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Neurology Lectures > Stroke (Nolte) > Flashcards

Stroke (Nolte) Flashcards

1
Q

What are the two different types of stroke?

  • ______(87%) - blocked blood flow to the brain
    • Thrombus- clot forming in brain artery
    • Embolus - clot from somewhere else breaks off and blocks
  • ______ - Bleeding into the brain
    • SAH (3%) bleeding into skull around brain
    • ICH (10%) bleeding directly into brain
A
  • Ischemic Stroke
  • Hemorrhagic Stroke
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2
Q

Evolution of cerebral atherothrombosis -

  • What is the most important aspect of the thrombus formation?
A
  • The pro-inflammatory matrix - activates T cells, macrophages
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3
Q

Etiologies of _________ ?

  • Intracranial atherosclerosis, carotid artery/VB artery stenosis
  • Valvular disease, paroxysmal afib, intracardiac thrombus
  • Paradoxical
  • Systemic hypercoagulability
A

Etiology of Embolic Stroke

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4
Q

FYI:

Formation of cerebral embolism - distal to the BIFURCATION

A
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5
Q

Subarachnoid Hemorrhage:

  • Due to? _____ or ______
    • What locations are the most common for this?
  • What is morbidity due to once the aneurysm is secured?
  • What medication is used 60q4hr, TCDs x 21 days

*Risk factors for rupture?

A
  • Trauma (cortical) or berry aneurysm
    • ACOMM, PCOMM, MCA bifurcation, TICA
  • Vasospasm
  • Nimodipine

* Tobacco, HTN

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6
Q

Intracerebral Hemorrhage

  • Most important prognostic factor?
  • What are subcortical hemorrhages due to?
  • ______ hemorrhages due to
    • trauma, ischemia, AVM, Mets, cerebral amyloid angiopathy, cerebral venous thrombosis
A
  • LOCATION, LOCATION, LOCATION
  • HTN
  • Cortical
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7
Q

Uncontrollable risk factors for stroke?

  • -
  • -
  • -
  • -
  • -
A
  • Age (>65)
  • Race (greater for AA)
  • Family history
  • Previous MI, stroke, TIA
  • Sex
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8
Q

Each year, about 55,000 more _____ than ____ have a stoke

  • _____ stroke incidence rates are greater at younger ages - but not at older ages
  • Male:female 1.25 (55-64), 1.5 (65-74), 1.07 (75-84), 0.76 (85+)
  • ESTROGENs - hypercoagulable
A

Women than men

  • Men’s
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9
Q

Controllable risk factors for stroke include:

        • risk 2x
    • independent risk factor, increasing risk about 5x
  • -
  • -
A
  • HTN
  • DM
  • Tobacco abuse
  • A fib
  • Previous TIA, stroke
  • Carotid or other artery disease
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10
Q

Secondary controllable risk factors for stroke:

  • (high RBC, sickle cell anemia)
  • Increased serum ______
  • ***
  • ***
  • Less well known - excessive EtOH intake, drug abuse; infection
A
  • Blood disorders
  • Cholesterol
  • PHYSICAL INACTIVITY
  • OBESITY
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11
Q

FYI:

  • Potential genetic risk factors for stroke:
    • mutations that lead to hypercoagulable state - factor V leiden and prothrombin
    • increased serum apolipoprotein e4
    • elevated homocysteine level
    • fabrys, homocysteinuria, ehlers-danlos syndrome, pseudoxanthoma elasticum
A
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12
Q

What symptoms should prompt you to think of stroke?

sudden onset of…

A
  • vision loss, blurred vision, double vision
  • slurred speech, difficulty speaking/understanding language
  • difficulties with swallowing
  • unilateral weakness or numbness
  • difficulties with balance or sensation of vertigo
  • severe headache with progressive decline in level of consciousness
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13
Q

What neuroimaging is needed for stroke?

A
  • CT stroke alert protocol
  • “fast brain” MRI
  • conventional angiogram
  • carotid US
  • transcranial dopplers
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14
Q

CT “acute stroke” protocol:

  • _____: to evaluate for presence of intracerebral hemorrhage or edema associated with underlying tumors
  • _____: to evaluate for presence of vascular occlusions or significant stenosis
  • ____: to evaluate for presence of areas of brain that are either infarcted “core” (or permanently damaged brain tissue) or “penumbra” (potentially salvageable tissue that is stunned)
A
  • Plain head CT
  • CTA head and neck with contrast
  • CTP
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15
Q

What does CTP tell us?

  • _____ blood volumes throughout the brain
  • _____ identifies the amount of time it takes to get to specific regions of the brain - increased in areas of brain distal to vessel occlusions
A
  • CVB: Identifies blood volumes throughout the brain -
    • core - decreased cerebral blood volume, so already infarcted
    • areas of preserved blood volume are still salvagable
  • MTT: identifies the amount of time it takes
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16
Q

A. What occurs in the setting of vessel occlusion,

  • CBV is preserved!
  • MTT is prolonged
  • Recanalization of occluded vessel may provide benefit

B. Occurs in the setting of vessel occlusion

  • CBV is decreased
  • MTT is prolonged
  • Recanalization of vessel puts the patient at risk for more adverse events than benefit
A

A. Penumbra

B. Core infarct

17
Q

What is the gold standard for treatment of acute stroke?

  • Approved for use within 3 hours of onset of neuro deficits in a defined population of patients
  • ​ASA has recognized the 3-4.5 hour window in selected pts

_____ is approved for use in patients who do not receive the above - with no contraindications, and 24 hours after receiving above if there is no hemorrhage on 24hr post___ CT/MRI scan

A

Recombinant tissue plasminogen activator

Aspirin 325 mg

18
Q

NINDS trial evaluating tPA showed that patients treated with tPA within 90 minutes, had…

(Lazarus effect [rapid improvement within the first 24 hours] was NOT shown to be sig. different)

  • Declining return on benefit when taking into account risk of hemorrhage from tPA over time
  • ECASS 3 - tPA could be used in a select group of patients outside the 3 hour window, still more benefit than risk
A

… more improvement from baseline neurologic deficit at 90 days than patients treated with ASA alone

19
Q

In order to consider tPA administration…

  • _____ stroke onset within 3 hours of drug administration
  • Measurable deficit on ______ examination
  • _____ does not show hemorrhage or nonstroke cause of deficit
  • Age is > __
A
  • Ischemic
  • NIHSS
  • Plain head CT
  • > 18
20
Q

FYI: do not give tPA is any below are true:

  • Minor symptoms or rapidly improving
  • Seizure at onset of stroke
  • Had another stroke or serious head trauma within the past 3 mos
  • Major surgery within the last 14 days
  • Known history or ICH
  • Sustained SBP of >185 mmHg, DBP >110 mmHg
  • Symptoms of SAH
  • GI or Urinary tract hemorrhage within the last 21 days
  • Arterial puncture at noncompressible site within last 7 days
  • Received heparin within the last 48 hours and elevated PTT
  • PT is > 15 seconds or INR >/= 1.7
  • Platelet count < 100,000
A
21
Q

Use tPA with caution if…

  • Large stroke scale score of ____
  • CT shows evidence of _______

How is tPA administered IV?

  • dose: 0.9 mg/kg (max dose 90 mg)
  • IA?
A
  • >22
  • Large MCA territory infarction (sulcal effacement or blurring of gray-white junction in greater than 1/3 of MCA territory)
  • IV: 10% bolused over first minute, rest of 90% given in IV infusion over 60 minutes
  • IA: dependent on physician and situation, can be combined with IV
22
Q

When monitoring after tPA is given,

  • what is the BP goal?
  • q15 min vitals + neuro checks x2 hrs; q30 min vitals + neuro checks x4 hrs, q1 hour vitals + neuro checks x24 hrs
  • 24 hour post tPA head CT or MRI to evaluate for presence of hemorrhagic transformation
  • Stat head CT for any acute decline in neuro status
A
  • Tight control with goal of < 180/105
23
Q

What are some adverse reactions that can occur following tPA administration?

A
  • Local bleeding
  • Anaphylaxis - angioedema can occur
  • Acute worsening of neuro exam
  • Cushing’s triad - HTN, bradycardia, irregular respirations
24
Q

What are some other options besides tPA?

Aspiration pneumonia, DVT, PE, decubitus ulcers, seizures, UTIs, constipations, depression are all examples of ________

A
  • ASA, intra-arterial therapy: tPA, solitaire stent retriever, PENUMBRA catheter
  • Post stroke complications
25
Q

Stroke Syndromes:

  • Anterior circulation: __________, ___, ___
  • Posterior circulation: ____ (PCA)
  • Dominant Hemisphere strokes
  • Nondominant Hemisphere strokes
A
  • Internal carotid artery, MCA, ACA
  • Vertebrobasilar system, PCA
26
Q

With anterior circulation strokes - what symptoms/exam findings do you see?

A
  • Hemiparesis, hemianesthesia, visual field deficit, slurred speech, ataxia
  • Gaze preference
  • Aphasia
  • Neglect
27
Q

With posterior circulation strokes, what symptoms/exam findings do you see?

A
  • Hemiparesis, hemianesthesia, visual field deficits, slurred speech, ataxia
  • Vertigo
  • Diplopia
  • “crossed track” findings
  • Dysconjugate gaze
28
Q
  • What symptoms are seen in dominant hemispheric strokes?
  • What symptoms are seen in nondominant hemispheric strokes?
A
  • Hemiparesis, hemianesthesia, dysarthria, gaze preference, visual field deficit, Aphasia
  • Hemiparesis, hemianesthesia, dysarthria, gaze preference, visual field deficit, neglect
29
Q

Case 1: Localize lesion, tPA candidate?

80 yof, slurred speech, ams - LKN: 2 hr prior, recent colon resection

  • NIHSS 20, R hemiplegia, 1 midline command, nonverbal, can’t mimic any one syllable sound, L gaze preference, R homonymous hemianopsia
A

Anterior circulation (ICA) - dominant hemisphere (aphasia)

Massive area of penumbra - gave tPA

30
Q

What can cause/ appear to cause Altered Mental Status?

A
  • Broca’s aphasia
  • Wernicke’s aphasia
  • Mixed aphasia
  • Basilar tip psychosis
  • ICH with pending herniation
  • Bilateral ACA strokes (akinetic mutism)
  • Bilateral PCA strokes (Anton’s syndrome or cortical blindness)
  • Mesial Temporal lobe infarct affecting the limbic structures
31
Q

Case 2: Localize lesion. tPA candidate?

  • 61 yom with VRFs of Afib on ASA - previous retroperitoneal hematoma, embolic ischemic stroke within 3 mos, HTN - bradycardia
  • LKN: 9 am, 10 am had R hemiparesis, decreased speech
  • NIHSS 24, globally aphasic, L gaze deviation, R arm/leg hemiplegia, R facial droop, R homonymous hemianopia
A

Anterior Circulation (ICA) - gaze preference, aphasia

not a tPA candidate!

32
Q

Case 3: Localize lesion. tPA candidate?

  • 56 yof with afib on ASA, previous L MCA embolic ischemic stroke with mild aphasia and dense R hemiparesis, HTN
  • LKN: within 2 hr, NIHSS 11, R>L facial droop, RUE and RLE plegia, LLE plegia, LUE 2/4, dense aphasia with more difficulties with spontaneous speech than comprehension, decreased sensation in L face/arm/leg, R gaze preference
A

Anterior circulation (aphasia, gaze preference) - R hemisphere (R gaze, L hemiparesis/plegia, R hemianesthesia)

tPA - w/in 3 hours, previous stroke, risk of ICH is 8-10%

33
Q
  • 6.4% of all patients who receive IV tPA will have symptomatic _______
    • When is the risk for this higher?
A

Intracranial hemorrhage

  • When given later after symptom onset, in older populations, with history of previous stroke, with underlying significant small vessel ischemic changes, with labile BP
34
Q

Case 4: Localize lesion. tPA candidate?

  • 44 yom - pmhx - HTM, multiple MI, stents, noncompliance with antiplatelets/statins
  • Sudden onset of R face, arm, leg weakness
  • NIHSS 4 –> 10, mild R facial droop, moderate R arm weakness, mild R leg weakness, profound sensory loss on R, severe ataxia in R arm/R leg
A

Can’t tell - initially thought to be a small vessel lacunar syndrome

  • clumsy hand dysarthria
  • ataxia hemiparesis

Give tPA!! standard of care, his perfusion imaging was concerning for a completed infarct and was no penumbra to save so IAT was not offered.

35
Q

Can IA thrombectomy be performed with core infarcts?

A

NO!

36
Q

Case 5: Localize lesion. tPA candidate?

  • 77 yom with afib, idiopathic parkinson’s disease who developed sudden onset R sided face arm leg weakness and decreased verbal output 6 hours prior to arrival
  • NIHSS 6, partial forced gaze to L, R facial droop, mild drift in the R arm and leg, mild dysarthria, moderate resting tremor in RUE with marked increased tone in RUE and RLE with moderate bradykinesia
A

Anterior circulation - ICA, dominant hemisphere

(aphasia, gaze preference)

No tPA - but IA thrombectomy

37
Q
  • tPA is an effective means at treating acute stroke and should be offered as ______ if there are no contraindications
  • ____ should ALWAYS be anticoagulated unless there is a very compelling reason to withold such medications
  • tPA is DANGEROUS!
A
  • standard of care
  • Atrial fibrillation

Neurology Lectures (12 decks)

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