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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
Created by: amitchaudharimd
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