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Neuro > Cerebrovascular Disease - Exam 4 > Flashcards

Cerebrovascular Disease - Exam 4 Flashcards

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1
Q

What are the 3 main arteries of the brain? Which one is each?

A

anterior cerebral: black

medial cerebral artery: red

posterior cerebral artery: blue

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2
Q

What are the 2 different types of strokes? What is the prevalence of each?

A

Ischemic stroke: 80% : clot that leads to lack of oxygen

hemorrhagic stroke: 20%

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3
Q

______ is the area of complete loss of flow = death of brain tissue within _____

A

Ischemic core

4–10 min

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4
Q

_____ is the surrounding tissue after an ishemic stroke which has only a reduction in flow and can remain viable for ____ after onset of stroke

A

penumbra

hours

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5
Q

What are the 2 different etiologies of an ischemic stroke? What are each related to?

A

thrombotic: ruptured atherosclerotic plaques leading to platelet activation

embolic: embolus originating from EXTRAcranial source and associated with ATRIAL FIBRILLATION

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6
Q

_____ is the MC place an artherosclerotic plaque ruptures from and causes a stroke

A

biforcation of the carotid artery

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7
Q

a spontaneous rupture of a cerebral artery leads to what 2 things?

A

cerebral ischemia resulting from loss of microvascular perfusion due to acute vasoconstriction and microvascular platelet aggregation

increased intracranial pressure

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8
Q

A hemorrhagic stroke can be due to _______ and _______ hemorrhages

A

intracerebral and subarachnoid hemorrhages

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9
Q

Intracerebral hemorrhage is MC caused by ________. What 3 things cause subarachnoid hemorrhage?

A

prolonged uncontrolled HTN

aneurysm, AV malformation, trauma

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10
Q

What are the 6 risk factors for a hemorrhagic stroke?

A

Advanced age
Hypertension (up to 60% of cases)
Anticoagulant use
Previous history of stroke
Alcohol abuse
Use of illicit drugs (eg, cocaine, other sympathomimetic drugs)

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11
Q

What is the BE FAST acronym stand for?

A
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12
Q

What is the difference between a stroke presentation and Bell’s Palsy?

A

Bells palsy: the entire 1/2 side of the face will be paralyzed (including the forehead)

stroke: more pronounced facial deficits from the eyes down. so the forehead is normal bilaterally

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13
Q

What are some additional s/s that are seen with HEMORRHAGIC strokes?

A

HA
N/V
seizures
syncope
AMS: LOC is more depressed in hemorrhage stroke presentation when compared to ischemic presentation

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14
Q

**What is the most important piece of history to obtain when considered about a stroke? What is that key piece of information is not available?

A

When did it start? need an EXACT time

When was the last known normal?

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15
Q

_____ strokes often deteriorate more rapidly

A

hemorrhagic strokes

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16
Q

What and where are Janeway lesions?

A

irregular, erythematous, nontender macules on the palms or soles

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17
Q

What and where are Osler’s nodes?

A
  • tender, erythematous nodules located on the hands and feet
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18
Q

What are some fundoscopy findings associated with stroke?

A

papilledema (ICP)

retinopathy, retinal emboli, retinal hemorrhage (signs of predisposing conditions)

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19
Q

If you find a tongue laceration on a suspected stroke pt, what are you thinking?

A

they had a recent seizure from the stroke

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20
Q

During the cardio PE you find a carotid bruit, what does that make you think?

A

thrombotic etiology

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21
Q

What 7 categories does the National Institutes of Health Stroke Scale (NIHSS) take into effect before calculating a score?

A

mental status/LOC
vision
motor function
cerebellar function
sensory function
language
neglect

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22
Q

**What is the NIHSS scale of stroke severity?

A
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23
Q

An NIHSS score of greater than ____ correlates with an 80% likelihood of ______

A

10

proximal vessel occlusion

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24
Q

T/F: History and physical can differentiate ischemic from hemorrhagic stroke

A

FALSE!! H&P alone CANNOT differentiate ischemic from hemorrhagic so need imaging!!

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25
What is included in the urgent work-up of a pt presenting with a stroke?
fingerstick glucose brain CT w/o contrast if the patient presents within 6 hours
26
What is the goal timeframe for a pt to get a CT if a stroke is suspected? If hemorrhage is present, what will it look like on CT? What will an ischemic stroke look like on CT?
within 25 minutes of arrival hemorrhage: acute bleeding appears hyperdense ishemic: will have NORMAL CT
26
What will a subarachnoid hemorrhage look like on CT?
Will look like a starfish
27
Under what stroke scenario do you need to avoid ABGs?
avoid if considering fibrinolytic therapy
28
In strokes, what do you need to keep the O2 stat above? Is the pt allowed to eat?
supplemental O2 to keep O2 saturation above 94% NO! NPO with IV fluids
29
When is a stroke pt allowed to eat?
after speech pathology clears them after assessing ability to swallow
30
When would you want to put the pt in Low Fowler's position?
any s/s of increased ICP aspiration cardiopulmonary decompensation/O2 desaturation (chronic CV or Pulm disease) no more than 30 degrees
31
in stroke patients ______associated with increased morbidity and mortality
Temp >100.4 if hot, cool them off, acetaminophen rectally or IV if cold, warm them up via warm blankets, bair hugger and warm IV fluids
32
What is the goal BS in stroke pts?
60-180
33
If a pt is having an hemorrhagic stroke and on a blood thinner, what do you do?
give the reversal agent!!
34
What is the reversal agent for warfarin?
4-factor prothrombin complex concentrate (PCC)¹ PLUS vitamin K
35
What is the reversal agent for dabigatran?
activated charcoal (only if the pt had just taken the medication within the last 2 hours) idarucizumab (Praxbind) PCC (last resort option)
36
What is the reversal agents for rivaroxaban (Xarelto), apixaban (Eliquis), fondaparinux (Arixtra), edoxaban (Savaysa)?
activated charcoal (only if the pt had just taken the medication within the last 2 hours) andexanet alfa (Andexxa) PCC
37
What is the reversal agent for heparin/LMWH?
protamine
38
**What is the goal BP range in order to be eligible for tPA? **If not in range, what do you need to give? What do you need to do if the BP is too low?
rt-PA Eligible: BP goal of SBP ≤ 185 and DBP ≤ 110 before rt-PA can be administered (class 1) IV nicardipine, clevidipine, labetalol IV fluids to maintain organ perfusion
39
Ischemic stroke **If a pt is NOT eligible for tPA, there blood pressure needs to be ?????? before you should treat it.
Do not treat unless SBP >220 or DBP >120
40
Ischemic stroke **if a pt is NOT eligible for tPA, BP should NOT be lowered more than ____ in the _____. Why? What should you give them?
15% first 24 hours due to risk of hyoperfusion if you drop the BP toooo low toooo fast IV nicardipine, clevidipine, labetalol
41
**Intracerebral Hemorrhage and a SBP 150-220 mmHg, what do you do?
careful titration of therapy to allow for smooth reduction of SBP to a goal of 130-140 mmHg (Class 2a)
42
**Intracerebral Hemorrhage and a SBP >220 mmHg, what do you do?
textbook answer: there is currently not enough evidence to provide specific recommendations “It is common practice to take a similar BP-lowering approach”. give same first line IV antihypertensives
43
What is the risk vs benefit argument with regards to elevated BP in intracerebral hemorrhage?
risk - loss of cerebral perfusion pressure leading to higher level of infarction benefit - decreased risk of rebleed
44
What was the "reasonable" recommendation for target BP in SAH? What are the preferred medications?
a SBP < 160 or MAP < 110 nicardipine, clevidipine, labetalol, or enalapril
45
What is the goal of BP treatment in SAH? What is the goal of choice?
to prevent vasospasms in SAH and prevent delayed cerebral ischemia nimodipine PO or via NG tube for 3 weeks
46
before intiating tPA _____ is the only lab value that must be assessed prior to initiation of therapy. _____ must also be obtained
glucose informed consent
47
What is the major risk for tPA?
**risk of hemorrhage, angioedema
48
**What are the 3 tPA inclusion criteria?
Clinical diagnosis of ischemic stroke causing measurable neurologic deficit Onset of symptoms within 4.5 hours before beginning of treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal Age ≥18 years
49
** is the special circumstance tPA inclusion criteria?
if their is an unclear time of onset with an DWI-FLAIR mismatch
50
What are the 4 relative exclusion criteria that shorten the window to less than 3 hours?
older than 80 oral anticoag use regardless of INR NIHSS score of greater than 25 (severe stroke) Combination of both previous ischemic stroke and diabetes mellitus
51
If tPA is appropriate for a pt, what are the general principles for admistinstration? What does the BP need to be kept under?
infuse tPA over 60 minutes send to stroke ICU neuro checks q15m for 3 hours, then q30m for 6 hours, then qhr x 15 hours Keep BP < 180/105 mmHg avoid microtrauma (no NG tubes, catheters or arterial caths) obtain CT at 24 hours post-tPA
52
What are the tTPA complications?
acute bleeding and angioedema
53
What is the tx for an acute bleed due to tPA? What is the tx for angioedema due to tPA?
cryoprecipitate or tranexamic acid (TXA) IV methylprednisolone, diphenhydramine and famotidine or intubate if edema is rapidly progressing
54
When is Endovascular mechanical thrombectomy an option during a stroke?
Alternative if rt-PA is CI or ineffective in a patient with a persistent potentially disabling neuro deficit (NIHSS ≥6) and. large artery occlusion in the anterior circulation (dx by CTA or MRA) with small infarct core and no hemorrhage (dx by MRI)
55
When must an endovascular mechanical thrombectomy be performed?
Treatment must occur within 24 hours of symptom onset and performed at a stroke center with surgeons experienced in procedure plus a bunch of additional eligibilty requirements
56
What are the neurologic complications that are common with strokes?
hematoma large intracranial hemorrhage cerebral edema increased ICP hydrocephalus seizures
57
When is hematoma evacuation recommended?
Evacuation via minimally invasive surgical procedures is recommended moderate to large ICHs (Class 2a) and large intraventricular extension of ICH’s. (class 1)
58
What is the difference between craniotomy and craniectomy? When are they used?
large intracranial hemorrhage as a result of a stroke
59
When does cerebral edema peak? What pt population is it worse in?
Peaks on day 2 or 3 - can be present for up to 10 days post stroke worse in patients with larger infarcts
60
What is the tx for cerebral edema?
fluid restriction and IV mannitol - watch for hypotension leading to worse infarct decompressive craniectomy (reduces mortality by 50%) in younger patient (< 60 y/o)
61
What is the tx for increased ICP due to strokes? What type of stroke are the associated with?
elevate head of bed 30° mild sedation to maintain comfort as needed osmotic therapy (i.e. mannitol, hypertonic saline) may be considered more often with hemorrhagic strokes
62
hydrocephalus may occur with _____. What do you need to watch for? What will imaging show? What do you need to do next?
SAH watch for worsening HA and progressively impaired neurological testing CT/MRI will show enlarged ventricles consult neurosx and consider shunt placement
63
seizures are seen more commonly with _____ strokes. What do you need to monitor?
seizures are seen more commonly with hemorrhagic strokes
64
When do you want to give primary prophylaxis for seizures in a stroke pt?
Impaired consciousness and evidence of seizure activity on EEG Hx of clinical seizures
65
What is the AED of choice for stroke pts? ____ is preferred for active seizure control
fosphenytoin is preferred for seizure prevention IV lorazepam is preferred for active seizures
66
What is considered primary stroke prevention?
Screen for and control all modifiable risk factors
67
What is considered secondary stroke prevention?
strict BP control!! initiate/restart BP meds for anyone withvBP > or = 140/90 goal: ICH - goal <130/80 statin therapy in ischemic strokes smoking cessation DM control Weight loss/exercise low fat/low salt diet avoid heavy alcohol intake
68
Statin therapy is recommended in _____ strokes
ischemic strokes
69
What are the additional prevention recommendations for pt with ischemic strokes? What are the starting timeframes depending on if they used tPA or not?
antiplatelet therapy for 21 days (+) tPA - start ASA 24-48 hours after tPA (-) tPA - start ASA and Plavix within 24 hours
70
When is anticoag therapy indicated in ischemic strokes?
Indicated in patients with a potential cardiac source of embolism MC is atrial fibrillation
71
What is a TIA? When do symptoms resolve?
a transient episode of neurologic dysfunction caused by cerebral acute ischemia WITHOUT death of brain cells most often symptoms resolve within 1-2 hours
72
When assessing someone with a possible TIA, what are you looking for?
73
When would you consider tPA in a pt with TIA?
if there is a persistent neurologic deficit that is potentially disabling work-up and tx them the same as if the pt were having a full on stroke
74
What are the high risk features of a TIA?
75
What is the medical management for TIA?
antiplatelet antihypertensive statin therapy address all modifiable risk factors
76
What is carotid artery stenosis often caused by? Where? What are some s/s? What will the PE reveal?
Carotid atherosclerosis is often most severe within 2 cm of the bifurcation of the common carotid artery Symptoms result from reduced blood flow and/or superimposed thrombus formation PE: carotid bruit or palpable sclerosis
77
What are the 4 imaging options for carotid artery stenosis?
Carotid duplex ultrasound (CDUS) MRA CTA Carotid angiography
78
Which imaging option for CAS (carotid artery stenosis) is the gold standard?
Carotid angiography most accurate in determining severity and collateral blood supply
79
Which CAS imaging? Pro: least invasive, least expensive, readily accessible, less time consuming Con: operator dependent; may ______ the degree of stenosis
Carotid duplex ultrasound (CDUS) overestimate
80
Which CAS imaging? Pro: produces a 3D image, more accurate for detecting high grade stenosis; less operator-dependent Con: more expensive, more time consuming, tight enclosure in supine position, CI in pacemaker, ferromagnetic implant
MRA
81
Which CAS imaging? Pro: produces a 3D image, more sensitive and specific than US and more specific than MRA Con: radiation exposure, requires contrast, CI in renal insufficiency
CTA
82
What is the management of asymptomatic CAS? What is considered asymptomatic? When would you consider sx?
Includes: statins, antiplatelet agents, treatment of hypertension and diabetes, smoking cessation and healthy lifestyle changes Asymptomatic disease (no hx of stroke or TIA symptoms) Referral to vascular surgery for a carotid endarterectomy (CEA) is indicated if carotid stenosis is between 60 and 99%
83
What is the tx for symptomatic CAD? What is considered symptomatic?
refer for carotid endarterectomy (CEA) and maximize medical management carotid stenting - second-line alternative to CEA for select patients Symptomatic disease (hx of TIA or ischemic stroke within previous 6 months)
84

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