CVA Case 3

Question 1

Name the three types of CVA

Answer 1

1. Ischemic
2. Hemorrhagic
3. Small Vessel (Lacunar)

Question 2

This type of stroke is caused by insufficient blood flow to part of the brain resulting in neuro deficits that last > 24 hrs

Answer 2

Ischemic

Question 3

If a stroke lasts < 24 hrs it is called what?

Answer 3

TIA
= transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction

Question 4

What type of stroke is this?

Occlusion forms locally at the site

Answer 4

Thrombotic

Question 5

What type of stroke is this?

Clot breaks off in another location and travels to the brain

Answer 5

Embolic

Question 6

What type of stroke is this?

• Extravasation of blood into the brain
• Ie: aneurysm, head trauma

Answer 6

Hemorrhagic

Question 7

What type of stroke is this?

• From occlusion of small arterioles
• Usually from longstanding HTN

Answer 7

Lacunar

Question 8

Some risk factors for CVA are?

Answer 8

Increasing age
Afib
Hypercoagulable states
HTN
Smoking
Diabetes
Dyslipidemia
Carotid Stenosis
TIA
Physical Inactivity & obesity
Drug use

Question 9

Signs and symptoms of stroke depend on what?

Answer 9

The area of the brain was deprived of blood flow

Question 10

Contralateral paralysis and sensory loss that mostly (or only) affects the leg is characteristic of an anterior, middle or posterior stroke?

Answer 10

Anterior Cerebral Artery (ACA)

Question 11

Abulia (apathy) is characteristic of an anterior, middle or posterior stroke?

Answer 11

Anterior Cerebral Artery (ACA)

Question 12

Urinary incontinence is characteristic of an anterior, middle or posterior stroke?

Answer 12

Anterior Cerebral Artery (ACA)

Question 13

Gait apraxia is characteristic of an anterior, middle or posterior stroke?

Answer 13

Anterior Cerebral Artery (ACA)

Question 14

Grasp reflex or sucking reflex is characteristic of an anterior, middle or posterior stroke?

Answer 14

Anterior Cerebral Artery (ACA)

Question 15

Hemiparesis primarily affecting face & arm is characteristic of an anterior, middle or posterior stroke?

Answer 15

Middle Cerebral Artery (MCA)

Question 16

Hemisensory deficit primarily affecting the face & arm is characteristic of an anterior, middle or posterior stroke?

Answer 16

Middle Cerebral Artery (MCA)

Question 17

Gaze preference toward the affected hemisphere is characteristic of an anterior, middle or posterior stroke?

Answer 17

Middle Cerebral Artery (MCA)

Question 18

Aphasia (if dominant hemisphere is affected) is characteristic of an anterior, middle or posterior stroke?

Answer 18

Middle Cerebral Artery (MCA)

Question 19

Hemianopsia is characteristic of an anterior, middle or posterior stroke?

Answer 19

Middle Cerebral Artery (MCA)

Question 20

May have apraxia and sensory neglect is characteristic of an anterior, middle or posterior stroke?

Answer 20

Middle Cerebral Artery (MCA)

Question 21

In a stroke, a patient’s eyes will gaze towards or away from the lesion?

Answer 21

Towards

Stroke on R side so they will gaze to R side

Question 22

Homonymous hemianopsia affecting the contralateral visual field that may be denser superiorly is characteristic of an anterior, middle or posterior stroke?

Answer 22

Posterior Cerebral Artery (PCA)

Question 23

Anomic aphasia (difficulty naming objects) is characteristic of an anterior, middle or posterior stroke?

Answer 23

Posterior Cerebral Artery (PCA)

Question 24

Alexia without agraphia (inability to read, but able to write) is characteristic of an anterior, middle or posterior stroke?

Answer 24

Posterior Cerebral Artery (PCA)

Question 25

Visual agnosia is characteristic of an anterior, middle or posterior stroke?

Answer 25

Posterior Cerebral Artery (PCA)

Question 26

Contralateral hemisensory loss and hemiparesis is characteristic of an anterior, middle or posterior stroke?

Answer 26

Posterior Cerebral Artery (PCA)

Question 27

Unilateral headache is characteristic of an anterior, middle or posterior stroke?

Answer 27

Posterior Cerebral Artery (PCA)

Question 28

Memory impairment is characteristic of an anterior, middle or posterior stroke?

Answer 28

Posterior Cerebral Artery (PCA)

Question 29

Oculomotor (III) nerve palsy is characteristic of an anterior, middle or posterior stroke?

Answer 29

Posterior Cerebral Artery (PCA)

Question 30

___________ involves absence of cortical signs (aphasia, agnosia, neglect, apraxia, hemianopsia), plus one of the following: - Pure motor hemiparesis (Can't move body parts well) - Pure sensory hemiparesis (can't feel face) - Ataxic hemiparesis (ipsilateral) - Sensorimotor stroke (weak and numb body parts) - Dysarthria/clumsy hand syndrome

Answer 30

Lacunar Infarction

Question 31

What test should we do for evaluation of CVA?

Answer 31

CT head (non-contrast): to eval for hemorrhage

Question 32

What is the inclusion criteria for tPA administration? Hint: - Age - Clinical dx - Time

Answer 32

- Age greater than or equal to 18 y.o - Clinical diagnosis of ischemic CVA with a measurable neurologic deficit - Time of onset <4.5 hours

Question 33

What are the most important Tpa EXCLUSION CRITERIA?

Answer 33

- Evidence of intracranial hemorrhage on CT - Previous intracranial hemorrhage - Known AVM, neoplasm or aneurysm - Severe uncontrolled HTN (SBP>185 or DBP >110) - Thrombocytopenia <100k - Current use of an anticoagulant with INR >1.7 or PT >15 seconds - Heparin use within 48 hours and abnormally elevated aPTT - Active internal bleeding - Significant stroke or head trauma in the previous 3 months - Recent intracranial or intraspinal surgery - Serum glucose < 50

Question 34

Relative Exclusion criteria for tPA (basically warnings)

Answer 34

- Minor or isolated neurologic signs - Rapidly improving stroke symptoms - Major surgery or serious trauma in the previous 2 weeks - GI or urinary tract bleeding in the previous 3 weeks - MI in previous 3 months - Seizure at the onset of stroke with postictal neurologiuc impairments - Pregnancy

Question 35

Relative exclusion criteria from 3-4.5 hours after sx onset

Answer 35

- Age >80 - Oral anticoagulant use regardless of INR - Severe stroke (NIHSS score >25) - Combination of both previous ischemic stroke and diabetes

Question 36

In an ischemic CVA, Before thrombolysis: lower SBP to _______ and DBP to _______

Answer 36

Before thrombolysis: lower SBP to <185 and DBP to <110

Question 37

After an inschemic stroke, BP needs to be maintained at ________ for at least 24 hours

Answer 37

Afterward, BP needs to be maintained <180/105 for at least 24 hours

Question 38

Antithrombotic therapy for CVA?

Answer 38

- Aspirin, clopidogral (Plavix), or aspirin-extended release dipyridamole (Aggrenox) all choices

Question 39

Antithrombotic therapy for CVA for patients with Afib?

Answer 39

Warfarin or NOAC for those with afib

Question 40

These are all important HPI signs of what? - Difficulty speaking - Unable to move right arm or leg - Last seen well the prior night at 10 pm - Has been having episodes of memory loss and loss of vision - Risk factors: HTN, smoker, overweight, recent MI

Answer 40

A stroke

Question 41

Admit note acronym- ADCVAANDISML stands for what?

Answer 41

``` Admit to Diagnoses Condition Vital signs Activity Allergies Nursing Diet IV Special instructions Medication Labs/Xrays ```

Question 42

When is the CHAD2 criteria used?

Answer 42

To determine a patient's risk for stroke that has afib and when to give them anticoags

Question 43

If a patient has a chads2 score of 2 or greater than 2, what should you do?

Answer 43

Put them on anticoags (warfarin/coumadin, xarelto, pradaxa, eliquis) *not plavix

Question 44

Name everything in the chads criteria

Answer 44

``` C- CHF (1 pt) H- HTN (1 pt) A- Age greater than or equal to 65 (1 pt) D- DM (1 pt) S- Stroke/Tia (2 pts) ```