Ischemic & Hemorrhagic Stroke

Question 1

Presentiation of large vessel ischemic stroke/TIA

Answer 1

• ==> deficits in multiple systems
• e.g. @ middle cerebral ==> hemiparesis, hemisensory loss, defect in visual field contralateral to ischemic side of brain

Question 2

General presentation of small vessel ischemic stroke/TIA

Answer 2

• ==> isolated motor or sensory deficit in one side of the body

Question 3

Common non-atherosclerotic causes of stroke in young patients

Answer 3

• coagulopathy
• sickle cell anemia
• oral contraceptives, post partum
• antiphospholipid ab syndrome

Question 4

Non-coagulopathy-related non-atherosclerotic causes of stroke in young patients

Answer 4

• alcohol abuse
• stimulant abuse
• physical inactivity
• congenital hearts: patent foramen ovale, ASD, VSD
• acquired cardiac dz: CHF, valvular, A-Fib, myxoma (non-cancerous tumor in heart)
• acquired vascular dz: carotid, vertebral, arch stenosis/ulceration

Question 5

Less common (but possible) non-atherosclerotic causes of stroke in young patients

Answer 5

• vasculitis
• migraine
• venous infarction
• vasospasm

Question 6

Rescuscitation related to stroke mechanism

Answer 6

• ischemic stroke <== thrombisis
• resuscitation ==> break up clot and maintain volume of blood to maintain brain perfusion

Question 7

Prevention related to stroke mechanism

Answer 7

• keep arteries healthy ==> prevention of atherosclerosis and hypercoaguability
  *

Question 8

Basic principles /goals of emergency tx of stroke

Answer 8

• preserve non-infarcted areas of brain
• prevent progression of infarction
• avoid complication
• initiate evaluation for long-term therapy

Question 9

Tx of ischemic stroke @ ER

Answer 9

• act fast even w/normal scans
  
  • If CT scan shows hemorrhage, then you know that it is hemorrhagic.
  • If not, you know it is ischemic when combined with the story and clinical signs.
• Re-open arteries with a catheter, thrombolytics.
  
  • generally a 4 hour IV window for thrombolytics
  • Tissue Plasminogen Activator (TPA) is the drug of choice.
• Keep fluids up, maximize cardiac output, and resist the temptation to lower blood pressure (unless dangerously high)
• treat hypoglycemia when it exists.

Question 10

Fluids used in emergency ischemic stroke tx

Answer 10

• Avoid lowering BP
  
  • most stroke patients have HTN following a stroke that fixes itself within 7-10 days
• If they won’t decompensate into heart failure, you can give normal saline.
• If they will, give d5W unless they are having a very large stroke and at risk for cerebral edema.

Question 11

Non-modifiable risks for stroke

Answer 11

• age
• gender
• ~race/ethnicity
• family history

Question 12

Modifiable risks for stroke

Answer 12

• HTN
• lipid disorders
• homocysteine elevations
• smoking
• obesity
• diabetes
• sedentary lifestyle

Question 13

Clinical presentation of ruptured intracranial aneurysm

Answer 13

• sudden onset neurological deficits
• headache
  
  • “worst headache of their life”
• nausea, vomiting
• depressed level of consciousness

Question 14

Clinical presentation of ruptured intracerebral hemorrhage

Answer 14

• begins: mild headache, mild neuro deficits, some nausea ==(minutes - hours)==> + decreased level of consciousness
• hemiparesis ==> hemiplegia
• decreased consciousness ==> coma

Question 15

Characteristics/causes of intracerebral hemorrhage

Answer 15

• Causes: HTN & age
• typical locations:
  
  • putaman
  • thalamus
  • pons
  • basal ganglia
• can also occur in deep white matter = “lobar hemorrhages”

Question 16

Clinical presentation of acute subdural hemorrhage

Answer 16

• Due to trauma or spontaneous
• confusion, lethargy, coma,
• focal neurologic symptoms, seizures
• headache, dizzines
• N/V, ataxia

Question 17

Clinical presentation of chronic subdural hemorrhage

Answer 17

• Spontaneous Subdural Hemorrhage can be relatively asymptomatic ==> “Chronic Subdural Hemorrhage” = expands over days to months.
• headache
• seizures
• vomiting
• limb weakness/spasticity
• speech difficulties, confusion
• drowsiness, impaired consciousness
• focal neurological deficit

Question 18

Clinical presentation of epidural hemorrhage

Answer 18

• trauma/injury ==> period of grogginess ==> lucid interval ==> worsening condition/consciousness
• commonly = traumatic temporal bone fracture tears middle meningeal artery

Question 19

Emergency treatment of hemorrhage

Answer 19

• if ischemic ==> hemorrhage then use anti-platelets/anticoagulants
• rapid dx ==> ICP monitoring device +/- drainage device
• reduce ICP via diuresis and reduction of blood pCO₂
• emergency surgery if neccessary
  
  • common in subdural and epidural hemorrhage