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Vascular
| @NeuroFOD | |
|---|---|
| Vascular | Vascular |
| Vascular Neurology | |
| Lesion? - apraxia, incontinence, abulia, cL leg | ACA stroke |
| Lesion? - pure motor leg>arm | Recurrent artery of Huebner. Comes from ACA, supplies anterior internal capsule |
| Lesion? - akinetic mutism | Bilateral recurrent artery of Huebner. Causes bilateral globus pallidus interna stroke |
| Lesion? - cL weakness, broca's aphasia | Superior M2 |
| Lesion? - cL numbness, wernicke's aphasia | Inferior M2 |
| Lesion? - cL weak, iL eye blindness | ICA stroke. Eye from opthalmic artery causing ipsilateral infarction |
| Internal capsule blood supply | Ant = ACA recurrent artery of Huebner. Middle = MCA lenticulostriate. Post = ICA Ant choroidal |
| Lesion? - iL ataxia, diplopia | Superior cerebellar artery. Affects midbrain nuclei and superior cerebellar peduncle |
| Lesion? - flexor posturing, ataxia, CN3 palsy | Distal basillar. Affects corticospinal tract above red nucleus, superior peduncle, and midbrain |
| Lesion? - vertical gaze defect | riMLF. In midbrain. Supplied by basillar |
| Lesion? - cL body iL face, facial diplegia, INO, CN6 palsy | Proximal basillar. Affects corticospinal tract prior to decussation, and pontiue nuclei |
| Lesion? - Horners, iL ataxia, CN8, hoarse, taste | PICA. Lateral medulla (Wallenburg) + inferior cerebral peduncle |
| Lesion? - Horners, iL ataxia, CN8, hoarse, taste, iL deaf | AICA. Lateral medulla + middle cerebral peduncle + labrynthine artery giving iL deafness |
| Frontal lobe lesion presentations | Depression, personality. Dorsolateral = apathy, ventromed/orbitofrontal = disinhib. Broca's |
| Lesion? - L hand apraxia | Corpus callosum. split hand syndrome |
| Lesion? - pseudobulbar palsy | Bilateral internal capsule. Associated with ALS, MS, TBI. Tx = dextromethorphine-quinidine |
| Lesion? - finger agnosia, L-R confusion, acalculia | Gertsmann syndrome. Dominant parietal angular gyrus. Angular artery of the MCA |
| Lesion? - optic ataxia, optic apraxia, simultagnosia | Balint syndrome. Bilateral superior occipito-pariteral |
| Lesion? - cortical blindness (apperceptive), confabulation | Anton syndrome. Confabulation because patient's in denial about their blindness |
| Lesion? - inability to recognize faces, achromatopsia | Prosopoagnosia. Dominant inferior occipito-temporal fusiform gyrus. PCA |
| Lesion? - hemibody pain | Post-thalamic stroke. Dejernine-Roussy syndrome. No NSAIDs, use Gabapentin / AEDs |
| Lesion? - loss of consciousness | Bilateral thalamic injury (possible artery of percheron stroke). Other possibility is brainstem |
| Lesion? - inability to read, but can write | Alexia without agraphia. L occipital + splenium of corpus callosum |
| Lesion? - pure word deafness (can't listen, but can read) | Temporal lobe Heschl's gyrus, but spares Wernicke's |
| Lesion? - dysathria, voluntary CN paralysis | Bilateral anterior operculum. Foix-Chavany-Marie syndrome |
| Lesion? - iL CN3, cL weak | Midbrain tegmentum. Weber's syndrome. Compare with Benedickt's and Claude's |
| Lesion? - iL CN3, cL weak, +tremor/chorea | Midbrain tegmentum. Benedickt's syndrome. Compare with Weber's and Claude's |
| Lesion? - iL CN3, cL weak, +tremor/chorea, +cL ataxia | Midbrain tegmentum. Claude syndrome. Compare with Weber's and Benedickt's |
| Lesoin? - supranuclear vertical gaze pals | Midbrain tegmentum, quadrigeminal plate. Parinaud's syndrome |
| Lesion? - iL CN6, iL CN7, cL weak, cL sens | Ventral pons. Millard-Gubler syndrome. Compare with Foville and Raymond |
| Lesion? - iL CN6, iL CN7, cL weak, cL sens, +INO | Pontine tegmentum. Foville syndrome. Compare with Millard-Gubler and Raymond |
| Lesion? - iL CN6, cL weak, cL sens, +INO, but spare CN7 | Ventral pons. Raymond syndrome. Compare with Millard-Gubler and Foville |
| Lesion? - iL ataxia (clumpsy hand), cL weak, cL sens | Base of pons. Marie-Foix syndrome |
| Lesion? - quadriplegia, facial diplegia, spare vertical gaze | Bilateral base of pons. Locked-in syndrome |
| Lesion? - cL weak, cL vibration loss, iL CN12 | Medial medulla. Dejerne syndrome |
| Spinal watershed area | Around T6-T10. Anterior spinal artery supplies till T7, Adamkiewiz joins around T8/T10 |
| Artery of Adamkiewiz | From descending thoracic aorta. Supplies anterior spinal cord from T8/T10 and below |
| Anterior spinal artery origin | Bilateral vertebral arteries |
| Posterior spinal artery origin | PICA or vertebral artery |
| Recurrent strokes, intractable HA, 20yo | CADASIL |
| Recurrent strokes, intractable HA, 20yo, +alopecia | CARASIL. Compare with CADASIL |
| Recurrent strokes, encephalopathy, seizures, deafness | MELAS |
| Recurrent stroke, keratitis, deafness | Cogan syndrome |
| Recurrent strokes, skin livedo reticularis | Sneddon syndrome |
| Hemorrhage subependymal germinal matrix stroke | Perinatal asphyxia. Anytime between 28wk fetus to 7days post-delivery |
| When does DWI scan become positive for stroke? | Minimum 6 hours after injury. Stays positive for about 2 weeks |
| Differential for +DWI but no ADC correlate? | Tumor, MS, infection, CJD |
| Volume of infarct that risks malignant cerebral edema | Anything over 82ml in MCA territory |
| Acute treatment of ischemic stroke | <3-4.5hrs = tPA, <24hrs = thrombectomy, otherwise ASA |
| tPA dosing | 0.9mg/kg. Give 10% as bolus, and rest 90% as drip |
| When to use dual antiplatelet therapy? | 90d for ntracranial atherosclerosis (SAMPRIS). Or 21d for TIA or NIHSS<3 (POINT/CHANCE) |
| Day of max swelling after ischemic stroke | Days 2-5 |
| When to use warfarin specifically (not NOACs)? | Warfarin is superior for valvular A.fib. For non-valvular, can use dabigatran or other NOACs |
| When to start anticoag for A.fib after ischemic stroke? | Varies (benefit prevent stroke, risk hemorrhagic transformation). Typically 5-15 days post stroke |
| When to undergo CEA? | If >70% carotid stenosis, or >60% with symptoms. If 100% stenosed, no point CEA, just Aspirin |
| Treatment for moyamoya disease | Aspirin. Can consider ECA-MCA bypass |
| Treatment for CNS vasculitis | Steroids. Cyclophosphamide better than other immunosuppressants |
| Treatment for stroke in sickle cell disease | NO tPA. Do PLEX with HemoglobinS goal <30% of total Hgb. Screen with yearly TCDs |
| Treatment for antiphospholipid syndrome | Warfarin or other anticoagulation. Antiplatelets alone NOT sufficient |
| Definition of TIA | Symptoms lasting <24 hours with NO DWI or other MRI changes |
| Treatment for stroke from PFO | Regular secondary stroke prevention. So far, no benefit from surgical closure of PFO |
| Blood changes in pregnancy | Increase RBCs, increase blood volume, increase fibrinogen (hypercoagulable) |
| Definition of pituitary apoplexy | Pit bleed from pit adenoma. All other pit bleeds = just ICH/SAH. Often used interchangeably |
| ABCD2 score after TIA | >60yo, BP>140/90, CHF, DM2, Duration (>1hr vs <1hr). Score >2 = 6% risk = treat |
| tPA contrainidcations | <18yo, BP>185/110, ICH, Warfarin INR >1.7, Any NOAC, Sz/tumor/AVM, surg 14d, trauma 3mo |
| tPA reversal | Cryo till fibrinogen >150. Can also transexemic acid and aminocaproic acid |
| CHA2DS2-VASc score in A.Fib | CHF, HTN, Age>75 (2), DM, Stroke hx (2), Vasc dx, Age>60 (1), Female. >2 = /\risk = anticoag |
| Aphasia - naming only | Semantic aphasia. Anterior temporal |
| Aphasia - repetition only | Conduction aphasia. Arcurate fasciculus |
| Aphasia - comprehension only | Transcortical sensory. MCA-PCA watershed |
| Aphasia - comprehension + repetition | Wernicke's aphasia. Superior temporal |
| Aphasia - fluency only | Transcortical motor. ACA-MCA watershed. Also symptoms of supplementary motor area |
| Aphasia - fluency + repetition | Broca's. Frontal operculum |
| Aphasia - fluency + comprehension, but intact repetition | Transcortical mixed. ACA-MCA-PCA watershed |
| Treatment of stroke in FMD | Aspirin. Scan renal artery for refractory hypertension |
| Treament of stroke in MELAS | L-ariginine, CoQ-10 |
| Most missed diagnosis in headache | Cerebral venous sinus thrombus |
| HA worse with valsalva/lying down, papilledema, CN def | Consider CSVT, tumors, other causes of elevated ICP |
| CSVT MRI finding | bilateral medial thalami hyperintensity |
| CSVT treatment | Anticoagulation. If pregnant, can only use heparin - no wafarin or NOACs |
| 2 pathophysiologies of hypertensive hemorrhage | #1 = lacunar lipohyalinolysis. #2 = Charcot-Bouchard aneurysms |
| Lobar hemorrhage likely etiology | Cerebral amyloid angiopathy. Note: clinically, HTN is still most likely, CAA is more specific |
| Time to maximum expansion of ICH | 6-24 hours |
| Time to maximum vasospasm in SAH | 4-14 days |
| MRI T1-T2 mneumonic for bleed chronicity | IbBy, IdDy, BiDy, BaBy, DoDo from hyperacute, acute, early subacute, late subacute, chronic |
| When to give platelets in ICH? | Only if surgery planned (per PATCH trial). Clinically still given empirically many times |
| Reversal - warfarin | PCC for immediate. Start vitamin K x3d, will take effect in ~1wk |
| Reversal - heparin | Protamine sulfate |
| Reversal - rivoroxaban, apixaban, etc | Andexanet-alpha |
| Reversal - dabigatran | Idarucizumab = specific antibody against dabigatran |
| Reversal - any agent <2 hours | Can consider oral charcoal |
| Steroids in ICH? | No indication. Not done clinically unless tumor |
| Seizure prophylaxis in ICH? | No indication. Often done clinically anyways with Keppra x7days |
| DVT prophylaxis in ICH? | Usually ok 24-48 hours after stable scan |
| ICH score components: | GCS score, ICH volume, presence of IVH, location infratentorial, age>80 |
| SAH most common etiology | <55yo healthy = aneurysm. >55yo/unhealthy = HTN |
| Dx of ipsilateral CN3 palsy | Pupil sparing = small vessel HTN/DM. Pupil involved = compression = tumor, PComm aneu |
| When does xanthochromia present in LP after SAH? | About 6 hours. Lasts weeks |
| When to use aminocaproic acid in SAH? | If SAH <72hours and high suspicion for aneurysm |
| Treament of vasospasm | Empiric nimodipine x21 days after SAH. If vasospasm = fluids, increase SBP, neuroIR |
| Seizure prophylaxis in SAH? | No indication. Often done clinically anyways with Keppra x7days |
| Nimodipine evidence for mortality/morbidity | Improves mortality and morbidity since it lessens vasospasm and subsequent stroke |
| Slow progressive caudal->rostal myelopathy | Consider dural AVF |
| Cavernoma imaging findings | Popcorn appearance on contrast MRI. NeuroIR angio will show nothing |
| Caput medusae finding on vessel imaging | Venous angioma. Not AVM or AVF |
| Galen aneurysm association | In babies, causes cystic dilation, hydrocephalus and lack of brain development. A/w HFpEF |
| Flame/string sign. Treatment? | Carotid dissection. Treatment is aspirin (not anticoagulation) |
| Progressive HA with stroke and SAH | Consider CADASIL, but also Primary Angitis of CNS (PACNS). Treatment = steroids, cyclophos |
| RCVS causes | Meth, SSRI, pregnancy |
| RCVS vs PRES | RCVS = vasoconstrict (stroke). Can -> PRES = diffuse capillary leak edema (encephalopathy) |
| RCVS vs PRES - treatments? | RCVS = calcium channel blockers. PRES = BP control, magnesium |
| Gene associated with cerebral amyloid angiopathy | ApoE only. Not the other Apo genes |
| Post-stroke time to necrosis | 0-48 hours |
| Post-stroke time to inflammation | 2-5 days |
| Post-stroke time to liquifactive necrosis | 1 week |
| Post-stroke time to reactive gliosis | 1-4 weeks |
| Post-stroke time to scarring | >1 month |
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amitchaudharimd
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