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Neuro II Exam 2 > 4-4 Stroke > Flashcards

4-4 Stroke Flashcards

(69 cards)

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1
Q

How frequent is stroke? How often is it deadly?

A
  • Third leading cause of death in the US (~6% of all deaths)
  • Incidence of strokes is 795K a year in the US (180K of them are recurrent strokes)

–1 stroke every 40 seconds in average

  • Prevalence—6.5 mln people with h/o stroke
  • Death rates from strokes per 100,000

–44.7–for white males

–70.5 for black males

–44.0 for white females

–60.7 for black females

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2
Q

What is the leading cause of long-term disability in the US?

A

stroke

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3
Q

What is the mortality after a stroke?

A

•Mortality after strokes—14-27% depending on age/gender/race

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4
Q

What is the cost of stroke in the US?

A
  • The estimated direct and indirect cost of stroke for 2009 is $68.9 billion.
  • The mean lifetime cost of ischemic stroke in the United States is estimated at $140,048.
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5
Q

What is a CVA?

A
  • Cerebrovascular Accident (C.V.A.)
  • Abrupt onset of a neurological deficit that is attributable to a focal vascular cause
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6
Q

What are the 2 major types of stroke? What is the relative prevalence of each?

A

•2 major types of stroke:

–Hemorrhagic stroke (caused by cerebral hemorrhage )

•15% of all strokes

–Ischemic stroke (caused by cerebral ischemia)

•85% of all strokes

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7
Q

Describe the ischemic cascade in terms of neurons, cell injury, and severity.

A
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8
Q

Describe the cascade of bad that happens following a vascular infarct in the brain, over the course of seconds - minutes - hours - days - weeks.

A
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9
Q

What is a ‘penumbra’?

A

•Brain tissue surrounding the cerebral necrosis that exhibit reversible ischemic changes

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10
Q

Name some causes of ischemic stroke under an embolism etiology.

A

Causes of Ischemic Stroke

Embolism:

Arterial: Carotid or Aorta

Heart: Atrial Source, Ventricular Source, or Valvular Lesions

Paradoxical Emboli

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11
Q

Name some causes of ischemic stroke that do not fall under an etiology of large artery thrombosis, embolism, or lacunar cause.

A

Causes of Ischemic Stroke, “Other” Category:

Watershed infarcts

Hypercoagulable disorders

Vasculitis

Vasospasm

Dissection of Artery

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12
Q

How do large artery thrombosis occur?

A
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13
Q

What are the types of emboli?

A

Type dependent on origin:

–Originating from an atherosclerotic plaque

–Originating from thrombus

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14
Q

What are the main sources of emboli?

A

•Source of emboli

–Heart

–Artery to artery

–Lower extremity DVT with paradoxical emboli

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15
Q

What are some atrial sources of cardiac emboli?

A

–Atrial Fibrillation/Flutter

–Atrial septal aneurism

–Atrial tumors (myxoma)

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16
Q

How does a-fib lead to thrombus formation?

A

•Fast and ineffective atrial contraction leading to stasis and thrombus formation

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17
Q

What is an atrial septal aneurism?

A

•Weakening and out-pouching of interatrial septum, leading to stasis and thrombus formation (mural)

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18
Q

How are atrial septal aneurisms classified?

A
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19
Q

How do atrial myxomas contribute to embolus?

A
  • Pieces of tumor may tear off and become emboli
  • Associated thrombus can embolize artery down the stream
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20
Q

What are some ventricular sources of cardiac emboli?

A

–Cardiomyopathy

–Myocardial Infarction

–Ventricular aneurisms

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21
Q

How does cardiomyopathy contribute to emboli?

A

•Weak and dilated ventricle isn’t pumping efficiently leading to blood stasis and thrombus formation

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22
Q

How does MI lead to emboli formation?

A

•Part of the wall is not moving creating stasis and leading to mural thrombosis

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23
Q

What are 7 valvular sources of cardiac emboli?

A

•Valvular source

–Rheumatic mitral stenosis

–Prosthetic valves

–Infective and non-infective endocarditis

–Nonbacterial thrombotic (marantic) endocarditis associated with malignancies and prothrombic states

–Calcification of valves

–Bicuspid aortic valves

–Inflammatory valvulitis (i.e., Libman-Sacks endocarditis, Behcet Disease, Syphilis)

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24
Q

What is an example of artery to artery embolic infarcts? What increases the risk of stroke in this instance?

A

•Carotid Artery atherosclerosis/stenosis

–Causes 5% of all strokes

–The tighter the stenosis the higher risk of stroke

–May cause embolic or thrombotic type of strokes

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25
What is a paradoxical emboli?
* Originate from the L.E. deep veins * “Hole” in the heart between left heart and right heart
26
Where do lacunar infarcts occur?
•Forms in subcortical areas of brain supplied by small deep penetrating arteries arising from the big arteries
27
What are lacunar infarcts often due to?
•atheroemboli or lipohyalinosis
28
What is a major risk factor for lacunar infarcts?
* 15-25% of all ischemic strokes * Hypertension is a major factor * Frequently asymptomatic
29
What is lipohyalinosis?
* High pressure of large arteries transmitted to small arteries * Hyperplasia of small vessel walls * Hyalinization of the vessel walls * Narrowing and then occlusion of the lumen
30
What are watershed infarcts?
•Ischemic infarct of the areas farthest from the large arteries
31
Why are watershed infarcts common? What causes them to develop?
* The most sensitive areas when perfusion decreases * Develops with conditions causing hypotension –Sepsis –Severe bleeding –Severe dehydration etc.
32
Name the areas of major watershed infarcts.
33
What is hemostasis typically a balance of?
•Hemostasis system consist of 3 parts that are normally in the state of homeostatic equilibrium –Coagulation system –Anticoagulation system –Thrombolytic system
34
Try to talk through the anti-coagulation system.
35
What are hypercoagulable disorders? What type of clotting do they promote?
* Disorders that promote coagulation over anti-coagulation * Most of them cause venous clotting more than arterial clotting due to slower venous flow
36
Name some hypercoagulable disorders.
* Factor V Leiden mutation (most common) * Protein C deficiency * Protein S deficiency * Antithrombin deficiency * Plasminogen deficiency * Prothrombin gene mutation
37
What are some disorders that are more likely to cause arterial clotting?
•Antiphospholipid antibody syndrome –Anticardiolipin antibodies (ACA) –Lupus anticoagulants (LA) •Hyperhomocysteinemia
38
In addition to diseases, what can also cause hypercoagulable states?
* Cancer (pancreatic, lung) * Pregnancy and exogenous estrogen use (including use of oral contraceptive pills-birth control pills) * Hormone replacement therapy * Prolonged bed rest or immobility, heart attack, stroke and other illnesses that lead to decreased activity * Myeloproliferative disorders such as polycythemia vera or essential thrombocytosis
39
How can vasospasm cause stroke?
•Vasospasm – mostly with subarachnoid bleeding, cocaine use
40
What is Moyamoya disease?
Moyamoya disease—poorly understood occlusive disease involving large intracranial arteries that can cause stroke
41
What does stroke presentation depend on?
•Depends on –Size of the affected vessel –Area of the brain supplied by the affected vessel
42
# Define the following terms: Hemiparesis Hemiplegia Homonymous hemianopsia Acalculia Agnosia
* Hemiparesis – weakness of one side of the body * Hemiplegia – complete paralysis of one side of the body * Homonymous hemianopsia (hemianopia) -- loss of vision in the same visual field of both eyes * Acalculia – difficulty to perform simple math tasks * Agnosia -- inability to recognize objects, persons, sounds, shapes, or smells
43
# Define the following terms: Aphasia Alexia Agraphia Dysgraphia Dysarthria
* Aphasia – inability to speak (motor or sensory) * Alexia – inability to read * Agraphia – inability to write * Dysphagia – difficulty swallowing * Dysarthria – slurred speech
44
# Define the following terms: Hemispatial neglect Apraxia Anosognosia Anomia Ataxia
* Hemispatial Neglect -- inability to attend to one side of the body or visual field * Apraxia – inability to perform a specific task * Anosognosia -- unawareness of or denial of the existence of disability * Anomia – difficulty with recalling words or names * Ataxia – unsteady gait
45
What is middle cerebral artery syndrome? What are the SSXs?
* Contralateral hemiplegia/sensation loss (sometimes in face and upper extremity only) * Contralateral Homonymous Hemianopsia * Dominant side: –Aphasia, alexia, agraphia, acalculia, finger agnosia, and right-left confusion. •Non-dominant side: –Unilateral neglect, dressing apraxia, anosognosia, and constructional apraxia
46
What are the SSXs of anterior artery syndrome?
•Contralateral sensory and motor loss of lower extremity
47
What are the SSXs of posterior cerebral artery syndrome?
* Homonymous hemianopsia * Alexia without agraphia * Visual or color anomia
48
What is lateral pontine syndrome? What are the SSXs?
* Anterior inferior cerebellar artery * Ataxia - arm and leg * Weakness - upper and lower extremity * Hemisensory loss - pain and temperature
49
What are the SSX of Lateral Medullary Syndrome?
Wallenberg Syndrome * Posterior inferior cerebellar artery infarction * Facial sensory loss and pain * Ataxia * Nystagmus * Vertigo * Hoarseness * Dysphagia * Horner syndrome * Hemisensory loss * Hiccups
50
What are some conditions that can result from basilar artery strokes?
Locked-in syndrome * Lateral pontine syndrome (Marie-Foix Syndrome) * Ventral pontine syndrome (Raymond Syndrome) Ventral pontine syndrome (Millard-Gubler Syndrome) * Ataxic hemiparesis * Cortical blindness (Anton Syndrome)
51
What are the SSXs of Locked-In Syndrome?
•Locked-in Syndrome –Quadriplegia, bilateral facial paralysis, dysarthria
52
What are the SSXs of Raymond syndrome?
•Ventral pontine syndrome (Raymond Syndrome) –Lateral gaze weakness –Contraletaral hemiplegia
53
What are the SSXs of Millard-Gubler Syndrome syndrome?
•Ventral pontine syndrome (Millard-Gubler Syndrome) –contralateral - upper and lower extremity weakness –Ipsilateral facial weakness
54
What are the SSXs of ataxic hemiparesis?
•Ataxic hemiparesis –Contralateral upper and lower extremity weakness and ataxia
55
What are the SSXs of Anton Syndrome?
•Cortical blindness (Anton Syndrome) –(blindness and denial)
56
In addition to focal deficits, what are some other SSXs of stroke?
* Headache * Nausea/Vomiting * Stupor/coma/amnesia/confusion/delerium
57
What is amaurosis fugax? What are the causes?
* Transient mono-ocular blindness * Often warning sign of an impending stroke * Several causes –Embolic (most often from carotid artery of the same side) –Hemodynamic –Ocular –Neurologic –Idiopathic
58
What is a TIA? What are the risks involved?
* A.K.A “mini-stroke” * The same symptoms (and etiology) as with stroke but lasting less than 24 hours * 15-40% of TIA results in infarcts * Patients with TIA have 10% risk of CVA within first 3 months
59
How is a stroke Dx'ed?
•History –Sudden onset –Symptoms described above * Complete neurological and mental status exam * CT of brain (without contrast) is quickest way. Only detects big strokes. R/O bleed * MRI of brain is very sensitive
60
How is the cause of a stroke assessed?
* History –Looking for risk factors * Lipids, blood glucose, cardiac enzymes * EKG –Arrhythmia, MI * Echocardiogram (transthoracic or trans-esophageal) –Intracardiac thrombosis, cardiomyopathy, valvular disorders, ASD * Carotid Doppler –Carotid stenosis * MR-A/CT-A
61
What are some DDXs of ischemic stroke?
* About 15-20% of patients with stroke like presentation * Hemorrhagic stroke/subdural hemorrhages * Seizures * Complex Migraines * CNS tumors * Nerves palsy, peripheral neuropathy * Encephalitis * Toxic metabolic encephalopathy * Syncope * Vertigo
62
The acute Tx of stroke involves what?
•Medications –rtPA (intra-venous and intra-arterial) –Aspirin * Iv-fluids * Keep Blood Pressure sufficient for saving penumbra but not too high * Swallowing evaluation * Early rehabilitation
63
What are the non-modifiable stroke risk factors?
* Age. –Risk doubles with each decade after 55 * Heredity (Family history) * Race –African Americans and Hispanics higher than Caucasians * Gender –More men has strokes in a given year in each age group –More than half of total stroke deaths occur in women •Personal h/o TIA, CVA, MI, any atherosclerosis
64
What are the modifiable stroke risk factors?
* Hypertension (increases risk 2-5 times) * Atrial Fibrillation (increases risk 2-3 times) * Smoking (increases risk 2 times) * Diabetes (increases risk 2-6 times) * Carotid stenosis (increases risk 2 times if no previous TIA or CVA) * Hyperlipidemia (increases risk 2-2.5 times)
65
What are the modifiable stroke risk factors?
* Physical inactivity and obesity * Alcohol and drug abuse * Geographic location –US South-East has more strokes •Socioeconomic factors
66
What can be done to prevent strokes?
•Diet –Low in saturated fat •Exercise –Aerobic exercises 30 min a day 3-5 days a week * Strict control of Blood Pressures, Blood sugars, blood cholesterol * Quit smoking
67
What are the stroke prevention meds?
•Antiplatelets agents –Aspirin –Clopidogril (Plavix) –Aspirin/dipyridamole (Aggrenox) •Anticoagulation agents –Warfarin (Coumadin) –Heparin and LMWH
68
What are the Tx options for carotid aa stenosis?
* Depends on degree of stenosis and on h/o CVA * Medical treatment (treat risk factors) * Surgical treatment with carotid endarterectomy * Stents –only for lesions not reachable with surgical approach –Patients have high surgical risk
69

Neuro II Exam 2 (4 decks)

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