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Flashcards in 17 - Stroke Deck (49):

What is a stroke?

Any disruption of blood flow to the brain


What looks like a stroke?

A LOT of things!

Tumors, others


Describe the epidemiology of strokes

Leading cause of disability worldwide

3rd cause of death in the US behind CAD and CA


What are the two types of stroke?

- Ischemia
- Hemmorrhagic


Describe an ischemic stroke

- Thrombosis (clot in brain - common)
- Embolic (clot thrown to brain)


Describe a hemmorrhagic strke

Lots of types – another lecture


What is a Lacunar stroke?

- Small stroke in deep penetrating arteries
- Fewer symptoms, better mortality


What is a TIA?

Transient Ischemic Attack


WHat is the old definition of a TIA?


Stroke-like symptoms that resolve in 24 hours….most in 3
- 10 % have a full stroke in 90 days
- TIAs can go home; strokes stay (basically if symptomatic in ER they stay)


What is the new definition of a TIA?


A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.


Who stays and who goes home?


Based on Age, BP, TIA symptoms, duration and diabetes – more points, higher chance of leading to stroke***



Give a case of a patient with a stroke that had to stay

High risk

84 y/o male with 2 earlier episodes of r hand weakness and difficult speaking that lasted a few minutes. PMH – htn, dm. Had short episode in ER.

CT of head negative, he stayed


What are the types of risk factors of a stroke?

- Thrombolic
- Embolic


What are the thrombolic risk factors of stroke?

- DM
- Vascular dz
- Sickle cell
- Smoking
- Age


What are the embolic risk factors of stroke

- A-fib
- Valve replacement
- MI
- Age


What is the differential diagnosis for a stroke?


- Seizure
- Hypoglycemia
- Metabolic d/o (low k, low Na)
- Encephalopathy
- Brain lesion
- Sepsis
- Medication
- Spinal cord issues


What are the signs and symptoms of a stroke?

- Weakness on one side
- Numbness on one side
- Issues with speech, thought, motion
- Balance problems
- HA
- Seizure
- Visual changes
- LOC (loss of consciousness)
- NOT syncope ***


Describe the case of myelitis

62 y/o female overweight but healthy/non smoker presents to ER c CP and weakness. Previous ER doc worked up – all negative and admitted (pt unable to ambulate)
When I arrived, paramedics begging me to go to the floor to evaluate
Bilateral weak and stiff and some anxiety
Mg/Phos/Sed Rate/CT head

Labs all fine/sed rate normal – new CT head read – radiologist states maybe tiny new lesion
Picture didn’t fit (Jacoby)


What are the speech deficits you can see?

Expressive or motor aphasia
Receptive aphasia


Describe an expressive or motor aphasia

Expressive or motor aphasia (can think of word but hard to get out)


Describe a receptive aphasia

Receptive aphasia (can’t think of the words or sentence…speech clear but doesn’t make sense)


What does the EMS crew do in the case of a suspected stroke?

Identify possibility of CVA
r/o other possibilities w/in their scope
BS, Narcan, vital signs
Stabilize/rapid transport
Notify hospital


WHat does the ER crew do in the case of a stroek?

Quick history and physical
Immediate head CT
Basic labs including coags


What is the ONLY widely used treatment for ischemic stroke?


The only widely used treatment for the treatment of ischemic stroke is THROMBOLYTICS ***


Describe the reasoning for a head CT

To make sure that a bleed isn’t the cause of the stroke
A bleed will be transported to center (or ICU) to watch/wait or have surgery (neurosurgery)


What can you see on a head CT?

- A new bleed
- A tumor or abscess
- A stroke that is 6-48 hours old or a huge stroke may show up sooner


Describe the use of thrombolytics


Once you decide via CT that the pt does not have a bleed, abscess or tumor… Then the decision to give thrombolytis needs to be made


Why do we use TPA?

Does NOT decrease mortality

INCREASES risk of bleed

We use it to decrease the DEFICITS that result from a stroke


Describe the specific risks of TPA

- Clot buster for the treatment of stroke
- 30% increase in good neuro outcome at 3 months
- Mortality the same
- 6% chance of bleed compared to .6% if no TPA


What is the stroke window?


There is a 3 hour window from the start of symptoms to start thrombolytics

This window can be extended to 4.5 hours to those under 80, not on a thinner,NIH Stroke Scale


Who cannot get TPA?


Bleed, tumor, huge stroke on CT with mass effect, brain swelling

More than 3 (to 4.5) hours from onset of symptoms (have to be precise – nap/going to bed starts the clock)


What are other exclusions for giving TPA?


- Resolving symptoms or minor symptoms ***
- h/o brain bleed or bleed d/o
- Ischemic stroke or severe head trauma w/in 3 months
- BP >185/110 (treating to get there okay)


What are some more exclusions for giving someone TPA?


- Recent MI, surgery or LP
- H/O brain vascular issue
- Pregnancy
- GI bleed w/in 3 wks
- Glucose 1.7 ***
- On heparin with increased PTT


Who's left? Who can get TPA?

Rare to have a patient who can jump through all of those hoops

Nothing acute on CT, meet time standards, not a bleeder, not too sick or too few symptoms


What percent of ischemic stroke patients get TPA?

In US,


Describe the reasoning for "the window"

- While most hospital now have a 4.5 hour window (based on AHA/ASA guidelines)– the FDA has NOT approved this.
- Overall, for every 100 patients treated within the first 3 hours, 32 had a better outcome as a result and 3 had a worse outcome
- Overall, for every 100 patients treated within the 3 to 4.5-hour window, 16 had a better outcome as a result and 3 had a worse outcome.[2]


What happens to a new stroke patient in the hospital?

- MRI (better look at brain)
- 2D Echo (clots/holes in heart)
- Carotid echo
- Evaluate risk factors (lipids, DM, etc..)
- Swallow study
- PT/OT/Speech


Not going to ask this... But, where is the lesion in stokes?

- Anterior Cerebral – opposite arm and leg
- Middle cerebral –opposite face, arm possibly leg
- Posterior cerebral – few symptoms
- Veterbrobasilar – (cerebellum, brain stem, visual cortex) dizzy, vertigo, CN palsy on same side possible symptoms opposite motor


What is the most common area of strokes to occur?

Posterior area of internal capsule
- Opposite paralysis
- Opposite lower face paralysis


What is the stroke mortality rate in the hospital?

- SAH – 31.9 (bleed)
- ICH – 25.6 (Bleed)
- IS – 6 (ischemic)


What is the morbidity seen in stroke patients following the stroke?

- 72% Independent at d/c
- If they drove prior, 50% drove 30 days later


What are the overall outcomes of stroke patients?

4264 patients with IS at 100 day f/u

13.9% died
53% functionally independent
33% depressed
Stroke 2002


Describe young adults who experience a stroke

Age 15-45
7% sz first year
4.5% mortality
22% smokers quit


Describe the cause of strokes in young adults

Stimulants a frequent cause in 18-44 y/o
Meth increases risk of hem. stroke 5X
Cocaine increases risk of both kinds of stroke 2X


What can you do in urgent care or your office if you suspect a stroke?

- Call 911
- Check BS
- Start IV
- TALK to the ER doctor
- Send records
- Educate patient


What is coming next in the research and development for strokes?

Multimodal CT – regular head CT, CT angio of head and neck and a perfusion CT. This can give information about brain tissue which can potentially come back and open the 3 hour or 4.5 hour window


What is intra-arterial TPA?

- Extend the window of treatment options out past 6 hours.
- Recent trials in US stopped, initial studies showed similar outcomes to IV TPA


Describe a mechanical thrombectomy

- Many different types
- Meri-Clot retriever – uses coil to unscrew clot (57% open up clot, 69% with TPA added)
- Penumbra – aspiration of clot (opens clot 81%)


Describe the possibility of an angioplasty and stenting in the brain

Technically difficult
Very small studies

Note –– just because you can open up artery doesn’t mean you’ll get function back – heart seems more forgiving than the brain