Lecture 4 - Stroke Flashcards by Alexander Lee

Ischemia vs Infarction

Ischemia - Decreased blood flow (reversible)

Infarction - death of tissue due to lack of blood low

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Thrombosis vs embolism

Thrombosis - formation of clot in vessel

Embolism- blot clot travels elsewhere and lodges in smaller vessel

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Stroke vs TIA

Stroke - Disruption of blood flow resulting in change in neurological function (lasting more than 24 hours.)

TIA- Transient Ischemic Attack - Usually less than 1 hour, up to 24 hours.

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T or F: a TIA will not show evidence on an MRI

T, it is a breif episode of dysfunction in the brain without evidence of an acute infarction on an MRI

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When is the highest risk of a stroke after a TIA?

1st 30 days after

90 day risk after a stroke is 3-17%

Those with TIA have an 18.8% strok risk in the next 10 years

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What are the categories of the ABCD tool used for evaluating the risk after a TIA ?

Age 60+ - 1pt

Blood pressure 140+ or DBP 90+ 1pt

Clinical features- unilateral weakness or speech impairment - 1 pt

Duration? 60+ minutes : 2 pt , 10-59 mins : 1 pt

Diabetes 1pt

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ABCD2 score interpretations?

What is it used for?

0-7

Used to assess risk of stroke after someone had a TIA

7 total points

6-7: high risk of stroke in 2 days: 8%

4-5: Moderate risk of stroke in 2 days: 4%

0-3: Low risk of stroke in 2 days: 1%

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What conditions can mimic a stroke?

Hypoglycemia/hypoxia

seizure

migraines

multiple sclerosis attacks

brain tumor/swelling

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Why is weakness in both hands or both legs likely not indicative of a stroke

Because it cannot be localized to a single blood vessel

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What is NOT an ischemic stroke?

Sudden loss of conciousness (note: this is true for a hemmorhagic stroke)

Pre-syncope/syncope

numbness in both feet

waxing/waning confusion

diffuse weakness

numbness in one and or foot

pain

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Stroke is the ___ leading cause of death in the US

Globally it is the __ leading cause of death

5th

2nd

Note: it is the leading cause of serious disability in the US

There has been a decline in stroke mortality over past decades

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What are considered modifiable risk factors for stroke

Hypertension

Diabetes

High Cholesterol

Heart disease

Smoking

Drug Abuse

Pregnancy

OCP(oral contraceptives)

Alcohol

Obesity

Physical Activity

Sleep Apnea

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Nonmodifiable risk for stroke

Older age

Male

Family History

Race (Blacks > Whites)

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Most strokes are :

Ischemic (87% of stroke)

note: 25-30% have undetermined etiology

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An ischemic stroke will appear ______-dense on a CT

Hypo-dense

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A hemorragic stroke will appear as _____dense on a CT scan

Hyperdense

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Most ischemic strokes are ________, the second most common is ________

Undetermined Etiology

Small Vessel Disease

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Of all thrombotic infarctions, –% had a warning episode

50%

Note: Thrombotic infarctions ofen happen during sleep, pt awakens w/ deficit

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MCA infarctions mainly affect the ______

Hemiparesis of contralateral face/arm

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MCA strokes can cause aphasia if which side of the brain is affected?

The dominant

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If an MCA stroke happens on the _______ side, your neglect is more significant

Non-Dominant side

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MCA strokes can cause _____ sensory loss and homonymous hemianopsia

Cortical

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MCA strokes can cause a loss of conjugate gaze to the _____ side

Opposite side

(trouble looking away from the weak side)

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Aphasia often starts as _______ and turns into only wernickes or broca’s aphasia overtime

Global Aphasia

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The anterior MCA supplies what language area? Posterior MCA?

Broca's Wernicke's

ACA strokes (rare) will cause deficits where?

Leg > arm

ACA can cause urinary incontinence usually only w/

bilateral infarcts

PCA infarcts often cause what?

Homonymous hemianopsia visual hallucinations cortical blindness inability to read (alexia)

Ischemia of Which cerebral artery can cause problems w/ motivation/organization behaviors

ACA

Symptoms of vertebrobasilar ischemia

Sensory/motor abnormalities in face/extremities vertigo/clumsiness/ataxia diplopia/dysarthria, dyphagia nausea/vomiting hearing loss/hiccups

Basilar strokes can cause **cranial nerve** problems on the _________ side and **weakness** in the body on the _______

Ipsilateral side Contralateral

cerebral emboli arise in the heart from:

Mainly atrial Fibrillation myocardial infarction akinetic segment endocarditis

How will a cardioembolic stroke appear on an MRI?

Diffuse throughout bran

_____(heart condition) can **increase** stroke risk x5 and x2 increase risk of death but ____________ therapy can **reduce** the risk of stroke by 2/3

A fib Oral anticoagulation therapy

What is Warfarin (coumadin)

An oral anticoagulant used to treat a-fib

3 places an embolic infarct can come from?

Aorta Large intracranial arteries Patent foramen ovale

What is a "lacunes" What are they usually related to/caused by? They typically affect what structures?

Small artery occlusion hypertension/diabetes Putamen/caudate/internal capsule/thalamus/corona radiata, pons

What are the classes/classic symptoms of lacunar infarctions Pure motor: Pure sensory: Sensorymotor: Dysarthria+ clumsy hand syndrome: Ataxia-Hemiparesis:

**Pure motor** - Hemiparesis (Internal capsule base of pons) **Pure sensory stroke**- (Posterolateral thalamus) - note: think dorsolateral column for sensory **Sensorimotor stroke**: Thalamus + internal capsule (anything motor includes internal capsule) **dysarthria and clumsy hand syndrome**: base of pons **Ataxia-hemiparesis** - Pons + Internal capsule or subcortex

+ Thalamic strokes cause ____________ sensory loss to all modalities + They may develop what syndrome? + Mild hemiparsis

Contralateral sensory loss May develop Thalamic pain syndrome

Hearing loss, facial weakness, ataxia, horner syndrome What (artery) stroke can cause these?

AICA

PICA/Vertebral artery strokes can cause ______ syndrome

Lateral medullar/wallenberg syndrome

ipsilateral ataxia and scanning/explosive speech Strokes of what artery can cause this?

Superior Cerebellar artery

What are rare causes of a stroke

Inherited disease inflammatory disorders hematologic disorders

What are the 6 steps to approaching a patient w/ an acute stroke? 1. _______ 2. Categorize _______ 3. Determine _______ 4. Calculate ________ 5. Determine ________ 6. Determine ______

Stabilize patient Categorize as ischemic vs hemorrhagic Determine last known normal Calculate NIHSS score Determine if theyre a candidate for acute thrombolytics Determine if theyre a candidate for endovascular intervention

What is the goal of door to needle time (time they enter hospital to time they get clotbuster (TPA)

45 mins note: the standard time is 60 mins

For every ______ delay in TPA administration, there is a 10% decline in probability of a good outcome

30 min delay

What is the most important aspect of the history of someone who's had an acute stroke?

Time of onset

11 Categories to the NIHSS

Conciousness Best gaze- horizontal eye movemnent visual field- determine if there's hemianopia or blindless Facial palsy - ask them to make faces Motor (arm)- ask them to raise arms Motor (leg)- ask them to raise leg in supine for 5 seconds Limb Ataxia - check finger to nose Sensory- use safety pin Language Dysarthria Extinction/neglect

What is the only FDA approved medicine for acute strokes?

TPA Tissue plasminogen activator

Contraindications for TPA: _____ hours from last known normal hemorrage head trauma or stroke in last 3 months severely high BP Endocarditis Bleeding disorder High Glucose 50+

4.5 hours from last known normal

T or F: TPA has no benefit to mortality of acute strokes

T No benefit to mortality However it does increase the likelihood of a good outcome within 3 months

For patients who have received TPA, BP must be measured ____________ for the first 24 hours

Check every 15 mins for first 2 hours every 30 mins for first 6 hours Every hour for next 18 hours

Patient's who have taken TPA need to maintain a bloodpressure of what?

Under 180/105, however it's suppose to be high, its bad if it's low or normal

BP goal for patient w/ TPA vs without?

With TPA: 180/105 Without? 220/110 Why? Because we want the higher BP in order to reestablish perfusion to the ischemic areas

If a patient is worsening after receiving TPA what should the medical team do?

Repeat imaging keep BP up Keep patient supine NO PT May do craniotomy to reduce swelling

What is a carotid endarterectomy?

Surgical procedure to remove plaque build up from carotid artery

An ischemic stroke on a DWI will appear : An ischemic stroke on an ADC will appear:

Light area on DWI Dark area on ADC

On a DWI, a new stroke will appear as a : An old stroke will appear as a:

New stroke: Light hyperdense area Old stroke: Dark hole

The highest rate of recovery for a stroke is seen when?

1st 3-6 months but can have improvement (small) for several years

What abilities usually recover quicker after a stroke?

Swallowing/facial movements/ gait note: recovery tends to begin proximally

What abilities recover more slowily after a stroke?

Language, spatial attention, dominant hand movement

What are signs of an intracranial hemorrhage?

Very rapid onset Intracranial pessure symptoms: Headache, vomiting, decreased conciousness CT scan will show blood fast

T or F, you can tell an ischemic and hemorrhagic stroke apart using a physical exam

F U need imaging

What are the causes of an intracerebral hemorrhage? Most common?

Most common: Hypertension Trauma Rupture of Arteriovenous malformation aneurysm tumor hemorrhagic conversion

Common locations of an intracerebral hemorrhage?

Putamen, cerebral hemisphere, thalamus, cerebellum, pons

A higher score on the glasgow coma scale means what?

More conscious note: 3 is minimum score

How to treat intracerebral hemorrhage?

Treat intracranial pressure (Craniotomy/ectomy) Intubate reversal of antiplatelet or anticoagulation Aggressive BP management

80% of subarachnoid hemorrhage are caused by what

**Rupture of intracranial aneurysm** Note: 10% die b4 medical attention 40% die in 3 months 50% of survivors have disabilities

Symptoms of aneurysm rupture?

Sudden explosive headache loss of conciousness stiff neck/light sensitivity nausea/vomiting Note: 50% of patients have a warning leak with more subtle signs b4 a rupture

What kind of stroke is the leading cause of death and disability

Aneurysmal subarachnoid hemorrhage

How can vasospasm from a hemorrhage lead to an ischemic stroke?

The blood irritates the smooth muscles of vessels and leads to vasospasm

Signs of a venous stroke?

Headache Focal neurological signs Hemorrhage Altered mental state/seizures Diagnose w/ CT or MRI

Who does a venous stroke usually occur in?

Pregnant woman/ women on birth control