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Block 3: Neuro > Clin Med: Stroke > Flashcards

Clin Med: Stroke Flashcards

(144 cards)

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1
Q

Stroke aka?

A

cerebrovascular accident

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2
Q

What is a stroke?

A

an acute neurologic deficit due to damage to the brain tissue from a vascular cause

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3
Q

Stroke is one of the leading causes of___ in the US & worldwide.

A

debility & mortality

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4
Q

What do transient ischemic attacks involve?

A

acute neurologic deficits that resolve w/o evidence of brain tissue damage.

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5
Q

What often precedes an CVA?

A

a TIA

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6
Q

What does primary and secondary prevention of stroke invovle?

A

modifying RFs

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7
Q

Global stroke facts:
__leading cause of death
__% lifetime risk after age __

A
  • 2nd
  • 25%, 25
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8
Q

US Stroke facts
__leading cause of death
Higher incidence among___
Gender prevalence

A
  • 5th
  • blacks/hispanics/asians
  • men > women at younger but not older
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9
Q

States in the “stroke belt”

A

TX, LA, AR, MS, AL, GA, NC, TN, MO, KY, WV, SC

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10
Q

SC Stroke death per 100,000
Laurens
Gwd
Gville
Spartanburg

A

Laurens = 92
Gwd = 86
Gville = 76
Spartanburg = 91

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11
Q

Two types of stroke?

A

Ischemic & Hemorrhagic

Ischemic (85-9-%) > Hemorrhagic (10-15%)

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12
Q

What is an ischemic stroke?

A

Damage to brain tissue occurs b/c of reduced blood flow to brain tissue

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13
Q

Causes of an ischemic stroke

A
  • clot
  • plaque rupture
  • embolus
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14
Q

What is a hemorrhagic stroke?

A

Intracranial hemorrhage causes damage to brain tissue due to toxic effects of blood or mass effect due to incr pressure

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15
Q

Causes of a hemorrhagic stroke

A
  • trauma
  • aneurysm
  • AVMs (arteriovenous malformations)
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16
Q

How are TIAs different from ischemic strokes?

A

the occluded vessel reopens prior to infarction

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17
Q

TIA symptoms last…

A

< 1hr up to 24hrs

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18
Q

What is the risk of stroke after a TIA?

A

10-15% usually w/n 2 days & up to 3 months

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19
Q

What is a workup for TIAs

A

Eval & workup should be similar to ischemic stroke w/ emphasis on prevention of stroke

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20
Q

Parts of the cerebrum?

A
  • Frontal lobe
  • Parietal lobe
  • Temporal lobe
  • Occipital lobe
  • Insula lobe
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21
Q

Functions of the cerebellum

A
  • Motor coordination
  • Proprioception
  • Eye movement control
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22
Q

Spinocerebellum Function

A

coordination of motor signals out to muscles

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23
Q

Spinocerebellum: medial portion Function

A

= vermis; control of axial muscles

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24
Q

Spinocerebellum: lateral sides Function

A

(adjacent to vermis)

control of arm and leg muscles

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25
Cerebrocerebellum function
interact w/ motor cortex of cerebrum to plan muscle movements
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Vestibulocerebellum (flocculonodular lobe) function
- balance & eye movements; - receives signals from vestibulocochlear nerve & sends signals to muscles involved w/ posture
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NOTE
Cerebellum receives signals from the CONTRALATERAL cerebrum & sends signals to IPSILATERAL body
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Parts of the basal ganglia
- Thalamus - Globus pallidus - Putamen - Caudate nucleus
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What are the 3 causes of an ischemia stroke/TIA?
1. Thrombosis 2. Embolus 3. Systemic hypoperfusion (watershed)
79
What is the thrombosis?
Clot formation in a vessel leads to stenosis or occlusion
80
Clot formation is promoted by:
- Athersclerosis* - Lipohyalinosis* Less common causes: - Infx (COVID!) - Vasculitis - Dissection - Vasoconstriction - Coagulation disorders - Inflammatory disorders
81
What is Lipohyalinosis?
thickening & narrowing of smaller BVs of the brain, likely due to HTN and/or inflammation
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Thrombosis: large vessel thrombus
- usually due to stenosis from atherosclerosis --> Usually affect the cerebrum
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Thrombosis: small vessel thrombus
- usually due to narrowing from lipohyalinosis --> Usually affect deep internal structures (basal ganglia, internal capsule, thalamus) --> “lacunar” strokes
84
What is an embolus?
Material from another site travels & occludes a vessel
85
Causes of an embolus
- Thrombus/ plaque debris (most common) --> Cardiogenic --> Arterial (usually aortic or carotid) --> Cryptogenic (unknown) - Infx (endocarditis) - Cholesterol, fat (bone fracture) - Air or other gas
86
Cardiogenic factors that cause embolus
- Afib - Mechanical heart valves - Patent foramen ovale - Rheumatic aortic valves - Systolic CHF w/ EF< 30% - Dilated cardiomyopathy - CABG surgery - Left atrial myxoma - Endocarditis
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What is systemic hypoperfusion (watershed)?
Areas b/t arterial systems are vulnerable to poor perfusion if BP drops too low
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Causes of systemic hypoperfusion
- Low cardiac EF / MI - Dehydration - Sepsis - Hemorrhage - Surgery
89
Describe TOAST classification
- Large vessel atherosclerosis (30%) - Cardioembolic (20%) - Small vessel occlusion (15%) - Stroke of other determined etiology (10%) - Stroke of unknown etiology (25%) --> 2 or more possible causes --> No workup or Incomplete workup --> Complete workup w/o definitive cause (Cryptogenic)
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Ischemic Stroke/TIA thrombosis symptoms description
fluctuating course, often more gradual
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Ischemic Stroke/TIA embolus symptoms description
sudden onset, severity of symptoms steady
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Symptoms of an ischemic stroke/TIA
- Behavioral changes - Confusion - Coma - Cranial nerve deficits - Gaze preference - Language issues - Loss of coordination - Nausea/vomiting - Neglect - Numbness/tingling - Visual field loss - Vertigo - Weakness
93
Ischemic Stroke/TIA watershed symptoms description
fluctuating course
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Steps when a pt comes in w/ a stroke.
- Early recognition & tx is key! - “Code Stroke” - 1st step: airway, breathing, circulation - Next step: stroke or not stroke
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Ischemic Stroke/TIA DDx
- Metabolic issue (hypoglycemia) - Hypertensive encephalopathy - Migraine - Seizure - Venous sinus thrombus - Conversion disorder - Encephalitis - Tumor - Abscess - Multiple sclerosis
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Ischemic Stroke/TIA History
- Specific symptoms - Course of symptoms - **Time of onset (last known normal)** - Activity at onset - Assoc. symptoms - Hx of prior CVA/TIA - Hx of prior CAD/PVD - Hx of heart dz - RFs - Meds
97
Ischemic Stroke/TIA PE
- General assessment (ABCs) - Vital signs - Cardiovascular --> Neck bruits --> Murmurs --> Irregular HR --> Pulses --> Edema - Lungs --> Fluid overload - Skin --> Evidence of endocarditis or vasculitis - Neurologic – thorough!
98
What is often elevated with in CVA?
BP
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When do ischemic & hemorrhagic strokes tend to occur?
- ischemic stroke--> while sleeping when blood flow is slower - hemorrhagic--> tend to occur when awake
100
Various location a stroke can occur
- Anterior cerebral artery - Medial cerebral artery - main - Medial cerebral artery - Lenticulostriate arteries - Internal carotid - Posterior cerebral artery - Vertebrobasilar
101
Describe presentation of symptoms w/ an anterior cerebral artery stroke?
- Contralateral motor &/or sensory deficits --> Leg > arm/face - behavioral changes
102
Describe presentation of symptoms with a medial cerebral artery - main stroke?
- Contralateral Arm/ **lower** face motor &/or sensory deficits - homonymous hemianopsia - Ipsilateral eye deviation - Dominant hemisphere: language deficits --> Broca’s vs Weirnicke’s - Nondominant hemisphere: contralateral neglect & confusion
103
What nerve controls muscles in the upper & lower face?
facial nerve
104
Where does the facial nerve receive it's input?
contralateral and ipsilateral input so forehead movement is preserved bilaterally in a cerebral infarct
105
Describe presentation of symptoms with a medial cerebral artery - lenticulostriate arteries stroke?
- Pure motor – contralateral face/arm/leg (all 3 - hemiparesis) - Pure sensory - Mixed sensory/motor - Ataxia + pure motor - Clumsy hand
106
Describe presentation of symptoms w/ an internal carotid stroke?
- Both MCA & ACA symptoms - Amaurosis fugax (Ophthalmic a.)
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Describe presentation of symptoms w/ a posterior cerebral artery stroke?
- Vision issues - Homonymous hemianopsia w/ preserved macular vision - Memory issues - Sensory loss -contralateral face/arm/leg
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Describe presentation of symptoms w/ a vertebrobasilar stroke?
- Cranial nerve palsies - Crossed sensory deficits (ipsilateral forehead & contralateral arm/leg - Dysphagia - Vertigo, n/v - Hiccups - Limb ataxia - Coma - Locked-in syndrome
109
The pons controls which cranial nerves?
CN V, VI, VII, VIII
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The medulla controls which cranial nerves?
CN IX, X, XII, XII
111
Describe Horner's syndrome
- ipsilateral miosis - ptosis - anhidrosis
112
Describe Wallenburg stroke
vertigo, nausea/vomiting, hiccups
113
What is the name of the stroke scale used?
NIH Stroke Scale (NIHSS)
114
Describe interpretation of the NIH stroke scale (NIHSS)
- 11 standardized tests, in order - Higher score = worse deficits - Good reproducibility when done correctly by trained admin - Administered on arrival, w/ any acute neurologic change, after tx, on discharge
115
Ischemic Stroke/TIA Initial workup: ER
- NIHSS / exam - Labs: --> blood glucose, CBC, BMP, PT/INR, PTT, troponin --> If female – pregnancy test --> Consider - toxicology screen, alcohol level, infectious workup Imaging: - EKG - CT head, non-contrast STAT (Goal: door-to-imaging time < 25 min) --> Evaluates for causes besides ischemia & helps rule out hemorrhage ----> Hemorrhage, mass, abscess --> Most common finding = **nothing abnormal**
116
If initial workup suggest probable ischemic stroke, what's the next step?
Is patient a candidate for reperfusion therapies? --> Thrombolysis or Thrombectomy
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What is the goal of reperfusion therapies?
restore blood flow
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If pt is a potential candidate for reperfusion therapy, next step?
obtain additional imaging studies
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If pt is NOT a potential candidate for reperfusion therapy, next step?
proceed w/ further evaluation for cause & acute management
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Additional studies needed once patient is a candidate for reperfusion therapy
CTA or MRA - Visualize if thrombus amenable to thrombectomy CT perfusion or MRI perfusion study - Assesses extent of infarct versus surrounding penumbra – helps w/ risks/benefit analysis
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What are the secondary prevention methods in ischemic strokes?
**Statins** - Goal - LDL < 70 - High dose statin if tolerated **Blood glucose control** - A1C <7.0 **BP control** - Goal - < 120/70 mmHg - Lifestyle modifications – smoking, drinking, diet, exercise - Anti-thrombotic meds
129
ABCD
- >/= 60yo (1 point) - uncontrolled BP (>/= 140 or >/=90) - clinical
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Most patients will get which type of Antithrombotic meds?
antiplatelet tx
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What causes of stroke call for antiplatelet tx for stroke?
large or small vessel occlusion, unknown etiology; TIA
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Antiplatelet
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Prevention Strategies for ischemic stroke/TIA & give options
Tx of carotid artery stenosis - carotid enterectomy - carotid artery stenting
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Describe when a carotid endarterectomy should be done.
- If stenosis 70-99% & likely cause of embolic stroke - No tx if 100% occlusion - Risk of embolism & stroke from plaque during removal
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How is carotid artery stenting done?
percutaneous stent placed
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Stroke/TIA in children presentation
seizures more common than in adults
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Causes of stroke/TIA in children
- Genetic disorders – Sickle cell dz, hypercoagulable disorders - Trauma w/ arterial dissection - Congenital heart dz
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Workup & tx for stoke/TIA in children
similar to adults
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Prognosis of an ischemic stroke/TIA?
- Recovery of function greatest during 1st 3 months & usually close to max recovery at 6mos - Depressive symptoms that can limit recovery - Higher NIHSS scores at discharge assoc. w/ worse outcomes - Higher risk of death compared to general population --> Hemorrhagic stroke higher risk than ischemic stroke
144

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