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
24
risk factor for intracerebral hemorrhage
HTN --> charcot-bouchard microaneurysms
25
lobar hemorrhage
superficial vascular rupture w/i cerebral lobes
26
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
42
acalculia
inability to perform simple arithmetic
43
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