Lecture 4: CVA Flashcards Preview

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Flashcards in Lecture 4: CVA Deck (35):
1

Types of Strokes

1) Hemorrhagic: 17%, occur as a result of bleeding in the brain due to an injury to head or ruptured aneurysm of a vessel (produce more fatalities)
2) Ischemic stroke: 83%, occur because of clot formation in blood vessels

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Types of Hemorrhagic Strokes

1) Intracerebral Hemorrhage (59%)- occurs when defective artery in brain ruptures and surrounding area of brain fills with blood
2) Subarachnoid Hemorrhage (41%)- occurs when b. vessel on surface of brain ruptures and bleeds into subarachnoid space btwn skull

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Types of Ischemic Strokes:

1) Cerebral Embolism (20%): result of clot (embolus) that forms in another part of body and is carried to brain, becoming lodged in artery that supplies blood to brain; flow is blocked
2) Artherosclerotic Cerebrovascular Dz (20%): stroke occurs due to severe arterial stenosis or occlusion due to severe arteriosclerosis and coexisting thrombosus
3) Lacunar Infacrts (25%): results from microatheroma, lipohyalinosis and other occlusive dz.'s of the small penetrating arteries in the brain (usually basal ganglia, pons, cerebellum)
4) Cryptogenic (30%): unknown cause

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Lacunar Strokes

-small infarctions occur secondary to small vessel damage
-usually resulting from HTN or DM

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Most common areas affected by lacunar strokes

Basal ganglia and internal capsule!
-other areas affected: pons, cerebellum, thalamus

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Clinical Features of Lacunar strokes

1) Pure Motor Hemiplegia
2) Pure Sensory Strokes
3) Ataxic Hemiparesis
4) Secondary Motor Syndrome
5) Dysarthria CLumsy hand syndrome

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Pure Motor Hemiparesis

-contralateral weakness involving face-arm-leg
-limbs equally affected
- lesions occur in pons or internal capsule

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Pure Sensory Stroke

parathesias in face-arm-leg
-lesions occur in thalamus

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Ataxic Hemiparesis

incoordination accompanied by weakness of some limbs
-lesions usually in pons

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Secondary Motor Syndrome

causes weakness and sensory deficits of face-arm-legs
-lesions in posterior limb of internal capsule

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Dysarthria Clumsy Hand syndrome

slurred speech with clumsy contralateral hand
-lesions in pontine or brainstem lacunes

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MCA Infarction

contralateral hemiparesis, aphasia, homonymous hemianopsia

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MCA infacrtion: Dominant side

Aphasia: Broca's, Wernicke's or global
Gaze preference: toward side of lesion

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MCA stroke: non dominant side

Neglect, spatial disorientation: do not recognize anything on dominant side (so contralateral neglect)

also have agnosia-anosognosia

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Anterior cerebral artery stroke

contralateral weakness: lower extremities and face

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posterior cerebral artery stroke

homonymous hemianopsia contralateral to side involved: so R sided lesion cannot see L side

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Basilar Artery Stroke

may present with: quadriplegia, coma, altered consciousness, pupillary abnormalities, ocular palsy

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Basilar Artery Stroke: depend on CN involved

but remember: have ipsilateral deficit with CN nerves
Example: CN VII involvement: ipsilateral facial weakness: upper and lower

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With Basilar Artery stroke: Locked in syndrome

can only move eyes vertically

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Vertebral Artery Stroke

-sx's similar to basilar artery: contralateral hemiplagia and sensory deficit and ipsilateral CN palsy

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Hemorrhagic Stroke: Etiology

***HTN
-amyloid angiopathy
-AV malformation
-cavernous angioma
-intracranial aneurysm
-dural venous sinus thrombosis
-coagulopathy
-hemorrhagic conversion of infarction
-neoplasm or infxn

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Intracerebral Hemorrhage

most common causes HTN
Other causes: bleeding disorders, anticoag therapy, liver dz, High EtOh or primary/secondary brain tumors

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Intracerebral hemorrhage sx's

LOC, N/V, evoloving hemiplaegia or hemiparesis

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Thalamic hemorrhage

loss of upward gaze, downward or skew deviation, pupillary inequalities

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Nonmodifiable risk factors for stroke

Age, Sex (male), race (AAs), prior stroke, fam hx

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Modifiable risk factors for stroke

HTN, Hrt. Dz, smoking, TIA, Diabetes, High cholesterol, Wt

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Specific cardiac risk factors for stroke

arrhythmia, valvular dz, endocarditis, aortic arch plaque, low ejection fraction, septal defect, CAD, anuerysm, atrial/ventr thrombosus

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Other Risk factors

Migraine, coagulopathies, hemoglobinopathies (thalassemia, Sickle cell, TTP, congenital defects); malignancy, hyper coagulable state; Vasculitis/vasculopathy (SLE, secondary sylph); Drygs/medds; Infectious dz.'s; trauma; venous sinus thrombosis

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Tx options

-IV TPA
-Intra arterial TPA
-Endovascular tx: penumbra, MERCI, angioplasty, stenting, microwire clot disruption
-decompressive hemcraniotomy

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IV TPA

-must be given in 3 hr window; window of 4.5 hrs accepted

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Specific Inclusion criteria for IV TPA

-NO recent surgery or procedure involving non compressible site
-INR < 1.7
-Glucose > 60, < 185/110
-platelet > 100,000
No h/o intracranial hemorrhage

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Intra-arterial TPA

not FDA approved; deliver TPA directly into clot they artery
-extends to a 6 hr window

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Intra arterial TPA drawbacks

invasive procedure; limited hospitals can do procedure; does not help lacunar strokes

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Work up of Strokes

-carotid doppler
-Echo (TEE)
-MRI/MRA: helps differentiate btwn new and old
-Blood tests: HgA1c, lipid, syph, toxicology
-Carotid endarterctomy
-Carotid artery stent replacement

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Meds for stroke

Anticoags/antiplatelets: ASA, plavix, aggrenox, Heparin/levanox/coumadin (reserved for embolic strokes)