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5 CNS: Strokes-AMS
Step Up to Medicine, Chap 5: Strokes, Movement Disorders, AMS
| Question | Answer |
|---|---|
| 3rd MCC death in US and leading cause of disability? | Ischemic stroke/CVA |
| Majority of strokes are ischemic or hemorrhagic? | Ischemic (85%) |
| Definition of TIA? | Neuro deficit that lasts from few min to 24 hours. Duration of symptoms is determining difference. |
| Risk of stroke in a person with TIA? | About 10% per year, so 30% 5-year risk |
| Most important risk factors for ischemic stroke? | Age and HTN |
| Where was the TIA?: temporary loss of speech; paralysis or parasthesias of contralateral extremity; clumsiness of one limb | Carotid system |
| What is amaurosis fugax? | type of TIA; transient, curtain-like loss of sight in ipsilateral eye due to microemboli to retina (assoc'd with carotid system TIAs) |
| Where was the TIA?: dizziness, double vision, vertigo, numbness of ipsilateral face and contralateral imbs, dysarthria, hoarseness, dysphagia, projectile vomiting, headaches, and drop attacks | Vertebrobasilar system (caused by decreased perfusion to posterior fossa) |
| MC etiology of TIA/CVA? | Embolic stroke (MC origin is heart) |
| What causes narrowing of the arterial lumen in lacunar strokes? | Thickening of the arterial wall (NOT thrombosis). Assoc'd with HTN and diabetes. |
| Classical presentation of thrombotic stroke? | Pt awakes from sleep with neuro deficit |
| MC affected artery in thrombotic stroke? | MCA |
| Neuro deficits seen in MCA? | Contralateral hemiplegia and hemisensory loss, aphasia (if dominant hemisphere), apraxia, contalateral body neglect, confusion (if non-dominant hemisphere) |
| Which type of stroke occurs if the lesion involves the internal capsule? | Pure motor lacunar stroke |
| Which type of stroke occurs if the lesion involves the thalamus? | Pure sensory lacunar stroke |
| What is the first imaging study you should obtain in a stroke? | Non-contrast CT head (differentiates btwn ischemic and hemorrhagic) |
| How does a non-contrast CT differentiate between ischemic and hemorrhagic? | Ischemia shows up dark on CT. Hemorrhage shows up white. |
| Name 3 conditions which warrant screening with a carotid duplex. | 1. Carotid bruit 2. PVD 3. CAD |
| What labs to order if pt presents with findings suggestive of a stroke? | 1. Non-contrast head CT 2. EKG 3. CXR 4. CBC w/platelet ct 5. PT, PTT 6. Electrolytes 7. Glucose |
| How soon should tPA be administered in case of acute stroke? | Within 3 hours of onset (do NOT give if time is unknown, or if more than 3 hours have passed) |
| Which drug should not be given if t-PA is administered? How long should you hold it for? | Aspirin; hold for 24 hours. |
| Target BP for acute stroke pt on t-PA? | <185/110 (generally do not give antihypertensives in setting of acute stroke) |
| In which type of stroke is anticoagulation considered the treatment of choice? | Embolic stroke |
| When should carotid endarterctomy be used? | In symptomatic pts with carotid a stenosis >70%. (In asymptomatic pts, no benefit; reduction of risk factors and aspirin are recommended) |
| Which type of hemorrhagic stroke is intraparenchymal? Extraparenchymal? | Intra: Intracerebral hemorrhage (ICH) Extra (into CSF): Subarachnoid hemorrhage (SAH) |
| MCC intracerebral hemorrhage? | HTN, particularly a sudden increase in BP |
| Where was the stroke?: contralateral lower extremity and face | Anterior cerebal a |
| Where was the stroke?: aphasia, contralateral hemiparesis | MCA |
| Where was the stroke?: ipsilateral (ataxia, diplopia, dysphagia, dysarthria, and vertigo), contralateral (homonymous hemianopsia with basilar-PCA lesions) | Vetebral/basilar |
| Where was the stroke?: pure motor hemiparesis | Lacunar: internal capsule |
| Where was the stroke?: dysarthria, clumsy hand | Lacunar: pons |
| Where was the stroke?: pure sensory | Lacunar: thalamus |
| Appropriate management of pt presenting with amaurosis fugax? | US of carotid aa to determine degree of stoneosis. Carotid endarterectomy may be indicated. |
| Abrupt onset of focal neuro deficit that worsens steadily over 30-90min, altered LOC/stupor/coma, HA, vomiting, papilladema. Dx? | Intracranial hemorrhage |
| Parameters for BP control in ICH? Tx of choice? | Tx indicated for systolic >160-180 or diastolic >105. Nitroprusside is agent of choice. Gradual reduction to avoid hypotension. |
| Tx for elevated intracranial pressure? | Mannitol or diuretics (do NOT give prophylactically) |
| One of MCC of stroke in young pts? | Cocaine. Assoc'd with ICH, SAH, and ischemic stroke |
| At what level was the ICH based on this pupillary finding?: pinpoint pupils | Pons |
| At what level was the ICH based on this pupillary finding?: poorly reactive pupils | Thalamus |
| At what level was the ICH based on this pupillary finding?: dilated pupils | Putamen |
| MCC subarachnoid hemorrhage? Location? | Ruptured berry (saccular) aneurysm. Found at bifurcation of Circle of Willis aa |
| Pt comes in complaining of worst headache of life. Non-contrast CT is negative. Your clinical suspicion is high for SAH. What do you do? | Perform lumbar puncture. LP is diagnostic: -Blood in CSF= hallmark of SAH (r/o trauma though) -Xanthochromia= GOLD STD dx of SAH (caused by RBC lysis) |
| SAH is diagnosed on your pt. What should you do next? | Order cerebral angiography (used to locate site for surgical clipping) |
| What test should be completed before doing a lumbar puncture? | Ophthalamologic exam to r/o papilledema. If papilledema is present, do NOT perform a lumbar puncture or you may cause a herniation. |
| Medical tx for SAH? | Bed rest, stool softeners (avoid straining), analgesia for HA (acetaminophen), IV fluids, anti-HTN, CCBs (nifedipine; for vasospasm) |
| LOC, vomiting, and HA point toward which type of stroke? | Hemorrhagic |
| Sudden onset points toward which type of stroke? | Embolic |
| Site of dopaminergic neuron loss in Parkinson's disease? | Substantia nigra and locus ceruleus |
| How is Parkinson's diagnosed? | Clinically |
| Define the nature of Parkinson's tremor. | Pill rolling tremor at rest that is worsened by emotional stress and relieved by movement. |
| Drug of choice in treating Parkinsonian sx? | Carbidopa-Levidopa (Sinemet) |
| Name 3 drugs that cause parkinsonian side effects. | Neuroleptics (chlorpromazine, haloperidol, perphenazine), metoclopramide, reserpine |
| Key neuronal finding in brains of Parkinson's pts? | Lewy bodies (hyalin inclusion bodies) |
| Parkinsonian sx + autonomic insufficiency (orthostatic hypotension, constipation, increased sweating, and oily skin) | Shy-Drager syndrome |
| Which system is blocked in Parkinson's and which system operates unopposed? | Dopaminergic pathway is blocked and cholinergic pathway operates unopposed |
| Differences between progressive supranuclear palsy (PSP) and Parkinson's? | PSP does NOT cause tremor. PSP DOES cause ophthalmoplegia (EOM paralysis) |
| Mechanism of selegiline? | Inhibits monoamine oxidase B (increases dopa activity) and reduces metabolism of levodopa |
| Which mutation causes Huntington's chorea? | Trinucleotide CAG repeat on chromo 4 leading to loss of GABA-producing neurons in the striatum |
| Young pt with movement disorder. | Consider Wilson's! |
| Metabolic causes of physiologic tremor. | Hypoglycemia, hyperthyroidism, pheo. |
| Ataxia, nystagmus, impaired vibratory sense and proprioception with onset by young adulthood. Dx? Inheritance? | Friedreich's ataxia. AR. |
| Ataxia, nystagmus, impaired vibratory sense and proprioception, and telangiectasias with childhood onset. Dx? Inheritance? | Ataxia telangiectasia. AR. |
| Tourette's must have onset before which age? Inheritance? | 21yo; AD. |
| Name 3 drugs used to treat Tourette's. | Clonidine (alpha 1 agonist), pimozide (antipsychotic), and haloperidol. |
| What improves each of the following tremors: Parkinsonian, cerebellar, and essential (familial) | P: action C: rest E: alcohol |
| Which anti-Parkinson drugs can delay the need for levodopa for several years? | Doapmine-receptor agonists (pergolide, bromocriptine, pramipexole). Pramipexole is MC agent. |
| Why might a physician want to delay use of levodopa for as long as possible? | SE include dyskinesias which develop 5-7 years after beginning therapy. Other SE include n/v, anorexia, HTN, and hallucinations. Also has "on-off" course which can cause fluctuating symptoms in advanced disease. |
| Most important risk factor in dementia? | Increasing age |
| Insidious onset of dementia due to diffuse subcortical white matter degeneration seen in pts with longstanding HTN and atherosclerosis | Binswanger's disease |
| CSF pressure and appearance of ventricles in wackly, wobbly, wet phenomenon? | Normal CSF pressure with dilated ventricles. NORMAL pressure hydrocephalus |
| Quantity of senile plaques (age-specific)-focal collections of dilated, tortuous neuritic processes surrounding a central amyloid core (amyloid beta protein) is characteristic of what disease? | Alzheimer's disease |
| Neurofibrillary tangles with bundles of neurofilaments in cytoplasm of neurons denoting neuronal degeneration is characteristic of what disease? | Alzheimer's disease |
| Tx for Alzheimer's? | Donepezil (anticholinesterase drug); tacrine has more SE and requires 4 doses per day compared to once daily donepezil |
| Which disease has features of both Alzheimer's and Parkinson's, but with a more rapid onset and visual hallucinations as the predominant initial symptom? | Lewy body dementia; other sx include EPS and fluctuating AMS |
| Tx for Lewy body dementia | Neuroleptics for psychotic features and hallucinations (be careful- they're more sensitive to neuroleptic adverse events) and selegiline to slow progression |
| Which procedure should be performed in any pt who is delirius and febrile? | LP |
| What is anisocoria? What is it a sign of in comatose pts? | Asymmetrical pupils. Sign of uncal hernaition. |
| Cause of the coma?: bilateral fixed, dilated pupils | Severe anoxia |
| Cause of the coma?: unilateral fixed, dilated pupil | Herniation with CN 3 compression |
| Cause of the coma?: pinpoint pupils | Narcotics, ICH |
| What causes locked in syndrome? | Infarction or hemorrhage of the ventral pons |
| Can a physician legally discontinue life support on a pt proven to be brain dead? | Yup |
Created by:
sarah3148
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