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CSI > stroke > Flashcards

stroke Flashcards

1
Q

can do what in 5 secs of walking in room

A 
ABCs (pt speaking)
when did this start?
-if woke up with stroke not eligible for tPA
-vitals: BP!
-oriented/confused
-family present
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2
Q

if on coumadin

A

not candidate for tPA

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3
Q

family can…

A

sign for tPA consent

verify onset

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4
Q

stroke vs. bells

A

stroke spares the forehead, can wrinkle

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5
Q

stroke brkdwn

A

80% ischemic, 20% hemorrhagic

global: low CO (MI, a fib)
focal: occlusion (thrombotic, emolic)

*3rd leading cause of death

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6
Q

strokes can be caused by

A

emobolism, thrombus,
hypoxic etiologys: hypoperf, or hypoxemia
happens during cerebrovasc. sx: affects watershed areas

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7
Q

risk factors for ischemic stroke

A 
DM
HTN
smoking
fam hx
high cholesterol
afib
drugs (cocaine)
hx of TIA or recent MI
hx of CHF
OCPs
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8
Q

ant. vs posterior circulation

A

will affect what type stroke

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9
Q

watershed zones: area covered by 2 arteries

A

ant and mid cerebral aa
post and mid cerebral aa

usually from hypotension
upper leg and upper arm weakness
defects in higher order visual processing

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10
Q

autoregulation

A

maintains constant level of CBF despite changing perfusion pressure

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11
Q

CPP normally driven by

A

pCO2, ICP dec. as CO2 dec. via vasoconstriction

  • hypervent theory in trauma, CVA*
  • can actually cause more damage
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12
Q

hypoxemia will

A

inc. CPP IF PO2

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13
Q

CPP=

A

MAP (BP)-ICP
if CPP=0–>brain dead
via blood flow study
a dec. in BP or inc. in ICP results in lowering of CPP

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14
Q

know charts

A

pg 463

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15
Q

chronic HTN

A

lower/upper levels of autoreg are raised–>tolerance of higher blood pressures, but more intolerance to lower BP
*used to give clonidine to reduce high BP-won’t stroke out–>but they do from low BP!
now we do NOT abruptly lower BP in asymptomatic chronic HTN pts it’s relative
put on antiHTN, not rapid

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16
Q

cerebral ischemia will lead to

A

liquefactive necrosis
emo/throm: focal OR
dim. syst: global OR
hypoxia

prolonged ischemia–>infaction
young or old

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17
Q

penumbra

A

transition zone between normal tissue and infarcted tissue

need to save!

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18
Q

ischemic histo timeline

A 
12-48 hr—red neurons
24-72 hr—necrosis w neutrophils
3-5 days—macrophages (microglia)
1-2 wks—reactive gliosis w vascular proliferation
>2ks—glial scar
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19
Q

irrev. damage

A

after 5 min hypoxia

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20
Q

most vulnerable areas

A

*hippocampus, neocortex, cerebellum, watershed areas

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21
Q

cerebral edema accumulates..

A

over 3-5 days after stroke–>death

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22
Q

2/3 ischemic strokes

A

cerebral atherosclerosis

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23
Q

1/3 ischemic strokes

A

cardiogenic emboli
afib
patent foramen ovale-DVT

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24
Q

etiology in younger pts: things that make you clot

A 
arterial dissections
DRUGS: *cocaine, OCPs(pro-coag), heroin(hypoximic)
endocardidtis
protein C or S deficiency
antithrombin III deficiency 
anti-PL AB
SCD
SLE
PFO: patent foramen ovale
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25
Q

stroke prevention

A 
control risk factors/reverse them
diet
smoking
HTN-don't take of BP meds
DM
high cholesterol
afib
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26
Q

a fib inc. CVA risk

A

17x
coum/warf therapy: INR 2-3x basement

Chad’s score/Chad 2 score/Chad vasc score know
-who with a fib need anticoags?

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27
Q

carotid stenosis

A

> 70% carotid endarterectomy(cleaned out) if high risk–>stunting

60–70% early carotid endarectomy best rather then deferring

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28
Q

TIA

A

transient neuro deficit
NO infection, neg MRI*

Lasting usually

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29
Q

lacunar stroke

A

Small lesions

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30
Q

anterior strokes

A

MCA, ACA, lateral striate, ophthalmic

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31
Q

Ophthalmic artery stroke

A

amaurosis fugax: sudden vis loss 1 eye, usually transient

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32
Q

ant cerebral art

A

(Motor and sensory cortex of lower limb)
Weakness + sensory loss contralateral leg
Urinary incontinence possible

Abulia: state of akinetic mutism (inability to make a decision) via B/L frontal lobe dysfunction.

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33
Q

mid cerebral art

A

embolic typically
contralat wkness loss of sense: face, arm, leg (arm>leg) via motor/sensory cortex lesion

gaze pref AWAY from side of weakness

temporal lobe lesion: Wernicke
frontal lobe lesion: Broca

aphasia if in dominant (typ. left) and hemineglet in nondominant side

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34
Q

mid cerebral artery dominant hem

A

global aphasia (expr and receptive)

35
Q

mid cerebral artery nondominant hem

A

anosognosia-unawareness of weakness

-hemineglect

36
Q

lateral striate art

A

lesion in striatum, int capsul
contralat wkness

common location of lacunar infarcts bc of uncontrl HTN

37
Q

comm artery strokes

A

lesions typ. aneurysms impinging on CNS, not strokes
acomm-visual field def, aneurysm most common, can lead to stroke

Pcomm: down and out: CNIII palsy ptosis and mydriasis, saccular aneurysm

38
Q

posterior strokes

A

ASA, PICA, AICA, PCA, basilary artery

39
Q

vertebrobasilar ischemia

A

dissiness , fluctuating drowsiness, diplopia, ataxia, bilat sens/motor symptoms
may be mistaken as vertigo

40
Q

basilar art stroke

A

occlusion of bl vertebral arteries
massive BS damage

coma, pinpoint pups, flaccid quadrip/sens loss
often fatal
spares medulla–>dysarthr,

locked in syndrome, somnolence, amnesia

pons, med, lower mdbran, CST and corticobulbar tracts, ocular cranial nerve nuc, paramedian pontine retic. formation

blinking and consciousness unaffected

41
Q

post cerebral art

A

lesion at occipital and visual cortex

thalamic synd: contralat hemisens distr–>pain, hyperpathia

contralat wkness
contralat homonymous heminopsia
macular vision may be spared-central

42
Q

ant spinal art strke

A

contralat hemiparesis of arm and leg, (LCST)

dec. contralat proprioception (ML)

ipsilat hypoglossal dysfuntion–>tongue deviates ipsilat* (hypoglos. nerv)

lesion of lat corticospinal tract; medial lemniscus; caudal medulla-hypoglossal nerve

43
Q

PICA

A

vomiting, vertigo, nystagmus, ataxia

dec. pain temp
ipsilat face, contralt body:
*crossed findings**

hoarse, dysphagia, dec. gag

ipsilate Horner's
lateral medullary (wallenberg) syndrome

lesion at inf cerebellar peduncle, lateral medullat, sp Trigem nuc, nuc ambiguussp. to PICA, sympathetic fibers

44
Q

Horner’s

A

ptosis
miosis
dec. sweating ipsilat face
*with PICA stroke

45
Q

Wallenberg’s

A

loss of pain/temp
contralto body, ipsilat face
*crossed finding dx for this syndrome
*PICA

46
Q

AICA stroke

-ant inf cerebellar

A

vomit, vert, nystag, ataxia
paralysis of face, dec pain/temp ipsilat
contralat dec. pain/temp of body

  • dec. lacrimation, salivation*
  • dec. tast ant 2/3 tongue*
    dec. corneal reflex

ipsilat Horner’s
dec. hearing ipsilat
lesion at middle and inferior cerebellar peduncles, lateral pons—cranial nerve nuclei, vestibular nuclei, facial nucleus (specific for AICA), spinal trigeminal nucleus, cochlear nuclei, sympthetic fibers

47
Q

cerebral venous thrombosis

A
  • occlusion of saggital sinus*
    usually: difficult to dx, hyperviscosis, hypercoag, preg, maxillofacial inf. SCD

symp: ha**, seizure, papilledema, focal neurolog def

dx: CT w. IV contrast or MRA
tx: steroid to lower ICP, anticoag

typ. present as ha not going away typically pregnant
if do CT w.OUT contrast, will not see unless v. large

48
Q

aphasia

A

higher order inab. to speak

49
Q

dysarthria

A

motor inab to speak

50
Q

Broca

A

nonfluent aphasia, broken up, comprehension intact-understanding, can’t speak effectively, impaired repetition
inferior frontal gyrus of frontal lobe
most commonly seen

51
Q

Wernike

A

fluent aphasia, impaired comprehension and repetition; very wordy, w.out making sense
*superior temporal gyrus of temporal lobe

52
Q

Broca’s aphasia

A

“expressive” cannot get words out, know what to say, start crying, intact comprehension

53
Q

Wernicke’s aphasia

A

“receptive”
fluent speech, meaningless
impaired comprehension, don’t know something is wrong

54
Q

conduction aphasia

A

Poor repetition
Fluent speech
Intact comprehension
Lesion: arcuate fasciculus

Can’t repeat phrases such as “no ifs ands or buts”

55
Q

global aphasia

A

Both wernicke and broca
Nonfluent aphasia
Impaired comprehension

56
Q

what kind of stroke? ischemic or hemorrhagic?? can tell from

A

CT

57
Q

thom or emolic?

A

H/P, cardiac echo, EKG

58
Q

where in brain?

A

CT: might not rev CVA for 6-24 hrs***

MRI/MRA: not available acutely? 3-30 min after CVA (takes about 45 min!)

doppler: ant only: carotids

cardiac echo

59
Q

carotid duplex

A

US of carotids, shows how much blockage: %

60
Q

hyperdense MCA sign

A

Indicative of acute thrombus within the middle cerebral artery

Seen on CT brain usually by 90 minutes
99% sensitivity, 30% specificity

see white arch in MCA
-determine density

61
Q

stroke dx

A

cardiac workup
CBC, PT/INR, PTT, lipids, BMP, cardiac enzymes, ekg, CT head without contrast, CXR

hypercoag studies? not in ER, but if young will do

UDS ??: not unless young–>cocaine, etc

62
Q

ddx stroke

A

Todd’s paralysis: unilat paralysis after seizure, typ. benign, determine seizure etiology

complicated migraine: involves neuro symps: unilat paralysis, numb, tingling, visual defects

63
Q

stroke tx : general

A 
ABCs
DVT prophylaxis (inpatient)
Early OT, PT, Speech tx, and Swallowing Evaluation
Blood pressure and glucose control
Temperature control
Management of depression
64
Q

stroke tx: anticaog: Heparin?

A

Heparin: used to be used, no evidence to support routine use for acute stroke, MIGHT reduce risk of recurrent stroke, offset by risk of ICH
*select pts

65
Q

stroke tx: antiplatelet tx?

A

tx of choice to prevent recurrent thromboembolism

-everyone gets ASA or plavix

66
Q

stroke tx: thrombolysis (tPA)

A

+1 signature, from family*

death

Benefits…stroke and symptoms resolve

67
Q

antidote to tPA?

A

aminocaprioic acid

68
Q

exclusions to tPA

A

Cva or head trauma
BP >185/110, reduce 1st if want to give, sacrifice perfusion
sx 15 seconds
glucose 400 could be having non-thrombotic stroke (hypo/hyperglycemic stroke)

69
Q

cerebral edema management

A

Worry about brain shift and herniation; only with large hemispheric infarctions

airway control-intubate
hypervent?? not really
mannitol: diuretic for brain
craniotomy

70
Q

HTN management in acute CVA

A

If SBP 220 or DBP>120-too high!
Titratable short acting IV drugs

Labetalol, nitroprusside, nicardipine
BP goal?: 180-200/100

180/110 for tPA

-protect the penumbra!, do not lower BP dramatically

71
Q

if give nitro

A

BP improves, stroke may get worse, edema, penumbra enlargers, involves consciousness

72
Q

ICH: “bleeding stroke”

A

Diffuse (SAH)
Focal (intraparenchymal)
20% of all strokes

73
Q

causes of ICH

A 
HTN—undiagnosed,  noncompliant
AVM
drugs
aneurysm
bleeding disorders
trauma/tumor
74
Q

intraparenchymal hemorrhage

A

“paintball to brain”
HTN causes it
goal: reduce mass effect:
mannitol or sx (last-ditch, hydrocephalus, high risk herniation)

putamen most common site: 40%
dec. LOC: mass effect, 
rise in ICP, or direct BS involvement
high BP, AMS
may extend into ventricles-->hydrocephalus
75
Q

SAH

A 
usually berry aneurysm rupture
strenuous activity: sex, exercise
thundeclap, HA, post. neck pain
LOC, N/V
CT/LP: blood or xanthochromia
2-3 days later: vasospasm -->rebleeding
76
Q

SAH: sentinel hemorrhages

A

baby SAHs: sm. aneurysmal leak, resolve after 1-2 days

like a TIA-precursor

77
Q

Charcot-Bouchard

A

chronic HTN
small vessels: basal gang, thalamus
microaneurysm

78
Q

saccular berry aneurysm

A

bifurcation in circle of Willis:
-bifurcation of anterior comm. and anterior cerebral aa
rupture most common comp: SAH, hem. stroke

bitemp hemianopia via optic chiasm compression
risk: older, HTN, tobacco, african amer
marfan’s, Ehlers danlos, polycystic kidney disease (ADPKD)

79
Q

AVM

A

tangles of arteries connected dir. to vv w.out intervening capillaries**–>bleeding
cause: congenital

HA, seizures, tinnitus, blurry vision, or hemorrhage

younger pts: sx excision, embolization, irradiation
>55: conservative

80
Q

right MCA sign

A

left arm>left leg weakness, slurred speech

81
Q

subarachnoid hemorrhage, diffuse on both sides

A

complications: vasospasm/rebleed

82
Q

slide 95 pics

A

blood in ventricles, hydrocephalus
poor px
intraparenchymal hemorrhage, typ. from uncontrolled HTN

83
Q

first aid

A

pg 466

84
Q

Chads2Vas score

A

65-74: 1
>75: 2

female: 1
CHF hx: 1
HTN hx: 1
stroke/TIA/thromboembolism hx: 2
vasc. disease hx: 1
DM: 1

CSI (75 decks)

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