CVA - 1b Dx, Clinical Presentation, Med Management

Question 1

why is a-fib a risk factor for strokes

Answer 1

inc risk of forming clots -> can dislodge and travel to brain -> ischemic stroke d/t embolic stroke

Question 2

what are 5 predictors of strokes and what do they all have in common

Answer 2

afib
HTN
hyperlipidemia
DM
AVN

all vascular in nature

Question 3

TIA vs CVA

Answer 3

TIA - temporary sx that will resolve w/i 24hrs
- “mini stroke”
- can be treated w dec likelihood of deficits

Question 4

according to literature on health inequities, what has led to best outcomes s/p CVA

Answer 4

go somewhere w specialized stroke unit
- not always available

Question 5

what are the 4 main characteristics of ischemic strokes that are different from hemorrhagic

Answer 5

more common
treated w tPa (clot busters)
clot - thrombus or embolus
dec O2 perfusion

Question 6

describe the use of tPa in ischemic strokes

Answer 6

clot busters - break down the blood clot to help restore blood flow
- get w/i certain window of opportunity from onset of sx for optimal efficacy (w/i few hours)

Question 7

what role does dec O2 perfusion play in ischemic strokes

Answer 7

can be secondary to or the cause of the stroke

Question 8

what are 6 reasons for dec O2 perfusion that can lead to an ischemic stroke

Answer 8

low BP
pulm cause
MI
blood loss (abdominal surgery, trauma)
sickle cell anemia
vasospasms

Question 9

what are vasospasms and when are they seen

Answer 9

blood vessels are spasming and constricting -> dec blood flow
- d/t raynauds, SAH

Question 10

how can ischemic strokes transition to hemorrhagic strokes over time

Answer 10

similar path of swelling and edema
- > transition to hemorrhagic

Question 11

what are the 2 types of hemorrhagic strokes

Answer 11

intracranial hemorrhage (ICH)
subarachnoid hemorrhage (SAH)

Question 12

what are the 5 main characteristics of hemorrhagic strokes that are different from ischemic strokes

Answer 12

inc mortality rate
inc risk of midline shift
inc edema
inc risk of hydrocephalus
inc risk for brainstem herniation

Question 13

why is there an inc mortality rate associated w hemorrhagic strokes

Answer 13

bleeding into brain -> inc fluid in brain -> inc fluid needs space -> pushes brain matter over -> midline shift d/t edema

Question 14

why is there an inc risk of hydrocephalus associated w hemorrhagic strokes

Answer 14

inc fluid in ventricles bc of blood -> putting a lot of pressure on brain

Question 15

what specific type of hemorrhagic stroke is hydrocephalus commonly seen in

Answer 15

SAH

Question 16

how is hydrocephalus commonly treated

Answer 16

w EVD (extra-ventricular drain)
- tube placed in ventricle to drain fluid and dec pressure

Question 17

why is back pain associated w hydrocephalus secondary to hemorrhagic strokes

Answer 17

blood more dense than CSF, then travels down SC and hangs out in base of SB
- blood is irritable to SC and toxic to neural tissue -> irritates nerves -> LBP and leg pain

Question 18

how is LBP and leg pain d/t hydrocephalus secondary to hemorrhagic strokes managed

Answer 18

transient - give them gabapentin (meds for nerve pain)
- blood eventually get resorbed

Question 19

what is the clinical significance of working w someone who is being treated for hydrocephalus

Answer 19

pay attention to ICP (<125)
- drain has to be clamped before movement, then not getting CSF movement out and can see issues w ICP

Question 20

what do clinical features of a stroke depend on (2)

Answer 20

location and severity of stroke

Question 21

why is your impairment exam of someone w CVA important even if you already know where they had the stroke

Answer 21

everyone’s neuroanatomy is different and might present differently
- depending on variations in circulation and collateral flow anatomy

Question 22

what are 8 general features of a CVA and why

Answer 22

impaired motor control
sensory deficits
*inc DTRs
*altered ms tone
*path reflexes
secondary weakness, impaired ROM, dec balance

UMNL

Question 23

what is critically important in a dx of a CVA

Answer 23

TIME = brain
rapid dx and intervention

Question 24

what scan is more commonly utilized when dx a CVA in an ED

Answer 24

CT scan

Question 25

pros and cons of a CT scan as a CVA diagnostic tool in the ED

Answer 25

pros: - quickly show if hemorrhagic or ischemic (quicker than MRIs) - more readily available than MRIs in ED - easier to monitor person during CT than an MRI cons: less specificity/sensitivity than MRIs - might not show brain abnormalities right away - could miss stroke if not timed well - hard time detecting smaller arteries

Question 26

use of MRI after stroke dx

Answer 26

person w stroke will always get an MRI to assess extent of neurologic damage in a completed stroke - question will be when

Question 27

pros and cons of MRIs as a CVA diagnostic tool in the ED

Answer 27

pros: - detect smaller arteries (esp important when assessing above brainstem) - more accurate in detecting acute stroke than CT - greater detail provided cons: - less accessible in ED - more contraindications - can be safety issue - harder to monitor person in MRI

Question 28

what are 4 other dx medical tests to do other than scans

Answer 28

1. blood tests: coag, blood sugar - hypoglycemia can present similarly to stroke 2. angiogram 3. US (carotid) - looking to identify any plaque formation in arteries 4. ECG

Question 29

how do CT scans work and how will they show ischemic vs hemorrhagic strokes

Answer 29

same principles as XRs - fluid filled cavities don't absorb as much so will show up as more black - blood is more dense and shows up whiter hemorrhagic strokes - show up bright white ischemic strokes - darker than normal brain (less dense)

Question 30

what is the best best imaging tool to use to see the full extent of a stroke

Answer 30

MRIs w diffusion/perfusion and contrast

Question 31

how do MRI scans work and how will they show ischemic vs hemorrhagic strokes

Answer 31

magnetic field ischemic strokes = white hemorrhagic strokes will show up white, but not as localized or dense as on CT - see it running thru the area

Question 32

what is the gold standard screening tool used by trained ED MDs and RNs for stroke dx

Answer 32

NIHSS - national institutes of health stroke scale

Question 33

what is the NIHSS

Answer 33

gold standard initial and serial exam of impairments can link neuroanatomy to sx and what part of brain impacted by stroke - quantifies severity of stroke and nature of deficits

Question 34

when is the NIHSS conducted

Answer 34

anyone suspected of stroke done in intervals - baseline - 2hrs post - 24hrs post - 1-2wks later

Question 35

what are the results of NIHSS helpful w

Answer 35

acute management prognostic outcomes and dc - <6 good outcome, low disability - >/=16 high mortality rate, and inc disability

Question 36

what is the goal of medical management of an ischemic stroke

Answer 36

restore blood flow to ischemic tissue that is receiving enough blood to survive, but not to function (penumbra)

Question 37

what is the ischemic core

Answer 37

dead neurologic tissue - necrotic in nature - won't regain function

Question 38

what is the penumbra

Answer 38

ischemic tissue around the core that is still viable - not full function bc not full O2 perfusion - want to restore O2 asap so can regain function of penumbra

Question 39

what types of medical management interventions are utilized w ischemic stroke

Answer 39

pharmacological management surgical removal of clot - corkscrew, suction manage treatable risk factors (ie cardiac dz)

Question 40

what ischemic strokes is surgical medical management appropriate for

Answer 40

large vessel occlusions

Question 41

what pharmacological intervention is utilized w ischemic strokes

Answer 41

tPa

Question 42

what is tPa and what are characteristics of using this as management of an ischemic stroke

Answer 42

tissue plasminogen activator - effective if given w/i 3hr of onset - inc risk of hemorrhagic transformation -> needs to be monitored closely

Question 43

what is the goal of medical management of hemorrhagic strokes

Answer 43

dec the high ICP and edema

Question 44

what are medical management interventions to dec ICP in hemorrhagic strokes

Answer 44

craniotomy or surgical decompression VP shunt/drain

Question 45

what role does neurosurgery have in the management of hemorrhagic strokes

Answer 45

coil or clamp the aneurysm/AVM

Question 46

what are other medical interventions (that are nonsurgical) for hemorrhagic strokes

Answer 46

manage ICP w HOB elevation meds vit K infusions - promote clotting

Question 47

where is the most common place for an aneurysm

Answer 47

ant communicating a.

Question 48

what is the goal of medical management for a TIA

Answer 48

prevent a stroke

Question 49

what are medical interventions utilized in managing a TIA

Answer 49

treat risk factors to dec risk of future strokes - HTN, hyperlipid, DM, afib - ASA, anticoag, BP meds, statins, antispasmodics lifestyle modification - nutrition, exercise, stress

Question 50

what are medical interventions for strokes in general when managed acutely (8)

Answer 50

1. prevent re-bleed, manage ICP 2. CO, BP, cerebral perfusion, respiration 3. sz prevention 4. bowel and bladder function 5. skin integ 6. DVT prevention 7. infection control 8. nutrition, electrolyte balance

Question 51

ICP level is a greater concern in which type of stroke and why

Answer 51

hemorrhagic watch for midline shift or herniation

Question 52

why are anti-sz meds often prescribed for pts after a stroke

Answer 52

stroke or brain injury in risk of pt having a sz d/t pressure and edema from strokes/TBIs result in abnormal cell mechanisms - high risk of sz