Clinical Care- Strokes

Question 1

internal carotid arteries branch from what?

Answer 1

common carotid artery

Question 2

what are the two major branches of the internal carotid artery

Answer 2

anterior cerebral artery ACA

middle cerebral artery MCA

Question 3

after the two vertebral arteries fuse to become the basilar artery where do they branch off?

Answer 3

branches off to become the right and left posterior cerebral arteries

Question 4

what does the verterbral basial arteries supply

Answer 4

cerebellum and brainstem

Question 5

the anterior communicator artery connects what?

Answer 5

the anterior cerebral arteries

Question 6

The posterior cerebral arteries (PCA) connects internal carotid artery and what?

Answer 6

the vertebral basilar arteries

Question 7

the MCA is a direct branch off of what artery ?

Answer 7

internal carotid artery

Question 8

definition of a stroke

Answer 8

acute neurological injury that occurs as the result of the interrupted blood flow to the brain

Question 9

definition of a hemorrhagic stroke

Answer 9

rupture of a blood vessel causing bleeding into the brain and lack of cerebral blood flow leading to ischemia

Question 10

definition of ischemic stroke

Answer 10

blockage of a blood vessel causing lack of cerebral blood flow leading to ischemia.

Question 11

subtypes of ischemic stroke

Answer 11

thrombotic
embolic
systemic hypo perfusion

Question 12

what is an obstruction of an artery due to a blockage that forms in the vessel

Answer 12

thrombosis

Question 13

what is an obstruction of an artery due to a blockage from debris that has broken off from a distal area

Answer 13

embolism

Question 14

what is lack of brain blood flow (due?) to decreased systemic blood flow?

Answer 14

systemic hypoperfusion

Question 15

definition of a TIA

Answer 15

defined as a transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischemia (without acute infarction)

Question 16

CVA is defined as what?

Answer 16

neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia WITH infarction

Question 17

what is the only way to differentiate between TIA and CVA ?

Answer 17

MRI

Question 18

what is the clinical manifestations of ischemic stroke

Answer 18

depends on the site.

in general, sudden onset focal neurological disorder.
more general diffuse finding for systemic hypo perfusion etiology.

Question 19

FASTER mneumonic

Answer 19

1) Face – drooping or numbness on one side of the face
2) Arms – one limb being weaker or more numb than the other
3) Stability – steadiness on feet
4) Talking – slurring, garbled, nonsensical words, inability to respond
normally
5) Eyes – visual changes
6) React – MEDEVAC immediately and note time of symptom onset

Question 20

what are some risk factors of ischemic stroke

Answer 20

(a) History of vascular disease
(b) Atrial fibrillation (not on meds)
(c) Atrial septal defect (ASD)
(d) Ventricular septal defect (VSD) with deep vein thrombosis (DVT)
(e) Recent myocardial infarction
(f) Atherosclerosis
(g) Clotting disorders

Question 21

What are the two subtypes of Hemorrhagic Strokes or Intracranial Hemorrhage (ICH)?

Answer 21

1) Intracerebral hemorrhage bleeds directly into the brain tissue
2) Subarachnoid hemorrhage bleeds into the subarachnoid space

Question 22

the clinical manifestation of this hemorrhagic stroke or ICH has maximal impact right away and usually with intense “worse headache of my life” headache?

Answer 22

SAH

Question 23

the clinical manifestation of this hemorrhagic stroke or ICH usually has a gradual onset as blood builds:

Answer 23

Intracerebral hemorrhage

Headache, vomiting, decreased LOC occurs in about half the patients with ICH.

Question 24

Risk factors for Hemorrhagic stroke or ICH?

Answer 24

hypertension
trauma 
bleeding disorders 
drug use (cocaine, meth) 
vascular malformations (aneurysms)

Question 25

patient management of both hemorrhagic and ischemic stroke

Answer 25

hx and physical
(exclude other causes: seizures, migraine, and hypoglycemia)

look for sources of emboli
(DVT, carotid bruits)

Thorough fundoscopic examination

1) Fundoscopic examination for papilledema which may indicate increased intracranial pressure
2) Thorough examination for signs of trauma
3) A tongue laceration (may have trauma from seizure)
4) Differential blood pressure readings between upper extremities may indicate an aortic dissection

Question 26

Initial interventions for ischemic stroke

Answer 26

1) Maintain oxygenation > 94%
a) Do not give oxygenation to non-hypoxic patients
2) Elevate head of bed to ~30 degree
3) Labs:
a) EKG
b) CBC
c) FBG
d) O2 sat
4) Imaging
a) Helps to differentiate between ischemic and hemorrhagic stroke
b) Non-contrast CT
c) MRI
5) Blood pressure

Question 27

considerations for blood pressure in ischemic stroke

Answer 27

a) May be cause of stroke or spike in response to blockage/stress
b) Do not lower it acutely as it may be the only thing maintaining adequate perfusion
c) UNLESS pressure is above systolic of 220 and/or diastolic of 120 in which case you should lower the pressure by 15%

Question 28

What drug are we giving for ischemic stroke?

Answer 28

Labetalol (Trandate) - non-selective beta blocker

(1 Dosing: 10-20 mg IV, may give same or double dose every 10-20 minutes to max of 150mg

Question 29

Adverse reactions and contraindications of Labetalol for stroke

Answer 29

Adverse Reactions: Orthostatic hypotension, fever, hepatotoxicity, fatigue, dizziness, bronchospasm, fatigue, depression

Contraindications: Sinus brady, heart blocks, bronchospastic disease, uncompensated CHF

Question 30

what kind of labs will we be taking for ischemic stroke

Answer 30

EKG, CBC, Finger stick blood glucose, 02 Sat

Question 31

what additional medication is indicated besides labetalol for ischemic stroke?

Answer 31

aspirin 325 mg

Question 32

Treatment of TIA?

Answer 32

If thorough Neuro exam reveals no abnormalities, can give Aspirin with MO guidance