor deficits, HA, N/V, Papilledema.
Dx: Do Head imaging, LP (1/3 have mets to CSF)
Tx: Surgery/Chemo/Radiation
What are some exclusion criteria for use of tPA? Give at least 2
Hemorrhagic stroke (or Hx of)
Stroke symptom onset >4.5 hours
Neurosurgery or trauma in last 3 months
uncontrolled HTN
Known intracranial AVM
Active internal bleeding eg. GI bleed.
a patient with sudden loss of motor control and sensation to the legs, as well as urinary incontinence, is most likely experiencing a stroke involving which artery?
Anterior Cerebral Artery
Middle Cerebral Artery
Posterior Cerebral Artery
Ophthalmic Artery
Anterior Cerebral artery - feeds PMC and PSC for BLE, bladder, genitals
Middle Cerebral artery - feeds PMC and PSC for face, BUE, trunk
Posterior Cerebral Artery - feeds thalamus, medial temporal/occipital lobes
Ophthalmic artery - feeds retina, optic nerve
Differentiate Wernicke's aphasia vs Broca's aphasia
Wernicke's aphasia = cant comprehend language. Production normal, content doesnt make sense (receptive aphasia)
Broca's aphasia = Know it, but can't speak. pt's get frustrated (expressive aphasia)
A patient comes in reporting a recurrent headache over the past 2 months, which usually only affects the left side of her head. She endorses photophobia and flashing lights in her field of vision when the headache is present, as well as mild nausea. This usually lasts roughly 8 hours then passes. She says she can feel when a headache is about to come on. This is most consistent with what headache?
Tension Headache
Migraine Headache
Cluster Headache
Hypertension Headache
Migraine headache
Which of the following has the highest risk of metastasis to the brain?
Lung
Breast
Melanoma
Prostate
Melanoma
Lung, breast are most common but thats because they are more common
Differentiate presentation and CT findings for Epidural vs. Subdural hemorrhage.
Which one is due to arterial or venous bleeding?
Epidural = convex (lemon) - Arterial
-Pt has LOC -> wakes up, then deteriorates over mins/hrs
Subdural = concave (banana) - Venous
-Pt has trauma without LOC -> rapid deterioration
Describe each of the following types of brain herniations related to hemorrhagic stroke
Uncal
Central
Transtentorial
Bonus:
Tonsillar
Transcalvarial
Uncal - medial temporal lobe herniates down thru tentorium cerebelli = compression of brainstem
Central - both medial temporal lobes herniate through tentorium cerebelli = compression of brainstem
Transtentorial - upward herniation of cerebellum thru tent. cerebelli
Bonus:
Tonsillar - cerebellar tonsils herniate thru foramen magnum
Transcalvarial - herniation through skull fracture
What are some things we assess when deeming someone high risk vs. low risk after a TIA? How does this change treatment?
ABCD2 score (assess stroke risk in TIA pts)
-Age >60 (1)
-BP >140/90 (baseline) (1)
-Duration of symptoms (1 for 10-59 mins, 2 for 60+)
-Nature of symptoms (aphasia/dysarthria = 1, hemiparesis = 2)
-Hx of DM (1)
>4 = high risk
High risk = DAPT (ASA + Plavix)
Low Risk = ASA
Carotid Endarterectomy if carotid stenosis >70%
in Idiopathic intracranial hypertension, name:
Most common population
PE/Diagnostic findings
Treatment (pharmacologic)
Most common population: AFAB of child bearing age, BMI >25
PE/Diagnostic findings: Papilledema, vision loss, increased opening pressure on LP.
Treatment (pharmacologic): Acetazolamide (decreases formation of CSF -> decrease ICP)
What else is acetazolamide used for?
Which of the following is a usually slow growing, benign neurological neoplasm, increasing in incidence with age and is related to exposure to ionizing radiation?
Medulloblastoma
Astrocytoma
Meningioma
Oligodendroglioma
Meningioma
A 77 year old patient presents with his wife to the ED after a fall. She reports he had a suddenly fell "out of nowhere", vomiting after, but didn't lose consciousness. He has a prior history of HTN, DM and HLD. On exam, you notice vertical nystagmus, and he has been having trouble swallowing since. Which artery is likely involved?
ACA
MCA
PCA
Vertebrobasilar
Vertebrobasilar = feeds cervical spinal cord brainstem, cerebellum, thalamus, and occipital lobes. Insufficiency can lead to drop attacks - sudden fall due to weakness, no LOC.
Will have nystagmus, bulbar weakness (swallowing/poss speaking deficit)
Differentiate what we are investigating when we order an angiogram vs. CT perfusion after a stroke.
Angiogram = tells us if there is a thrombus that can be treated mechanically
CT perfusion = did ischemia lead to infarct?
What is the most commonly involved cerebral artery in strokes? What areas of the brain does this affect? What sensory and motor deficits will result?
Middle Cerebral Artery (MCA stands for most common artery - thanks cramthepance)
Supplies frontal/parietal/temporal lobes. in particular sensory/motor cortex for BUE, trunk, face, as well as wernicke's and broca's area.
Stroke -> CONTRALATERAL sensory and motor loss to the face (facial droop w/ forehead spared), upper extremity and trunk. Aphasia (if dominant side is affected).
What are some associated symptoms with a headache that may concern you for a mass effect headache?
New worsening headache in mid-late life, gets progressively worse as mass grows. May compress other structures leading to neuro deficits (eg. vision loss). Associated fever, night sweats, weight loss common.
Match each presentation to its respective neurocutaneous disease (NF1, NF2, Tuberous Sclerosis, Encephalofacial Angiomatosis)
Cafe Au Lait Spots
Portwine Nevus in unilateral trigeminal distribution
BIL Vestibular Schwannomas
Lisch Nodules
Shagreen Patch
Ash Leaf Patches
Mala angiofibroma
Cafe Au Lait Spots - NF1
Portwine Nevus in unilateral trigeminal distribution - Encephalofacial Angiomatosis (GNAQ gene)
BIL Vestibular Schwannomas - NF2
Lisch Nodules - NF1
Shagreen Patch - Tuberous Sclerosis (TSC1/TSC2)
Ash Leaf Patches - Tuberous Sclerosis (TSC1/TSC2)
Malar angiofibroma - Tuberous Sclerosis (TSC1/TSC2)
BONUS: What type of urgent referral should be made in patients with encephalofacial angiomatosis?
In the setting of hemorrhagic stroke, what does a CNIII palsy potentially indicate?
increased ICP -> Uncal/Central brain herniation -> brainstem compression (CNIII is the most superior CN exiting brainstem so it'd be tickled first)
Differentiate the presentation and pathophysiology of intracerebral vs. subarachnoid Hemorrhagic strokes
Intracerebral
due to microaneurysms in penetrating arteries (small vessels) = slower bleed.
Symptoms increase gradually (minutes-hours), are not maximal at onset. HA, N/V, Decreased consciousness.
Subarachnoid
Due to either rupture of arterial aneurysm at the base of brain, or AVM rupture (larger vessels) = faster bleed. abrupt onset, maximal at onset - sudden HA/Weakness, N/V
With a temporal bone fracture leading to disruption of the middle meningeal artery, what is the most concerning complication?
Subdural Hemorrhage
Epidural Hemorrhage
Intracerebral Hemorrhage
Epidural Hemorrhage
Differentiate diagnostic criteria/presentation and treatment of migraine vs. cluster headache
Migraine HA: Presents as pulsatile, lasting 4-72 hrs, unilateral (can spread to be BIL), nausea, disabling. With or without aura (visual disturbance most common).
Treat acutely with NSAIDs/Tyl/Triptans/DHE. PPx with Beta blockers, TCAs, SNRI, anti-seizure meds
Cluster HA: Presents as unilateral periorbital pain episodes (15min-3hr) with 1 of: lacrimation, congestion/rhinorrhea, eyelid edema/ptosis, facial swelling (all ipsilateral).
Treat acutely with IM/Nasal triptan, PPx with verapimil (CCB)
Medulloblastoma
Meningioma
Astrocytoma
Glioblastoma
Ependymoma
Oligodendroglioma
Schwannoma
Neuroma
Medulloblastoma - Malignant
Meningioma - Mostly benign
Astrocytoma - malignant
Glioblastoma - malignant
Ependymoma - malignant
Oligodendroglioma - malignant
Schwannoma - benign
Neuroma - benign (disorganized axons s/p injury)