10-25 Stroke

Question 1

Stroke Warning Signs

Answer 1

—Sudden weakness or numbness of the face,
arm or leg, especially on one side of the body
—Sudden confusion, trouble speaking or understanding
—Sudden trouble seeing in one or both eyes
—Sudden trouble walking, dizziness, loss of
balance or coordination
—Sudden, severe headache with no known
cause

Question 2

Stroke Mimics

Answer 2

 Seizures 
 Brain tumors 
 Migraine 
 Hysteria 
 Inner ear disorders (vestibulitis) 
 Hypoglycemia 
 Hypotension/severe hypertension 
 Multiple sclerosis

Question 3

DWI vs PWI

Answer 3

diffusion weighted vs. perfusion weighted
—diffusion weighted shows infarction
—PWI shows penumbra

Question 4

possible targets of neuroprotective therapy

Answer 4

 Prevention of early ischemic injury
 Prevention of reperfusion injury
 Prevention apoptosis and promotion of repair,
regeneration
**all have failed so far, but ETHANOL maybe!

Question 5

Time limit for tPA

Answer 5

3 hrs

Question 6

Intra-arterial thrombolysis Time window

Answer 6

6 hrs

Question 7

Mechanical devices to remove clot Time window

Answer 7

8 hrs

Question 8

Prevention of Stroke (In order of effectiveness?)

Answer 8

¡¡¡Warfarin for atrial fibrillation!!!

 Carotid endarterctomy for symptomatic dz
 Smoking cessation
 Antihypertensive therapy if BP elevated
 Statins if cholesterol elevated
 Aspirin

Question 9

Risk Score for Stroke?

Answer 9

Modified Framingham Stroke Risk

1. Age
2. un-tx’d SBP
3. Tx’d SBP
4. H/o DM
5. Smoking
6. CVD
7. A. fib
8. LVH on EKG

Question 10

Causes of Hemorrhagic Stroke

Answer 10

A) Subarachnoid hemorrhage 
1. Aneurysms (berry, e.g.)
2. Trauma (more commonly here)
3. Drugs 
B) Intracerebral hemorrhage 
1. Small artery disease/Hypertension (MOST COMMON HEM STROKE)
2. Anticoagulants (esp subdural; iatrogenic or natural)
3. Trauma 
4. Bleeding disorders 
5. Tumors 
6. Aneurysms (Berry)/AVMs

Question 11

Prevention of Hemorrhagic Stroke

Answer 11

 Prevent inappropriate anticoagulation
 Control BP and smoking
 Prevent head injuries and illicit drug use

Question 12

Important Differences between MI and CVA

Answer 12

a. Painful vs. no pain and often poor awareness b. Public recognizes symptoms and need for action vs poor recognition of symptoms and need for action
c. Bleeding into the heart doesn’t occur vs brain hemorrhage is common
d. Diagnosis is easy using EKG and cardiac enzymes vs there is no easily available “stroke-o-gram”
e. Cause is in-situ plaque rupture vs causes are numerous!

Question 13

transient monocular blindness (TMB; amaurosis fugax)

Answer 13

dimunition or loss of vision in one eye that:
—comes on quickly (secs)
—lasts 1-5min
—resolves over 12-20 mins
SWENSON: “Acute development of neurologic symptoms due to ischemia that completely resolve within 24 hours.”

Question 14

transient ischemic attack

Answer 14

—resolves fully w/o no residual sx after 1 hr
—tx goal: prevent full blown stroke
—work-up: CBC, PT, aPTT, ESR syph, glucose, EKG, DWI or CT; consider angio or doppler of carotids
—tx: don’t lower BP; heparin, ASA/clopidogrel, statins; carotid endarterectomy > stenting

Question 15

do terms on website

Answer 15

http://www.dartmouth.edu/~dons/part_3/chapter_27.html

Question 16

How common is stroke?

Answer 16

Over 750,000 people have strokes per year (it is the #3 killer).

Question 17

What % of stroke = ischemic?

Answer 17

~80%

Question 18

What are potential sites of emboli to the cerebral circulation?

Answer 18

arteries, heart and aorta
—major % from plaques in the aorta, carotids or vertebrobasilar arteries
—Cardiac sources include a.fib, severe valvular dz (incl endocarditis), CHF (or ventricular dyskinesia, with blood pooling + clotting), or recent MI
—Emboli may also pass from the venous side to the arteries via right to left shunts (such as a patent foramen ovale)

Question 19

Risk factors for small vessel dz + TX

Answer 19

—Lipohyalinosis is the most common pathology and HTN, DM and age are main risk factors.
—Vasculitis and stimulant abuse are other causes.
—If vasculitis/substance abuse — tx that, otherwise anti-platelets. no real definitive therapy

Question 20

Lipohyalinosis

Answer 20

Lipohyalinosis is a small-vessel disease in the brain characterised by vessel wall thickening and a resultant reduction in luminal diameter

Question 21

Risk Factors for large vessel dz + tx

Answer 21

—large vessel disease = atherosclerosis
—RFs incl: HTN, hyperlipidemia, fam Hx, age, smoking and homocystinemia.
—Tx = platelet antagonists, folic acid (helps decrease homocysteine), and carotid endarterectomy (if there is high grade carotid stenosis)

Question 22

What are some causes of stroke due to increased viscosity of the blood?

Answer 22

—severe dehydration
—dysproteinemias
—polycythemia
—thrombocytosis
—leukocytosis (rarely and with severe elevations such as leukemia).

Question 23

Major risk factors for stroke

Answer 23

hypertension, age, cardiac disease, heredity, smoking, DM, hyperlipidemia, obesity, homocysteinemia (remember folate/B12/B6), hyperviscosity, alcohol excess, hypercoaguable states, sedentary lifestyle.
—OCPs may in young women, particularly if they are a smoker, with migraine. The stroke may be due to venous thrombosis of the sagittal sinus.

Question 24

What major factors prevent the development of stroke with occlusion of cerebral blood vessels?

Answer 24

collateral circ

Question 25

What are the stages of recovery from stroke?

Answer 25

—Recovery from stroke may be complete or incomplete. Some tissue is functionally damaged but not killed (ischemic penumbra) and this area may recover early on. —There is some redundancy of function and other areas can take over. There is some resolution of cytotoxic edema (not treatable by steroids). —There is some plasticity, even in the adult brain and this can be encouraged by rehabilitation. While there may be new neurons produced, we are not sure whether they are functionally important. —Later recovery involved compensation, when other methods of recovery fail. Compensation requires recognition of deficits and the ability to incorporate strategies to get around the deficits.

Question 26

How can ischemic stroke result in death?

Answer 26

—cytotoxic edema, with swelling and ultimate brain herniation (this swelling can not be treated with steroids although osmotic agents may temporarily help) —subsequent hemorrhage due to weakening of the blood vessels in the damaged tissue. —complications of general debility (pneumonia, pulmonary emboli, poor nutrition, decubiti).

Question 27

What are the therapeutic options for a stroke in progress?

Answer 27

Aspirin and oxygen may be helpful. Do not lower blood pressure excessively. —Thrombolysis may be effective in treating patients in the very acute stage (less than 3 hours from the moment of onset). —Cytoprotection under investigation

Question 28

Causes of stroke chez les jeunes

Answer 28

hypercoagulability or hyperviscosity, arterial dissection, cardiac abnormalities or paradoxical embolism (through right to left shunt).

Question 29

What major factors prevent the development of stroke with occlusion of cerebral blood vessels?

Answer 29

collateral circ