Ch. 10 - Stroke Flashcards Preview

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Flashcards in Ch. 10 - Stroke Deck (69):
1

Stroke definition

sudden neuro deficit 2/2 vascular etiology lasting > 24 hrs

2

TIA definition

transient neuro deficit lasting < 24 hrs

3

Stroke types

ISCHEMIC (infarct) vs HEMORRHAGIC vs both

4

Primary stroke prevention

lifestyle modification and treatment of risk factors in pt without cerebrovascular sx

5

Stroke risk factors

smoking, HTN, diabetes, heart dz (a fib), hypercholesterolemia, age, males, smoking

6

most common cause of cardiogenic cerebral infarct

non-valvular atrial fibrillation

7

treatment of atrial fibrillation

warfarin with INR 2-3 for pts 60+, ASA adds moderate benefit

8

Secondary stroke prevention

tailored to underlying stroke pathology including antiplatelet therapy, warfarin, CEA, and stenting

9

ASA mechanism

irreversible inhibition of platelet cyclooxygenase (no thromboxane for plt aggregation)

10

clopidogrel mechanism

inhibits platelet ADP (receptor that activates plt aggregation)
- small ARR compared to ASA but more expensive = second line
- can combo with ASA

11

dipyridamole mechanism

inhibits PDE, maintaines high levels of cAMP/cGMP to prevent platelet activation
- can combo with ASA

12

CEA indications

beneficial for pts with > 70% stenosis

13

TIA work up

CT, carotid doppler, ECG, +/- echo within 24 hrs

14

amaurosis fugax sx

transient monocular blindness "shade pulled over one eye"

15

MCA occlusion

contralateral hemiplegia (arm > leg), hemianesthesia, homonymous hemianopia, aphasia, inattention, cortical sensory loss

16

ACA occlusion

hemiparesis (mostly leg)

17

PCA occlusion

homonymous hemianopia, disconnecting syndromes, hemianesthesia, amnesia, midbrain/thalamic syndromes

18

vertebrobasilar thrombosis

quadriparesis, bulbar paralysis, impaired gaze, cortical blindness, coma

19

ventral pontine infarct

quadriparesis, bulbar paralysis, absent horizontal gaze, normal consciousness, "locked in" syndrome

20

lateral medullary syndrome

ipsilateral ataxia, horners syndrome, nystagmus, facial numbness, CN9/10 palsy, contralateral spinothalamic loss

21

lacunar infarcts most likely secondary to

HTN causing 'lipohyalinosis'

22

most common cause of cardiogenic embolism

non-valvular arterial fibrillation > valvular heart dz, MI, post cards surgery, prosthetic valves, endocartis, atrial myxoma

23

Types of cerebral hemorrhage

intracerebral vs subarachnoid hemorrhage

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risk factor for intracerebral hemorrhage

HTN --> charcot-bouchard microaneurysms

25

lobar hemorrhage

superficial vascular rupture w/i cerebral lobes

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risk factor for lobar hemorrhage

amyloid angiopathy

27

Principles of stroke management

early recognition, rapid transport to tx facility "time is brain", early triage/imaging, assess for thrombolysis, monitoring in stroke unit

28

ddx stroke

cerebral tumor, subdural hematoma, abscess, migraine, metabolic disturbances, epilepsy

29

all patients with suspected stroke need a...

CT or MRI. MRI better at identifying acute ischemia and just as good at ID'ing hemorrhage

30

Do you ever LP a suspected stroke patient?

yes if negative imaging and you suspect meningitis or SAH

31

Major difference in treatment: ischemic vs hemorrhagic stroke

ischemic stroke = indication for thrombolysis. hemorrhagic stroke = absolute contraindication

32

clinical factors important for tPA administration

ischemic stroke, given w/i 3 hours of stroke onset

33

most common site of cerebral infarct

middle cerebral artery. classified as cortical or deep

34

difference between cortical or subcortical infarcts

subcortical = deep perforating vessels supplying internal capsule, thalamus, basal ganglia and brainstem

35

lacunar infarct

occlusion of single perforating vessel <1.5 cm, assoc. w/ htn

36

classic lacunar infarct presentations

pure motor hemiparesis, pure sensory stroke, sensorimotor stroke, ataxic hemiparesis and dysarthria/clumsy hand

37

classic cortical infarct presentations

dysphasia, apraxia, anosognosia, sensory/motor/visual agnosia, acalculia, right/left confusion, dysgraphia, cortical sensory loss (2 pt discrimination, astereognosis, dysgraphasthesia)

38

apraxia

difficulty with motor planning to produce speach

39

dysphasia

inability to comprehend/form speech

40

anosognosia

denial of stroke

41

agnosia

inattention

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acalculia

inability to perform simple arithmetic

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dysgraphia

inability to write

44

dysgraphesthesia

inability to perceive what is written

45

astereognosia

inability to id object by touch

46

presentation of hemorrhagic stroke

rapid onset of stroke w/ early depression fof conscious state

47

work up of stroke patient

1. blood glucose
2. ECG - a fib, acute MI (causes of thromboemboli)
3. CT brain = MRI, also consider MRA/CTA
4. duplex doppler (less urgent)

48

dedicated stroke units have reduced mortality by __%

25%

49

initial management of a stroke

1. monitoring vitals/neuro/cardiac status
2. ASA (if no tPA)
3. ID prior fxnal status and current deficits
4. early mobililization/ROM
5. aspiration precautions - drop NG if dysphagic
6. basic precautions: prevention of DVT, pneumonia, bed sores, UTI

50

what hemodynamic instability is tolerated during acute stroke?

hypertension is common and settles over 2-3 days. avoid hypotension = decreased cerebral perfusion

51

preferred fluid for acute stroke

NS. avoid glc containing fluids (hyperglycemia)

52

most common cause of mortality in stroke patients by week

week 1: transtentorial herniation
week 2: secondary systemic factors
week 3: pneumonia, PE, cardiac

53

progressive deteriorating neuro deficit seen in what percent of stroke population? 2/2 to what?

33% caused by cerebral edema. NOT helped by corticosteroids, no evidence for mannitol, hemicrani may help some

54

when is heparin indicated following a stroke?

pt at high risk for recurrent embolism, otherwise risk of hemorrhagic transformation too risky

55

when is neurosurgical intervention indicated?

cerebellar hemorrhage, young patients with lobar hemorrhage = possible evacuation

56

subacute follow up of stroke

1. Tx underlying cause: warfarin @ 1w for a fib, CEA for carotid stenosis
2. REHAB

57

Rarer causes of strokes, usually younger adults

migraine, OCPs, mitral valve prolapse, vasculitis, extracranial arterial dissection, fibromuscular dysplasia, moya-moya dz, hypercoagulability

58

work up of rarer causes of stroke

angiogram, TEE, LP, hematologic investigation

59

migraine-induced stroke presentation

pt with persistent neuro deficit following classic migraine. dx of exclusion

60

OCP-induced stroke presentation

estrogen containing OCPs (hypercoag). dx of exclusion

61

rare cardiac associated with stroke in young pt

mitral valve prolapse/PFO, req TEE to tx

62

causes of cerebral vasculitis

polyarteritis nodosa, granulomatous angiitis, giant cell arteritis, heroin/amphetamines/cocaine, TB/syphilis, opthalmic herpes zoster

63

lab/imaging findings of vasculitis

beading of arteries on angiography, lymphocytosis in CSF, elevated ESR

64

FMD

females, assoc. with renal FMD, increased risk of berry aneurysms/dissection. Tx w/ aspirin

65

moya moya

obliterative arterial condition = fine telangiectatic web of anastamotic intracranial vessels = "puff of smoke" appearance on angio. Tx with revascularization

66

hypercoagulable states assoc. with stroke

lupus, activated protein C resistance, deficiencies in protein C/S

67

cerebral venous thromboembolism presentation

insidious HA, papilledema --> hemiplegia, drowsiness, fever, seizures, meningismus in hypercoagulable state (post partum, OCPs, lupus) or in pts with infxn

68

carotid artery dissection presentation

neck pain, eye pain and horner's syndrome

69

Indications for carotid endarterectomy

Symptomatic carotid stenosis of 70-99% and life expectancy of at least 5 years PLUS
- surgically accessible lesion
- absence of clinically significant comorbid conditions
- no prior ipsilateral endarterectomy