STROKE: #3 MCCOD in USA, TIAs are embolic

ICP Signs: HA, meningeal, vomiting, AMS, stupor, coma

Cortical Signs: aphasia, agnosia, neglect, apraxia, hemianopsia

-Contralateral motor & sensory loss of the leg

-Abulia (lack of will or initiation)
-Dyspraxia, emotional disturbance
-Urinary Incontinency
= ACA occlusion

1) Ischemic: Abrupt FNDs + no ICP

h/o TIAs, no HA, maintain consciousness
40% Ischemic embolic: s/s fluctuate
2/2 athlerosclerosis (HTN, DM2)
#1: AFIB
#2: ICA
#3: aorta
#4: ASD/PFO
30% Ischemic thrombotic s/s abrupt, multi-focal
2/2 atherlosclerosis, MCA
20% Ischemic Lacunar: small vessel thrombosis, <15mm
2/2 small vessel dz (MC), emboli, large vessel athlersclerosis (emboli)
@ BG (putamen, GP, thalamus, caudate)
@ Subcortical White (internal capsule, corona radiata)
@ Pons
2) ICH: Gradual FNDs --> ICP ssx
2/2 HTN, coagulopathy, vasospasm (drugs)
3) Spontaneous SAH: Abrupt ICP + no FNDs
2/2: rupture of betty aneurysm from AVM
tPA indicated if < 3-4.5h in an ischemic stroke
tPA contraindications:
3m stroke, h/o ICH, 14d surgery, seizure,
BP 185/110, platelets < 110, glucose < 50, INR > 1.7

-Contralateral motor & sensory impairment (face + arm + leg)

-Ipsilateral Gaze
-Ipsilateral Homonymous Hemianopia
-Left MCA: aphasia
-Right MCA: hemineglect, constructional apraxia
= MCA occlusion (lateral convex)
-Contralateral hemiplegia & ataxia
-Ipsilateral occulomotor (CN3) paralysis (down & out)
= Midbrain stroke
= (webers, benedikt, claudes, nothnagels, parinauds)

-Contralateral motor impairment (lower face + arm + leg)

-no sensory dfs
-no cortical dfs
-no visual dfs
-no speech dfs
= Lacunar infart of PLIC (anterior choroidal)

-Ipsilateral limb ataxia

-Contralateral eye deviation
-Paralysis of face, arm, leg
= Medial midpontine syndrome

Cerebellar Tumors
-ipsilateral ataxia
-nystagmus
-intention tremor

-Ipsilateral Trigeminal motor and sensory ssx

-Ipsilateral loss of muscles of mastication
-Ipsilateral loss of facial sensation
-Contralateral limb ataxia
= Lateral Pontine syndrome

-Gait ataxia and impaired limb coordination

(no paralysis, no CN defects)
= Cerebellar infarction

Carotid System
-temporary loss of speech
-contralateral limb paralysis or parasthesia
-contralateral clumbsiness
-Amaurosis Fugax (TIA):
transient curtan-like loss of sight in ipsilateral eye
2/2 microemboli to retina

Idiopathic ICP: obese women of childbearing age

tetracyclines, hypervitaminosis A
ssx: morning HA, transient vision loss, pulsitile tinnitus, diplopia
PHEX: ICP nerve sheath papilledema, peripheral vision loss, CN6 palsy
DX: MRI or LP w OP > 250
Tx: stop VitA or Tetracyclines, wt loss, acetazolamide
Epidural Hematoma: HA, confusion, somnolence, FNDs hours after trauma: leucid
interval, talk and die
SDH: trauma + old, bridging veins, HA, thunder-clap HA
MS: episodic numbness multi-focal, weakness, SPASTIC paraparesis, paresthesias, gait
abnormalities, vision dfs, bladder involvment
ALS: pure motor, UMN + LMN: weakness, df chewing, swallowing, cough, breath, DTRs,
spasticity, fasciculations
Cyclosporine: reversible HA, visual disturbances, seisure, tremors, akinetic mutism
Wilsons = Hepato-Lenticular degeneration (liver + basal ganglia)
ssx: resting TRAP + hepatitis + depression + hemolytic anemia
dx: liver bx, ceruloplasmin < 20, UCu excretion, KF rings
MG vs EL: Both: insidious, proximal, ptosis, diplopia
EL: DTRs, autonomics
MG: dysarthia
HIT: [hep + PF4 + IgG] + platelet
= (hep-PF4-IgG)~platelet
= platelet activation + hypersplenism
= thrombus + thrombocytopenia
HypoK: weakness, fatigue, muscle cramps, flaccid paralysis OR tetany, hyporeflexia,
rhabdomyolysis, arrythmias (<2.5)
EKG: flat T waves, U waves, ST depression, PVCs AFib, TdP, VFib
HyperK: ARF, rhabdomyolysis: sine wake EKG, Tx calcium gluconoate -> Insulin (takes 30
mins)

-Ipsilateral Horners (PAM)

-Ipsilateral loss of facial pain & temp sensation
-Ipsilateral palate, pharynx, vocal cords
-Ipsilateral cerebellar ataxia
-Contralateral body loss of pain & temp
= Lateral Medullary (Wallenberg)
-Contralateral hemiplegia & ataxia
-Ipsilateral cranial nerve involvement
= Vertebrobasilar occlusion
(aka brainstem / alternate syndromes)

Vertebrobasilar system
-decreased perfusion to posterior fossa
-dizziness, diplopia
-ipsilateral face numbness
-Contralateral motor paralysis (spastic hemiplegia) of arm & leg
-contralateral limb numbness
-Contralateral sensory loss of touch, vibration and proprioception
-dysarthia, hoarsness, dysphagia
-Ipsilateral tongue deviation
-projectile vomiting
= Medial medullary syndrome @ vertebrobasilar / assoc branches
-headaches
-Drop attacks

Subclavian Steal
Steels blood from ipsilateral basilar system

Gait
PD: festinating gait
Tabes: wide, clumbsy, foot-dropping gait
Hemiparesis: extended limbs, wide semicircular movments
DMD: waddling gait 2/2 gluteal muscle weakness + gowers
Tremor
-Intention Tremor: cerebellar disease, ataxia, dysmetria, gait
-Resting Tremor: PD, Wilsons, 5hz, with intention, legs + hands
-Bilateral, sparing legs, relieved by etOH, no FNDs: ET
-Physiologic Tremor 2/2 sympathetic, T3, GAD, coffee, +face, intention