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5 CNS: Strokes-AMS

Step Up to Medicine, Chap 5: Strokes, Movement Disorders, AMS

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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