Cerebrovascular

Question 1

Definition of a stroke

Answer 1

Destruction of a portion of brain tissue as a result of circulatory failure in the distribution of a specific arterial vessel

Question 2

Ischemic strokes

Answer 2

Make up 87%

Defined as embolic or thrombotic

Question 3

Hemorrhagic strokes

Answer 3

13% of strokes

Intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, or intraventricular hemorrhage

Question 4

Stroke facts

Answer 4

1 in 4 are recurrent

Leading cause of disability

Reduces mobility in over half of survivors 65 and over

80% are preventable

Question 5

Non- modifiable stroke risk factors

Answer 5

Race

Age

Gender

Genetics

Question 6

Modifiable stroke risk factors

Answer 6

Hypertension

Heart disease

A-fib

Hypercholesterolemia

PFO

Carotid artery stenosis

Dissection

DM

OSA

Hypercoagulability

Depression

ETOH

Drug use

Smoking

Oral contraceptive pills

Migraine

Smoke exposure

Inactivity

Obesity

Poor nutrition

Post menopausal hormone therapy

Question 7

Occlusion pathophysiology

Answer 7

Decreased blood flow due to blockage. Neurons are deprived of oxygen and glucose. Within seconds to minutes of loss of perfusion edema and cell death occur

Question 8

Transient ischemic attack

Answer 8

A transient episode of neurological dysfunction caused by focal brain cell ischemia without acute infarction

Increased risk of stroke within 48 hours of a TIA.

Workup should include HCT, carotid ultrasound, CTA/MRA, echo, lipids, and ECG

Question 9

Subjective assessment finding after stroke

Answer 9

Headache
Difficulty speaking
Dizziness
Loss of coordination
Falling
Dropping objects
Numbness and/or tingling
Visual abnormalities- blurred, double, or vision loss

Question 10

Objective assessment findings after stroke

Answer 10

Decreased LOC
Disorientation
Aphasia
Gaze preference toward stroke
Motor weakness
Sensory abnormalities
Cerebellar signs

Question 11

Possible cranial nerve deficits in strokes

Answer 11

Visual abnormalities: field cut, amaurosis fugax, diploma

EOM palsy

Facial weakness

Decreased cough or gag

Airway compromise

Dysarthria

Question 12

Stroke timeline

Answer 12

Door to Dr- 10 minutes
Door to stroke team- 15 minutes
Door to CT- 25 minutes
Door to CT results- 45minutes
Door to drug- 60 minutes
Door to floor- 3 hours

Question 13

Tests done for stroke

Answer 13

Non-contrast CT
Blood glucose
O2 saturation
CBC, BMP, PT/PTT, INR
EKG
Cardiac ischemia markers if doesn’t delay tPA

PRN
BAC
Pregnancy test
Toxicology
Hepatic function
CTA/MRA
Chest x-ray
EEG

Question 14

BP goals

Answer 14

Pre-TPA <185/<110
Post TPA <180/<105

No-Go TPA <220/<120 lower by 15% within first 25 hours after onset

Question 15

Anoxic injury

Answer 15

Technically a stroke
Caused by hypoxia/ischemia
Mostly poor prognosis

Question 16

ICH Causes

Answer 16

Primarily caused by hypertension

Question 17

BP goal for ICH

Answer 17

Systolic <140

Question 18

Intraventricular hemorrhage

Answer 18

Usually an extension of ICH and rarely isolated
If risk of hydrocephalus place EVD

Question 19

Cerebral aneurysm

Answer 19

An abnormal local dilation in the wall and artery in Circle of Willis caused by defect, disease, or injury

Question 20

Risk factors for cerebral aneurysm

Answer 20

HTN, ETOH abuse, smoking, illicit drug use, connective tissue disease, family genetics

Question 21

Assessment of cerebral aneurysm

Answer 21

Usually asymptomatic and an incidental finding

Larger aneurysms can cause compression resulting in double vision, ptosis, increased eye pressure, and redness

Cavernous aneurysms can cause cranial nerve 3 or 4 palsy, proptosis, and increased intraoccular pressure

Question 22

Aneurysmal subarachnoid hemorrhage

Answer 22

Caused by aneurysm rupture resulting in blood in the subarachnoid space

Medical emergency with high morbidity and mortality

Question 23

Grading systems used for subarachnoid hemorrhage

Answer 23

HUNT and HESS: rates 1-5

World Federation of Neurological Surgeons Grading System: rates 0-5 with 0 being unruptured

Question 24

What is monitored for after a bleed

Answer 24

Hydrocephalus
Seizures
Vasospasm
Delayed cerebral ischemia
Cerebral edema
Increased cranial pressure

Arrhythmia
ECG changes
Left ventricle dysfunction
Stress cardiomyopathy

Airway protection
Pulmonary edema
Pneumonia

Cerebral salt wasting
SIADH

Question 25

Arteriovenous Malformation

Answer 25

Congenital mass of abnormal blood vessels Used Spetzler Martin Classification System Risk of rupture resulting in ICH or IVH

Question 26

Assessment findings and interventions of arteriovenous malformations

Answer 26

Presents with seizures, headache, stroke symptoms Conservative is imaging and monitoring. If causing issues surgical reduction or resection

Question 27

What is a dural arteriovenous fistula

Answer 27

Pathological shunts between dural arteries and dural venous sinuses, meningeal veins, or cortical veins Caused by trauma, venous thrombus, venous HTN, or are idiopathic Due to the drainage pattern they are a hemorrhage risk Also found in the spine

Question 28

Assessment findings in dural arteriovenous fistulas

Answer 28

Pulsatile tinnitus, headaches, seizures, progressive neuro deficits, dementia Spinal may cause pain, lower extremity weakness, and sensory changes

Question 29

Interventions for dural arteriovenous fistulas

Answer 29

Same as arteriovenous malformations

Question 30

Cavernous malformations

Answer 30

Also called cavernous hemangiomas, canvernomas, or cavernous angiomas Low flow, low pressure lesions made up of dilated capillaries with risk of rupturing

Question 31

Moya moya disease

Answer 31

Progressive large intracranial artery narrowing and the development of small vessel collaterals Increased risk of ischemic and hemorrhagic strokes

Question 32

Cerebral venous sinus thrombosis overview and assessment

Answer 32

Thrombosis of cerebral veins or dural sinus causing increase in venous or capillary pressure Leads to edema, venous infarct, or hemorrhage Presents with headache, papilledema, and visual problems due to increased intraocular pressure. Can also have focal deficits and seizures

Question 33

Symptoms of anterior cerebral artery ischemic stroke

Answer 33

Altered mental status Impaired judgement Contralateral weakness and hypesthesia Gait apraxia

Question 34

Middle cerebral artery ischemic stroke findings

Answer 34

Contralateral hemiparesis Contralateral hypethesia Contralateral homonymous hemianopsia Gaze preference toward side of lesion Agnosia Receptive or expressive aphasia

Question 35

Posterior cerebral artery ischemic stroke symptoms

Answer 35

Homonymous hemianopsia, cortical blindness, visual agnosia Altered mental status, impaired memory Dizziness Limb weakness Paresthesias Nausea Language dysfunction

Question 36

Vertebrobasilar system ischemic stroke symptoms

Answer 36

Wide variety of cranial nerve, cerebellar, and brain stem deficits Vertigo, nystagmus, diplopia, visual field deficits, dysphagia, dysarthria, facial hypesthesia, syncope, ataxia Variety of neurological syndromes

Question 37

What is Hunt and Hess used for?

Answer 37

Grading of aSAH

Question 38

Hunt and Hess Grade 1

Answer 38

Asymptomatic

Question 39

Hunt and Hess grade 2

Answer 39

Severe headache Stiff neck No neuro deficit except cranial nerve palsy

Question 40

Hunt and Hess grade 3

Answer 40

Drowsy Minimal nerve deficit

Question 41

Hunt and Hess grade 4

Answer 41

Stuporous Moderate or severe hemiparesis

Question 42

Hunt and Hess grade 5

Answer 42

Deep coma Decerebrate posturing

Question 43

World federation of neurological surgeons grading system for aSAH

Answer 43

0- unruptured 1- GCS 15 2- GCS 13-15 3- GCS 13-15 with focal neurological deficits 4- GCS 7-12 with or without deficits 5- GCS 3-6 with or without deficits