Stroke - Questions & Vignettes

Ischemic stroke risk can be reduced with medical therapy including _________ and clopidogrel.

aspirin

The treatment for a TIA is enteric-coated __________ in the acute phase followed by long-term antiplatelet therapy for noncardioembolic TIA and anticoagulation for cardioembolic etiology.

aspirin

Which of the following fibrinolytic agents can be used in patients with acute ischemic stroke? A. Alteplase (recombinant tissue plasminogen activator) B. Streptokinase C. Urokinase D. Tenecteplase

Alteplase

A 70-year-old man is brought to the emergency department because of left-sided weakness for one hour. The patient reports that he suddenly could not move his left leg at home. The patient denies any history of a bleeding disorder, active bleeding, or recent surgery. His past medical history is significant for hypercholesterolemia, hypertension, atrial fibrillation, and tobacco abuse. Physical examination shows 5/5 strength in the left upper extremity and 1/5 strength in the left lower extremity. There is decreased sensation in the left leg and foot. A computed tomography scan of the brain shows no hemorrhages. Which of the following is the next best step in management? A. Alteplase B. Aspirin C. Clopidogrel D. Unfractionated heparin E. Warfarin

Alteplase Altepase is a tissue plasminogen activator (tPA). These medications should be given to patients with symptoms of stroke within 3-4.5 hours of initial onset.

A 75-year-old female with hypertension presents to the emergency room with one hour of slurred speech. Her symptoms resolve while she is waiting to see the physician. Which of the following tests is NOT part of the initial work-up for this condition? Electrocardiogram Non-contrast head CT scan Carotid doppler Transthoracic echocardiogram Ambulatory cardiac event monitor

Ambulatory cardiac event monito Any patient with a suspected transient ischemic attack (TIA) should undergo urgent evaluation due to the high risk of a subsequent stroke. Work-up should include ECG, non-contrast head CT, carotid doppler, and an echocardiogram.

A 45-year-old female comes to the emergency department because of a severe headache for 20 minutes. She states that she often gets headaches, but that this one feels different. Medical history includes hypertension. CT-scan is obtained. Lumbar puncture shows xanthochromia. Which of the following is the most likely vasculature associated with her condition? A. Anterior communicating artery and anterior cerebral artery junction B. Middle cerebral artery and internal carotid artery junction C. Middle meningeal artery D. Posterior cerebral artery and basilar artery junction E. Posterior cerebral artery and posterior communicating artery junction

Anterior communicating artery and anterior cerebral artery junction Subarachnoid hemorrhages are most commonly caused by ruptured berry aneurysms and bleeding arteriovenous malformations. The most common location for a ruptured berry aneurysm is the junction of the anterior communicating artery and anterior cerebral artery.

A 75-year-old woman comes to the emergency department because of weakness and hyperreflexia in her right arm and leg for the past hour. Neurological examination shows loss of right sided vibratory sensation and proprioception and deviation of the tongue towards the left. Which of the following vessels is most likely involved in this patient's condition? A. Anterior spinal artery B. Right middle cerebral artery C. Right anterior cerebral artery D. Left posterior inferior cerebellar artery E. Anterior communicating artery

Anterior spinal artery Medial medullary syndrome is caused by an infarct of the anterior spinal artery. Medial medullary syndrome is characterized by contralateral muscle weakness, ipsilateral tongue deviation, and contralateral loss of sensation from the body, sparing the face.

A 53-year-old man with a past medical history of hypertension and hyperlipidemia is hospitalized following an ischemic stroke. He is alert and responsive. On initial neurological exam, he is asked to stick out his tongue. He looks puzzled, as if he is trying very hard to follow the instruction but cannot. Two minutes later he sticks his tongue out spontaneously. Which of the following is the most likely diagnosis? A. Expressive aphasia B. Agnosia C. Astereogenesis D. Abulia E. Apraxia

Apraxia is a disorder of higher-order motor control leading to difficulty performing skilled movements. It is not due to a problem with the primary motor systems or due to a lack of understanding.

A 48-year-old man presents to the ER with a sudden-onset, severe headache. He is vomiting and appears confused. His wife, who accompanied him, says that he has not had any trauma, and that the patient has no relevant family history. He undergoes a non-contrast head CT that shows blood between the arachnoid and pia mater. What is the most likely complication from this condition? Blindness Arterial Vasospasm Hemorrhagic shock Bacterial Meningitis Renal failure

Arterial Vasospasm The patient has had a subarachnoid hemorrhage (SAH), and arterial vasospasm is the most common complication from this disease.

A 58-year-old man comes to the emergency department because of unresponsiveness for at least 15 minutes. He was found on the floor by his coworkers after they heard him fall down in his office. They performed CPR while awaiting emergency medical services. His medical history includes factor V Leiden mutation. Physical examination shows spastic paralysis of all four extremities and an inability to produce facial, mouth, or tongue movements. Glasgow coma scale score is 4, and it is determined that the patient is in a coma. Three days later, he exhibits vertical eye movement in response to questions and it is determined that the patient is conscious. Which of the following arteries is most likely infarcted? A. Anterior inferior cerebellar artery B. Anterior spinal artery C. Basilar artery D. Posterior cerebral artery E. Posterior inferior cerebellar artery

Basilar artery Locked-in syndrome is a condition caused by a stroke involving the basilar artery that is characterized by the preservation of vertical eye movement and consciousness in the presence of quadriplegia and loss of voluntary mouth, tongue, and facial movements. These patients are said to be locked in their paralyzed bodies.

A 47-year-old male presents to the emergency department with headache. He reports that he suddenly developed a throbbing, bitemporal headache about five hours ago "out of nowhere". He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines. The patient took his prescribed sumatriptan with no relief in his symptoms. The patient also endorses nausea, and he reports that he vomited once before arrival in the emergency department. The patient denies any recent trauma to the head. His past medical history is significant for migraines and hypertension. He has a 20 pack-year smoking history and a history of cocaine use. He drinks 5-6 beers per week. On physical exam, he appears to be in moderate distress and has pain with neck flexion. He has no focal neurologic deficits. A head CT is performed and can be seen in Figure A. This patient's condition affects which of the following spaces or potential spaces? A. Between periosteum and skull B. Between periosteum and galea aponeurosis C. Between skull and dura mater D. Between dura and arachnoid mater E. Between arachnoid and pia mater

Between arachnoid and pia mater This patient presents with a sudden, severe headache and a head CT showing bleeding in the subarachnoid space, which confirms a diagnosis of subarachnoid hemorrhage. The bleeding in a subarachnoid hemorrhage occurs between the arachnoid and pia mater.

Which of the following statements regarding carotid endarterectomy (CEA) is (are) true? A. CEA is indicated in the presence of a completed stroke B. CEA is indicated in the presence of a complete arterial occlusion C. randomized, controlled trials have established the benefit of CEA over standard medical therapy for the treatment of carotid artery stenosis D. CEA has been established as the treatment of choice in patients with a documented TIA and a tightly stenotic lesion greater than 70%

CEA has been established as the treatment of choice in patients with a documented TIA and a tightly stenotic lesion greater than 70%

________ imaging can detect ischemic changes in the brain 6-24 hours following the injury.

CT

__________________________ has been established as the treatment of choice in patients with a documented TIA and a tightly stenotic lesion greater than 70%

Carotid endarterectomy

In a patient with amaurosis fugax what is the most appropriate initial diagnostic study? A. Ophthalmoscopy B. Schiotz tonometry C. MR angiography D. Carotid ultrasound

Carotid ultrasound The most common cause of amaurosis fugax is an atherosclerotic plaque in the carotid artery which can be identified with ultrasound.

A 61-year-old man is sitting down the cardiology clinic waiting room when he falls to the left side of the chair onto the floor. He did not hit his head with the fall, but continues to have leg weakness. He has a DM type 2, and had a myocardial infarction two years ago. His medications include metformin, atorvastatin, lisinopril and aspirin. On physical examination his vitals are within normal limits, he is alert and oriented, and there is profound weakness and absent sensation of his entire left leg. He is taken to the emergency department for further management in consultation with neurology. Glucose level is 103 mg/dL, and a non-contrast head CT is negative for intracranial bleeding. What is the next best step in management? A. Serial neurologic exams every 2 hours B. Administer tissue plasminogen activator (tPA) C. Order MRI/MRA and diffusion weighted MRI to confirm diagnosis D. Consult neurosurgery for embolization of suspected ruptured aneurysm. E. Administer Morphine, Oxygen, Nitrates, and Aspirin

Cerebral infarction is a type of ischemic stroke caused by blockage of the cerebral arteries. Tissue plasminogen activator (tPA) may be used to dissolve a clot in the acute (<3 hours from onset) setting of ischemic stroke. This patient's presentation is highly concerning for an ischemic stroke (or cerebral infarction) in the anterior cerebral artery (ACA) which covers the motor and sensory to lower limbs. Ischemic strokes are due to blockage of cerebral vessels by three main mechanisms: thrombus formation, embolism, or global hypoxia.

A 74-year-old man is brought to the emergency department because of an acute onset of left arm paralysis and expressive aphasia. Medical history is significant for hypertension, coronary artery disease, hypercholesterolemia, and atrial fibrillation. Neurological examination shows left arm strength 2/5, hyperreflexia on the bicipital reflex, and intact sensation for temperature and pain. The patient's CT is shown. Which of the following is the most likely diagnosis? A. Brain tumor B. Cerebrovascular accident C. Epileptic seizure D. Sepsis E. Subarachnoid hemorrhage

Cerebrovascular accident is characterized by sudden onset of weakness, facial droop, or difficulty talking. On a CT scan, the area affected by the stroke is represented by a hypodense region of vasogenic edema with or without surrounding sulcal effacement and an hyperdense, occluded artery leading to the affected area.

A 60-year-old woman comes to the emergency department with the complaint of a severe headache, nausea, and sensitivity to light. Past medical history reveals a seizure disorder secondary to a left temporal A-V malformation. Soon after arriving to the emergency department, the patient develops loss of consciousness requiring endotracheal intubation. Vital signs reveal a blood pressure of 185/90 mm Hg. Which of the following is the most appropriate initial study to support the diagnosis for this patient? A. Magnetic resonance angiography of the head and neck B. Cerebral angiography C. Computed tomography of the head with contrast D. Computed tomography of head without contrast E. Magnetic resonance imagine of the head

Computed tomography of head without contrast An intracranial hemorrhage is simply bleeding within the skull. There are many causes of intracranial bleeding, including physical trauma or rupture aneurysm. Anticoagulant therapy and disorders with blood clotting increase the risk for intracranial hemorrhages. These hemorrhages are classified into two groups, intra-axial and extra-axial. This patient is suffering from a subarachnoid hemorrhage, or bleeding into the subarachnoid space. The initial study of choice in patients suspected of having a subarachnoid hematoma is computed tomography of the head without contrast. Once hemorrhage is identified by computed tomography, cerebral angiography should then be performed. If cerebral angiography is found to be negative, the next step is to perform an magnetic resonance of the head.

A 65-year-old man comes to the emergency department because of a sudden onset of aphasia and dysarthria for the past four hours. He has since developed left-sided hemiplegia. Patient's medical history is significant for hypercholesterolemia, hypertension, and diabetes mellitus type 2. Physical examination shows spastic hemiplegia with hyperreflexia on deep tendon reflexes in the left upper and lower extremities. CT scan without contrast shows no abnormalities. Which of the following imaging modalities would most likely detect a diffusion restriction within the brain at the earliest stage? CT perfusion Diffusion weighted MRI GRE/SWI T1 MRI T2 MRI

Diffusion weighted MRI (DW-MRI) is the imaging modality that detects ischemic stroke at the earliest, minutes within the initiation of the infarct.

________________ is obtained in all patients with acute ischemic stroke in whom cardiogenic embolism is suspected.

Echocardiography

(Thrombotic /Embolic) are caused by a blood clot or plaque debris that develops elsewhere in the body and then travels to one of the blood vessels in the brain through the bloodstream.

Embolic

(Thrombotic/Embolic) stroke is a type of ischemic stroke that involves obstruction of a vessel with a foreign body from another part of the body.

Embolic

Which of the following is the most important modifiable risk factor for ischemic stroke? A. Patent foramen ovale B. Oral contraceptive use C. Sickle cell disease D. Hypertension E. Sickle Cell Disease

Hypertension

A 75-year-old man comes to the emergency department because of inability to move his right upper and lower extremity after waking from a nap one hour ago. Physical examination shows mild aphasia and left-sided facial droop. A non-contrast head CT scan is obtained and reveals hypo-attenuation within the middle cerebral artery distribution. During physical examination the patient develops a sudden headache, right pin-point pupil and poor gag reflex with increased respiratory effort. Which of the followings is the most appropriate next step in management? A. Administer thrombolytic therapy B. Immediate intubation C. Immediate neurosurgical consultation D. Rapid nitroprusside infusion to reduce blood pressure E. Repeat stat CT scan without contrast

Immediate intubation An ischemic stroke may convert to a hemorrhagic stroke. Any patient with a mental status change and an altered respiratory drive with poor gag reflex requires evaluation of airway, breathing, and circulation with appropriate airway management.

A 69-year-old man comes to the office because of altered facial appearance for 2 hours. His wife states that they were eating dinner together, when she looked up and noticed her husband's face looked different. She thinks that his face appeared normal prior to starting dinner. The gentleman states that since eating his dinner, he feels nauseated and like he is on a boat. Medical history includes hypertension for which he takes enalapril. Examination shows a flattened left nasolabial fold and inability to smile on the left side. He is able to raise both of his eyebrows and wrinkle the skin of his forehead bilaterally. Which of the following is the most likely etiology of his condition? A. Idiopathic B. Infiltration C. Infection D. Inflammation E. Infarction

Infarction Facial nerve paralysis can be caused by upper or lower motor neuron lesions. Because of facial nerve anatomy, upper motor neuron lesions (such as ischemic stroke) characteristically have normal strength in upper facial muscles. In contrast, both upper and lower facial muscles are affected equally in lower motor neuron lesions. This man has had an acute cerebral infarction or stroke. This is suggested by his facial nerve paralysis affecting only the lower face, and by his associated symptom of vertigo.

A 26-year-old man who presents to the ED with sudden left side motor weakness which occurred during class. He also complains of headache, chronic fatigue, and excessive daytime sleepiness. Blood pressure (BP) was reported to be 197/145 mm Hg in the admission examination, but the patient had no history of taking medication for HTN. What is the most likely diagnosis? A. Thrombotic Stroke B. Embolic Stroke C. Subararchnoid Hemorrhage D. Intracerebral Hemorrhage

Intracerebral Hemorrhage

An abrupt onset of a focal neurologic deficit that worsens steadily over 30 to 90 minutes, altered level of consciousness, stupor, or coma. Headache, vomiting and signs of increased ICP. What is the most likely diagnosis? A. Thrombotic Stroke B. Embolic Stroke C. Subararchnoid Hemorrhage D. Intracerebral Hemorrhage

Intracerebral Hemorrhage

A 55-year-old African American man comes to the emergency department because of sudden weakness and numbness on the entire right half of his body. Medical history includes atrial fibrillation and type 2 diabetes mellitus. Examination shows diminished motor strength and sensory deficit in his right extremities. He is unable to follow verbal or written commands and repeat phrases. His speech, however, is spontaneous and of good quality. Which of the following is the most likely cause of the patient's symptoms? A. Intra-cerebral hemorrhage of the middle cerebral artery due to poor sugar control B. Intra-parenchymal hemorrhage due to rupture of the lenticulostriate vessels C. Intracranial hemorrhage into the subarachnoid space from disrupted vessel wall integrity D. Ischemia caused by blockage of the left inferior division of the middle cerebral artery E. Ischemia caused by blockage of the left superior division of the middle cerebral artery

Ischemia caused by blockage of the left inferior division of the middle cerebral artery Ischemic stroke is commonly caused by embolic disease due to atrial fibrillation. Another significant cause of an ischemic stroke is atherosclerosis. Right-sided motor and sensory deficits are caused by contralateral left-sided cerebral involvement which can include Wernicke and Broca area.

The role of computed tomography (CT) scanning within the first 24 hours of a stroke includes which of the following? A. to exclude hemorrhages B. to exclude tumors C. to exclude abscesses D. to diagnose stroke E. a, b, and c

Ischemic stroke changes usually will not show up on a CT scan or magnetic resonance imaging (MRI) scan within the first 24 hours. Therefore, the role of CT scanning is to rule out structural abnormalities such as hemorrhages, tumors, or abscesses.

A 70-year-old man is brought to the emergency department because of slurred speech, confusion, and weakness in his right side for the past hour. He has complete hemiparesis of his right upper and lower extremities. Patient's medical history is significant for hypertension, atrial fibrillation, and diabetes for the past 26 years. His temperature is 37.8°C (100°F), pulse is 100/min, respirations are 14/min, and blood pressure is 150/92 mm Hg. Oxygen saturation is 94% in room air. Physical examination shows a right-sided facial droop to the lower portion of his face, symmetric forehead wrinkles, and symmetric eyebrow elevation. Which of the following is the most likely diagnosis? A. Acute hemorrhagic stroke B. Acute ischemic stroke C. Bell palsy D. Complex hemiplegic migraine E. Subarachnoid hemorrhage

Ischemic stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurological function. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke. Acute ischemic stroke accounts for 80% of all CVAs, and is from embolism or local thrombosis. CT scan is used for evaluation of early hemorrhagic infarct or subarachnoid hemorrhage. Consider stroke in any patient presenting with acute neurological deficit or any alteration in level of consciousness. Common stroke signs and symptoms are abrupt onset of hemiparesis, monoparesis, or (rarely) quadriparesis, hemisensory deficits, monocular or binocular visual loss, visual field deficits, diplopia, dysarthria, facial droop, ataxia, vertigo, nystagmus, aphasia, and sudden decrease in level of consciousness. The goal for the emergent management of stroke is to complete the following within 60 minutes of patient arrival: assess airway, breathing, and circulation (ABCs) and stabilize the patient as necessary, complete the initial evaluation and assessment, including imaging and laboratory studies, and initiate re-perfusion therapy, if necessary. Ischemic stroke therapies include fibrinolytic therapy, antiplatelet agents, and mechanical thrombectomy.

A 78-year-old man comes to the emergency department because he crashed his car an hour ago. He says he is feeling confused and is unsure what caused him to swerve off the road. He denies a loss of consciousness. He says he had a lot of difficulties filling out his admission paperwork. Particularly, he found writing extremely difficult, and could not sign the document. His vital signs show no abnormalities. Physical examination shows a man with some minor bruises and scrapes. Neurological examination shows an inability to differentiate his left and right, to write, and to distinguish his fingers from one another. There is no further motor or sensory loss. In which of the following is the lesion most likely to be located? A. Left temporal lobe B. Left cerebellar hemisphere C. Left parietal lobe D. Left occipital lobe E. Left frontal lobe

Left Parietal Lobe Gerstmann syndrome is a lesion of the dominant inferior parietal lobe or parietal-temporal cortex and presents with agraphia, finger agnosia, acalculia, and right-left confusion. This man is exhibiting signs of Gerstmann syndrome. This syndrome results from a lesion of the dominant, usually the left, inferior parietal lobe. Most often this is caused by an infarction in this region, which is supplied by the middle cerebral artery and posterior cerebral artery. Ischemic stroke in this region is most commonly caused by atherosclerosis, embolism, and dissection. This syndrome is characterized by agraphia (inability to write), finger agnosia (inability to distinguish the fingers on the hand), acalculia (difficulty learning or understanding mathematics), and right-left confusion. This can be remembered using the mnemonic, "Gerstmann came from AFAR," Agraphia, Finger agnosia, Acalculia, and Right-left confusion. In addition to exhibiting the above symptoms, many adults also experience aphasia, which is a difficulty in expressing oneself when speaking, in understanding speech, or in reading and writing. Treatment of Gerstmann syndrome is largely supportive. Engagement with occupational therapists and speech language therapists may enable patients to reduce the burden of this illness on their daily life.

A 60-year-old man is brought to the emergency department because of right upper and lower extremity weakness and the inability to speak for the past day. Medical history is significant for hypertension and coronary artery disease. Physical examination shows that he is able to follow verbal commands, understands what you are saying to him, but patient is unable to form words. Further physical examination shows 3/5 strength in his right lower extremity, 0/5 strength in the right upper extremity, and 5/5 on the left upper and lower extremities. Which of the following arteries is most likely affected in this patient's condition? A. Internal thoracic artery B. Left middle cerebral artery C. Lenticulostriate arteries D. Posterior inferior cerebellar artery E. Right anterior cerebral artery

Left middle cerebral artery The left middle cerebral artery supplies the cortical motor output to the right side of the body, primarily the upper extremity, and it also supplies Broca area. It is important to know the blood supply to the different regions of the brain and the function of each part of the brain.

A 74-year-old man is admitted to the hospital after waking up with slurred speech and paralysis on the right side of his body. Paralysis is present on the left side of his face, his right arm, and his right leg. Neurologic examination reveals hyperreflexia on his right side and a positive Babinksi's sign on his right foot. His sensory examination was normal. An incident in which of the following areas of the brain likely caused these symptoms in the patient? A. Left dorsal medulla B. Left dorsal pons C. Left postcentral gyrus D. Left precentral gyrus E. Left ventral pons

Left ventral pons A lacunar infarct near the left ventral pons would likely affect the pyramidal portion of the corticospinal tract, which would affect muscle innervation on the contralateral, or right, side.

(Coagulative/Liquefactive) necrosis is seen following an ischemic stroke.

Liquefactive

A 77-year-old male with hypertension and a 46 pack year history presents to the Emergency Department from an extended care facility with acute onset headache, nausea, vomiting, and neck pain which began 2 days prior. He is alert, but his baseline level of consciousness is slightly diminished per the nursing home staff. He is immediately sent for an urgent head CT, which is normal. What is the most appropriate next step in his management? Brain MRI EEG Ultrasound (echoencephalography) Lumbar puncture Cerebral angiography

Lumbar puncture In a patient with high pre-test probability of aneurysmal subarachnoid hemorrhage with a normal head CT, a lumbar puncture is indicated to assess for xanthochromia.

A 68-year-old woman comes to the emergency department because of acute onset of generalized right body weakness and left-sided ptosis. Her medical history is relevant to type II diabetes, high blood pressure, and coronary artery disease. She currently takes dual antiplatelet therapy, telmisartan, and metformin. Physical examination shows right side hemiplegia, and her left pupil is pointed down and out. The patient claims to have problems while walking and that she stumbles easily. While watching her walk you notice a shuffling gait on her right leg. Her temperature is 36.7°C (98°F), pulse is 80/min, respirations are 16/min, blood pressure is 130/90 mm Hg. Which of the following areas is most likely damaged? A. Cerebellum B. Internal capsule C. Medulla D. Midbrain E. Pons

Midbrain The patient in the vignette is experiencing Weber's syndrome. Weber's syndrome (also known as superior alternating hemiplegia) is a rare midbrain stroke syndrome characterized by the presence of an ipsilateral oculomotor cranial nerve palsy and contralateral hemiparesis or hemiplegia. This condition is caused by a midbrain infarction as a result of occlusion of the paramedian branches of the posterior cerebral artery. This lesion is usually unilateral and affects several structures in the midbrain, such as oculomotor nerve fibers, substantia nigra, corticospinal fibers, corticobulbar tract. Given the anatomical disposition of tract fibers and the lesion, symptoms will be characteristically contralateral to the lesion. For example, damage to substantia nigra will result in contralateral parkinsonism because its dopaminergic projections to the basal ganglia innervate the ipsilateral hemisphere motor field, leading to a movement disorder of the contralateral body (i.e., right shuffling gait). Similarly, contralateral hemiparesis and upper motor neuron findings happen because it occurs before the decussation in the medulla. Lastly, patients present with ipsilateral oculomotor nerve palsy with diplopia and fixed wide pupil pointed down and out.

________________ is a calcium channel blocker commonly used to treat the vasospasm seen in subarachnoid hemorrhage two to three days after the injury.

Nimodipine

Which of the following is a classic symptom of subarachnoid hemorrhage? A. Seizure B. Aphasia C. Photophobia D. Numbness/weakness

Photophobia The hallmark of subarachnoid hemorrhage is the immediate onset of severe headache with signs of meningeal irritation. Individuals may describe this headache as their "worst ever." Nausea, vomiting, neck pain, and photophobia are also classic symptoms, although they are not always present. Neurological deficits may be acute or may manifest hours to days after the onset of the bleeding.

A 75-year-old man is brought to the emergency department because of bilateral visual loss and muscle weakness for the past 4 hours. The man has an extensive history of poorly controlled hypertension and does not recall any precipitating events to this episode. A physical examination shows visual loss in both eyes. He has a muscle strength of 1/5 in his right shoulder and thigh. Which of the following is the next appropriate step in management for this patient? A. Latanoprost B. Non-contrast computed tomography scan C. Brain natriuretic protein levels D. Tissue plasminogen activator E. Mannitol

Non-contrast computed tomography scan A watershed stroke is an ischemic stroke of the distant border regions where two arteries meet. These patients can experience bilateral vision loss and weakness in the thighs and shoulders. A non-contrast computed tomography scan should be the first step in management. A watershed stroke is used to describe an ischemic stroke of the border zones where the anterior cerebral, posterior cerebral, and middle cerebral arteries meet to form dual circulation. These border zones are known as watershed regions because that is where blood flow is at its lowest. Hence, patients with cardiovascular disease such as congestive heart failure, hypertension, and carotid artery stenosis are prone to suffering from watershed strokes due to the hypoperfusion of these locations. Ischemic watershed strokes will show up on magnetic resonance imaging or computed tomography imaging as a "wedge" appearance. Like other strokes, watershed strokes should be recognized using the FAST protocol (facial droop, arm weakness, slurred speech, and time to intervention). Patients with watershed stroke will classically show bilateral vision loss with weakness of the arms and shoulders. This is sometimes known as the "man inside the barrel" because of the sparing of the face, hands, and feet. Once recognized, the first step in management and diagnosis should be a non-contrast computed tomography scan of the head. This will rule out hemorrhagic stroke. Then, depending on the time frame and etiology, tissue plasminogen activator can be administered.

A 56-year-old man is brought to the emergency department because of sudden onset posterior cranium headache, acute vision loss, and confusion. Patient says he feels dizzy and with nausea. His son says that he has been bumping into objects since headache started. Patient rates the pain as a 9 on a 10-point scale. Medical history is significant for atrial fibrillation and hypertension. Physical examination shows a fixed, bilateral, homonymous visual-field cut. Which of the following is the most likely diagnosis? A. Anterior cerebral artery stroke B. Carotid stenosis C. Middle cerebral artery stroke D. Posterior cerebral artery stroke E. Vertebral artery atherothrombosis

Posterior cerebral artery stroke syndrome is a condition whereby the blood supply from the posterior cerebral artery (PCA) is restricted, leading to a reduction of the function of the portions of the brain supplied by that vessel: the occipital lobe, the inferomedial temporal lobe, a large portion of the thalamus, and the upper brainstem and midbrain. The most common long-term sequelae of PCA strokes are visual and sensory deficits.

A 72-year-old woman is brought to the emergency department because she fell suddenly while mowing the lawn. The patient says that she was in her garden when all of the sudden she felt dizzy, nauseous, and fell without losing consciousnesses. She has past medical history of hypertension, diabetes mellitus, atrial fibrillation, and atherosclerosis. Physical examination shows a right-sided ptosis, loss of lacrimation, and a pupil of 2 mm and minimally responsive to light. Her left eye shows no abnormalities. Neurological examination shows decreased sensation to pain and temperature on the right side of the face and left side of her upper and lower extremities, dysphagia, and ataxia. Which of the following arteries is most likely involved in her condition? A. Anterior cerebral artery B. Anterior spinal artery C. Left external carotid artery D. Middle cerebral artery E. Posterior inferior cerebellar artery

Posterior inferior cerebellar artery Occlusion of the posterior inferior cerebellar artery causes Wallenberg Syndrome (lateral medullary syndrome). Hallmark symptoms include hoarseness and dysphagia. Lateral medullary syndrome (also called Wallenberg syndrome and posterior inferior cerebellar artery syndrome) is a disorder in which the patient has a constellation of neurologic symptoms due to injury to the lateral part of the medulla in the brain, resulting in tissue ischemia and necrosis. This syndrome is characterized by sensory deficits affecting the trunk (torso) and extremities on the opposite side of the infarction and sensory deficits affecting the face and cranial nerves on the same side with the infarct. Specifically, there is a loss of pain and temperature sensation on the contralateral (opposite) side of the body and ipsilateral(same) side of the face. This crossed finding is diagnostic for the syndrome. Clinical symptoms include swallowing difficulty, or dysphagia,slurred speech, ataxia, facial pain, vertigo, nystagmus, Horner syndrome, diplopia, and possibly palatal myoclonus.

A 55-year-old right-hand dominant man presents with a 4-hour history of weakness and tingling of his right hand and numbness of the right side of his mouth. Mild difficulty was noted with word finding. His symptoms have improved since onset but have not fully resolved. There is no significant medical history. Physical examination revealed flat right nasolabial fold, subjective numbness of the right hand, right pronator drift, clumsiness of finger tapping on the right hand, increased deep tendon reflexes on the right, as well as a present Babinski. What is the most likely etiology for this patient's problem? A. migraine headache B. peripheral neuropathy C. syncope D. transient ischemic attack E. seizure

Question 4 Explanation: Three key features of a transient ischemic attack include sudden onset and complete reversal of symptoms within 24 hours, usually within 15 minutes. The symptoms are usually in the anatomical distribution of a single blood vessel. This patient's history is not suggestive of migraine or syncope. His physical examination findings do not correlate with peripheral neuropathy or seizure.

A 72-year-old woman comes to the emergency department with her son because he believes she suffered an ischemic stroke the night before. Physical examination shows left-sided spastic hemiplegia with hyperreflexia and Babinski sign. Sensation is intact throughout the body. Her right eye is turned down-and-out while the left side of her face is paralyzed below the eye. Tests of the pupillary light reflex show direct and consensual responses by the the right pupil and the left pupil is unresponsive and fixed. Which of the following is the most likely location of the lesion? A. Left sensory cortex B. Left thalamus C. Right midbrain D. Right thalamus E. Superior cervical ganglion

Right midbrain Stroke symptoms of spastic hemiplegia, hyperreflexia, and Babinski sign indicate an upper motor neuron lesion. Muscles of facial expression located below the eye receive innervation from only the contralateral cerebral cortex, and those above the eye receive innervation from both sides of the cortex.

A 55-year-old woman presents to the emergency department with a headache. She states that she felt a bad headache come on this morning while she was gardening and carrying heavy pots, and it has not been improving. The patient has a past medical history of hypertension and diabetes which is currently being treated by her primary care physician. Her blood pressure is 157/99 mmHg. Which of the following is the best explanation for the most likely diagnosis? A. Abnormal vascular tone in the CNS B. Dehydration and stress C. Hypersensitivity of the trigeminal nerve D. Muscular pain and strain E. Rupture of a berry aneurysm

Rupture of a berry aneurysm This patient is presenting with a sudden headache and blood in the subarachnoid space on head CT suggesting a diagnosis of subarachnoid hemorrhage (SAH), which commonly results from rupture of a berry aneurysm. SAH typically presents with a sudden onset "thunderclap" headache that is often described as the "worst headache of my life." Hypertension is a common risk factor. The diagnosis should be quickly confirmed with a non-contrast head CT. If the head CT is negative but SAH is still suspected, a lumbar puncture can help confirm the diagnosis (demonstrating xanthochromia). Patients should be referred to neurosurgery once the diagnosis is confirmed.

A 35-year-old male comes to the emergency department because of a stiff neck and vomiting. He states that these symptoms developed suddenly, while he was out for his daily run. Medical history is noncontributory. His temperature is 37.3°C (99°F), pulse is 87/min, respirations are 18/min, and blood pressure is 117/78 mm Hg. Examination shows a fit appearing man. A non-contrast CT-scan is obtained. Which of the following is the most likely diagnosis? A. Contusion B. Epidural hematoma C. Subarachnoid hemorrhage D. Subdural hematoma E. Meningitis

Subarachnoid hemorrhage Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space, the area between the arachnoid membrane and the pia mater surrounding the brain. While SAH commonly occurs in older people, it can affect people of any age.

A. 47-year-old woman presents to the emergency room with a stiff neck, photophobia, and an extremely severe headache that began while she was at the meet and greet social after Sunday church service . She states her symptoms came on immediately and she is in severe distress. What is the most likely diagnosis? A. Thrombotic Stroke B. Embolic Stroke C. Subararchnoid Hemorrhage D. Intracerebral Hemorrhage

Subararchnoid Hemorrhage

A 70-year-old man is brought to the emergency department because of left-sided weakness. The weakness began an hour ago, while at home, when he noticed that he was suddenly unable to move his left leg. Medical history is contributory for hypercholesterolemia, hypertension, and tobacco-dependence. Physical examination shows 0/5 strength in the left lower extremity and 5/5 strength in the left upper extremity. The left leg and foot also have decreased sensation. A CT scan of the brain shows no hemorrhage. Which of the following arteries is most likely affected by this patient's condition? Internal thoracic artery Lenticulostriate arteries Middle cerebral artery Posterior inferior cerebellar artery Right anterior cerebral artery

The right anterior cerebral artery is the blood supply to the right medial parietal lobe of the brain, and an ischemic stroke here leads to left-leg weakness and sensation deficit.

A 65-year-old man presents to the emergency department for a loss of vision. He was outside gardening when he suddenly lost vision in his right eye. He then immediately called emergency medical services, but by the time they arrived, the episode had resolved. Currently, he states that he feels fine. The patient has a past medical history of diabetes and hypertension. Cardiac exam is notable for a systolic murmur along the right sternal border that radiates to the carotids. A CT scan of the head demonstrates mild cerebral atrophy but no other findings. Which of the following is the next best step in management? A. Tissue plasminogen activator B. MRI C. Heparin bridge to warfarin D. Ultrasound of the neck

This patient is presenting with a transient ischemic attack (TIA) that has resolved. After the acute episode, the best next step in management is an ultrasound of the neck. Amaurosis fugax (a type of transient ischemic attack) presents with painless loss of vision from dislodged emboli. By the time these patients present, they often are asymptomatic and the episode has resolved. These patients should still receive a head CT/MRI to rule out any other abnormalities. After the acute episode, the next step in management is to perform ultrasound of the neck to search for plaques, since many emboli can originate at the bifurcation of the carotid.

Silent strokes typically (are/are not) detected with neuroimaging techniques.

are

(Thrombotic /Embolic) strokes are caused by a blood clot that develops in the blood vessels inside the brain. Often preceded by transient ischemic attacks (TIAs).

Thrombotic

____________ stroke is a type of ischemic stroke that involves clot formation directly at the site of infarction, typically over an atherosclerotic plaque.

Thrombotic

a 73-year-old male with a history of hyperlipidemia, tobacco use, and diabetes arrives at the ER with slurred speech. He was eating dinner with his daughter earlier that night when the symptoms began. She notes that he had a similar episode one year ago that resolved within an hour, as well as an episode of right arm weakness two months ago that resolved within 2 hours. His current symptoms resolve in the ED. His vital signs are as follows: T 99.6 F, BP: 146/96, HR: 76 and O2: 98% on room air. Physical exam reveals bilateral carotid bruits. What is the most likely diagnosis? A. Ischemic Stroke B. Hemorrhagic Stroke C. Transichemic Ischemic Attack D. Subarachnoid Hemorrhage E. Locked-In Syndrome

Transichemic Ischemic Attack

_______________ is seen on lumbar puncture of a patient with a subarachnoid hemorrhage.

Xanthochromia

The use of anticoagulation is clearly effective in preventing recurrent cardioembolic strokes from atrial fibrillation, a recent myocardial infarction, valvular disease, or a patent foramen ovale. Contraindications to the use of anticoagulation include which of the following? A. hemorrhage on CT scan B. large cerebral infarctions C. evidence of bacterial endocarditis D. a and b E. all of the above

a and b

TIA is most closely associated with which of the following? A. amaurosis fugax B. subarachnoid hemorrhage C. lacunar hemorrhage D. intracranial aneurysm E. fusiform aneurysm

amaurosis fugax A TIA usually represents thrombotic particles causing an intermittent blockage of circulation or spasm. Amaurosis fugax, which is described by patients as "a curtain coming down in front of my eyes—a blackout," may be a TIA of the ophthalmic artery. This is associated primarily with the carotid circulation and may also be manifested with contralateral weakness of the face, arm, and legs or numbness. In the situation of a patient with a noncardioembolic stroke or TIA, the use of aspirin (81 mg to 325 mg ), low-dose subcutaneous heparin, or both as well as statins is indicated. A complete workup, including CT scanning to exclude a hemorrhage, MRI, magnetic resonance angiography, and carotid Doppler imaging, is warranted to search for treatable causes of TIA. TIA is a medical emergency, and this group of individuals represent those at highest risk for development of an acute stroke. Those with a TIA have approximately three times the risk for development of an ischemic stroke than those who already have had a stroke, with 50% of the risk coming in the first 48 hours.

Stroke involving the _________ cerebral artery affects the motor and sensory cortices of the contralateral lower limbs, resulting in paralysis and sensory loss.

anterior

The most common site of saccular aneurysm rupture causing subarachnoid hemorrhage is at the junction of the __________ _____________ artery and anterior cerebral artery.

anterior communicating

Rupture of an _______________ plaque can cause a thromboembolic ischemic stroke.

atherosclerotic

Treatment of previous embolic stroke includes treatment of predisposing conditions such as ___________ _____________.

atrial fibrillation

Stroke involving the paramedian pontine reticular formation forces the eyes to look (toward/away from) the lesion.

away from

A Ruptured _______________ _______________ accounts for approximately 75% of nontraumatic cases of subarachnoid hemorrhage and has a mortality rate of 50%.

berry aneurysm

Ischemic stroke involves acute ________ of vessels and resulting ischemia.

blockage

45-year-old woman presents to the ED with acute painless loss of vision, photophobia associated with a smaller unilateral pupil on the involved side. Which of the following is the most likely diagnosis? A. central retinal vein occlusion (CRVO) B. iritis/uveitis C. retrobulbar hemorrhage or hematoma D. hyphema E. central retinal artery occlusion

central retinal artery occlusion Central retinal artery occlusion is characterized by acute visual loss usually attributed to ischemic or thrombus to the major retinal arterial blood supply.

Saccular aneurysmal ruptures that cause subarachnoid hemorrhage occur most frequently in the anterior half of the _____ _____ ______.

circle of Willis

Stroke involving the ________ lobe results in disinhibition, deficits in concentration, orientation, and judgment.

frontal

There are many sources of potential emboli that may cause a CVA. The most common source of cerebral emboli is which of the following? A. carotid arteries B. aortic arch C. heart D. vertebral¬basilar arteries E. middle cerebral artery

heart

The cerebral blood vessels most commonly affected by thrombotic stroke are the branching points of the ____________ ___________ artery, and the middle cerebral artery.

internal carotid

Thrombotic ischemic stroke causes a (red/pale) infarct.

pale

A 41-year-old woman presents to the emergency department complaining of a sudden onset of the "worst headache of my life." A stat computed tomography (CT) scan of her head is found to be normal. The next appropriate step in the diagnosis of this patient would be: A. outpatient magnetic resonance imaging (MRI) of the brain B. complete blood cell count (CBC) with differential C. injection of sumatriptan (Imitrex) D. lumbar puncture E. repeat CT scan in 48 hours

lumbar puncture The hallmark of a subarachnoid hemorrhage is the very sudden onset of a severe headache. The headache is often described as the "worst headache of my life." A CT scan will detect a subarachnoid hemorrhage in more than 95% of cases. When the history suggests subarachnoid hemorrhage and the CT scan fails to detect bleeding, a lumbar puncture is mandatory. The lumbar puncture will yield bloody cerebrospinal fluid in subarachnoid hemorrhage. Outpatient MRI or repeat CT scan in 48 hours would create a potentially harmful delay in diagnosis. CBC with differential may be ordered but will not confirm the suspected diagnosis. Treatment with Imitrex is contraindicated in the presence of a potential cerebrovascular syndrome.

Stroke involving the caudal (medulla/pons) affects the hypoglossal nerve, resulting in ipsilateral tongue deviation.

medulla

Strokes involving the lateral pons or _____________ may result in dysmetria, ataxia, and ipsilateral Horner syndrome due to involvement of cerebellar peduncles and sympathetic fibers.

medulla

Stroke involving a portion of the reticular activating system located in the ____________ may result in reduced levels of arousal and wakefulness, possibly resulting in a coma.

midbrain

Stroke involving the ___________ cerebral artery involves the motor and sensory cortices controlling the contralateral upper limb and face.

middle

The (anterior/middle) cerebral artery is most commonly affected by embolic ischemic strokes.

middle

Before tissue plasminogen activator can be administered for a stroke, (contrast/non-contrast) head CT should be performed to rule out hemorrhage.

non-contrast

A subarachnoid hemorrhage is a type of cerebral hemorrhage that presents with headache and ___________ ___________

nuchal rigidity.

The main difference between a migraine and subarachnoid hemorrhage is that subarachnoid hemorrhage has a (sudden/slow) onset.

sudden

Ischemic stroke risk can be reduced by optimizing control of blood pressure, blood _________ , and lipids.

sugar

Treatment for ischemic stroke includes __________ ___________ ____________ if given within 3-4.5 hours of symptom onset and no risk of hemorrhage.

tissue plasminogen activator

Stroke involving the frontal eye fields forces the eyes to look (toward/away from) the lesion.

toward

A 42¬year¬old white man presents to your office with a complaint of decreased vision that, with further questioning, he describes as "a curtain coming down over my eyes." The patient's past medical history included hypertension and hyperlipidemia, and he recently admitted to extensive use of cocaine. He denies intravenous drug use, vertigo, diplopia, ataxia, or an abnormal heart rate. If you had the choice of one test to help determine the etiology of his symptoms, what would that be? A. ultrasonography of the carotid arteries B. CT scan of the brain C. MRI scan of the brain D. lumbar puncture

ultrasonography of the carotid arteries This patient has had a TIA. Amaurosis fugax and his cocaine use may have contributed to this TIA. Cocaine probably caused an intense vasospasm; it is an intensely powerful vasoconstrictor, much more powerful than either angiotensin II or thromboxane. This patient needs an ultrasound examination of his carotid arteries, and he needs it soon. Treatment will be based on etiology, and a workup and consultation should be conducted quickly.

A 77 year old woman presents to the emergency department with the following signs and symptoms: dysarthria and dysphagia, vertigo, nausea, syncope, memory loss and disorientation, and ataxic gait. On physical examination, the patient has nystagmus, homonymous hemianopia, numbness in the area of the 12th cranial nerve, and facial weakness. You suspect a CVA. Which of the following arteries is most likely to be involved? A. middle cerebral artery B. posterior cerebral artery C. vertebral-basilar artery D. anterior cerebral artery E. posterior inferior cerebellar artery

vertebral-basilar artery This patient has had a CVA involving the vertebral-basilar system. The signs and symptoms of vertebral-basilar stroke are (1) dysarthria and dysphagia; (2) vertigo, nausea, and vomiting; (3) disorientation; (4) ataxic gait (ipsilateral cerebellar ataxia); (5) visual symptoms (double vision and blurred vision); (6) dysphagia; (7) ocular signs (nystagmus, conjugate gaze paralysis, and ophthalmoplegia); (8) akinetic mutism (locked¬in syndrome when basilar artery occlusion occurs); (9) numbness of lips and face; (10) facial weakness, alternating motor paresis; and (11) drop attacks, syncope (Doppler studies can detect vertebrobasilar embolic sources).