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Caroline Summer 25 2.0 > Lecture 4 - Stroke > Flashcards

Lecture 4 - Stroke Flashcards

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1
Q

Ischemia vs Infarction

A

Ischemia - Decreased blood flow (reversible)

Infarction - death of tissue due to lack of blood low

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2
Q

Thrombosis vs embolism

A

Thrombosis - formation of clot in vessel

Embolism- blot clot travels elsewhere and lodges in smaller vessel

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3
Q

Stroke vs TIA

A

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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4
Q

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

A

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

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5
Q

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

A

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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6
Q

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

A

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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7
Q

ABCD2 score interpretations?

What is it used for?

0-7

A

Used to assess risk of stroke for the next 2 days 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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8
Q

What conditions can mimic a stroke?

A

Hypoglycemia/hypoxia

seizure

migraines

multiple sclerosis attacks

brain tumor/swelling

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9
Q

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

A

Because it cannot be localized to a single blood vessel

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10
Q

What is NOT an ischemic stroke?

A

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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11
Q

Stroke is the ___ leading cause of death in the US

Globally it is the __ leading cause of death

A

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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12
Q

What are considered modifiable risk factors for stroke

A

Hypertension

Diabetes

High Cholesterol

Heart disease

Smoking

Drug Abuse

Pregnancy

OCP(oral contraceptives)

Alcohol

Obesity

Physical Activity

Sleep Apnea

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13
Q

Nonmodifiable risk for stroke

A

Older age

Male

Family History

Race (Blacks > Whites)

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14
Q

Most strokes are :

A

Ischemic (87% of stroke)

note: 25-30% have undetermined etiology

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15
Q

An ischemic stroke will appear ______-dense on a CT

A

Hypo-dense

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16
Q

A hemorragic stroke will appear as _____dense on a CT scan

A

Hyperdense

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17
Q

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

A

Undetermined Etiology

Small Vessel Disease

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18
Q

Of all thrombotic infarctions, –% had a warning episode

A

50%

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

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19
Q

Anterior circulation

A

ICA, MCA, ACA, anterior communicating, ophthalmic

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20
Q

Posterior circulation

A

Basilar, Vertebral. ASA, AICA, PICA, PCA

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21
Q

Picture a brain scan with the areas affected by an MCA, ACA and PCA stroke

A
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22
Q

MCA infarctions mainly affect the ______

A

Hemiparesis of contralateral face/arm

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23
Q

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

A

The dominant

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24
Q

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

A

Non-Dominant side

N for N

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25
MCA strokes can cause _____ sensory loss and homonymous hemianopsia
Cortical
26
MCA strokes can cause a loss of conjugate gaze to the _____ side
idk but eyes go to the lesion side
27
Aphasia often starts as _______ and turns into only wernickes or broca's aphasia overtime
Global Aphasia
28
The anterior MCA supplies what language area? Posterior MCA?
Broca's Wernicke's
29
ACA strokes (rare) will cause deficits where?
Leg > arm
30
ACA can cause urinary incontinence usually only w/
bilateral infarcts
31
PCA infarcts often cause what?
Homonymous hemianopsia visual hallucinations cortical blindness inability to read (alexia)
32
Ischemia of Which cerebral artery can cause problems w/ motivation/organization behaviors
ACA
33
34
Symptoms of vertebrobasilar ischemia
Sensory/motor abnormalities in face/extremities vertigo/clumsiness/ataxia diplopia/dysarthria, dyphagia nausea/vomiting hearing loss/hiccups
35
Basilar strokes can cause **cranial nerve** problems on the _________ side and **weakness** in the body on the _______
Ipsilateral side Contralateral
36
cerebral emboli arise in the heart from:
Mainly atrial Fibrillation myocardial infarction akinetic segment endocarditis
37
How will a cardioembolic stroke appear on an MRI?
Diffuse throughout bran
38
_____(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
39
What is Warfarin (coumadin)
An oral anticoagulant used to treat a-fib
40
what is a risk of taking anticoagulants? name others besides warfarin
increases risk of bleeding rivaroxaban apixaban dabigatran
41
how do clinicians determine whether to place a pt at risk of a stroke on anticoagulants? (since its a risk itself)
use CHA2DS2-VAS add up points, if 2 or greater, place them on meds note: a stroke is one factor with 2 points alone so if they've had a stroke already they get put on the meds
42
3 places an embolic infarct can come from?
Aorta Large intracranial arteries Patent foramen ovale
43
embolic stroke of uncertain source (ESUS)
no cardiac etiology found signs of embolism but doctors cant find where from
44
What is a "lacunes" What are they usually related to/caused by? They typically affect what structures?
Small artery occlusion <1.5cm hypertension/diabetes Putamen/caudate/internal capsule/thalamus/corona radiata, pons
45
what are the different syndromes that can result from lacunar infarcts?
pure motor pure sensory sensorimotor dysarthria + clumsy hand syndrome ataxia & hemiparesis
46
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
47
+ Thalamic strokes cause ____________ sensory loss to all modalities + They may develop what syndrome? + Mild hemiparsis
Contralateral sensory loss May develop Thalamic pain syndrome
48
Hearing loss, facial weakness, ataxia, horner syndrome What (artery) stroke can cause these?
AICA
49
PICA/Vertebral artery strokes can cause ______ syndrome
Lateral medullar/wallenberg syndrome
50
ipsilateral ataxia and scanning/explosive speech Strokes of what artery can cause this?
Superior Cerebellar artery
51
What are rare causes of a stroke
Inherited disease inflammatory disorders hematologic disorders
52
What are the 6 steps to approaching a patient w/ an acute stroke?
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
53
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
54
For every ______ delay in TPA administration, there is a 10% decline in probability of a good outcome
30 min delay
55
What is the most important aspect of the history of someone who's had an acute stroke?
Time of onset
56
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
57
What is the only FDA approved medicine for acute strokes?
TPA Tissue plasminogen activator
58
Contraindications for TPA:
> 4.5 hours from last known normal hemorrhage head trauma or stroke in last 3 months severely high BP Endocarditis Bleeding disorder High Glucose 50+
59
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
60
2 post stroke disability scales
modified rankin scale - 0 (no symptoms) to 6 (death) barthal index - 10 basic ADL functions
61
For patients who have received TPA, BP must be measured ____________ for the first 24 hours
Check every 15 mins for first 2 hours then every 30 mins for first 6 hours Every hour for next 18 hours
62
why does BP go up so high after a stroke?
body naturally does this, so its normal but needs to be monitored and should be decreased after tpa meds Why? Because we want the higher BP in order to reestablish perfusion to the ischemic area
63
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
64
when can you start PT after a stroke?
wait 24 hrs, first priority is fixing BP
65
BP goal for patient w/ TPA vs without?
With TPA: <180/105 Without? <220/110
66
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
67
What is a carotid endarterectomy
Surgical procedure to remove plaque build up from carotid artery vs using a stent as a noninvasive approach
68
What is the NNT for a thrombectomy?
2,8 meaning you need to treat about 3 patients for a good outcome (good!)
69
antiplatelet/anticoagulation post stroke managment
embolic - anticoagulation large vessel - DAPT x 90 days small vessel DAPT x 21 days
70
An ischemic stroke on a DWI will appear : An ischemic stroke on an ADC will appear:
Light area on DWI Dark area on ADC
71
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
72
a stroke pt condition is worsening, what do you do?
no PT! keep BP up, lower head of bed, repeat imaging want to get BF back to ischemic area and save penumbra
73
The highest rate of recovery for a stroke is seen when?
1st 3-6 months but can have improvement (small) for several years
74
What abilities usually recover quicker after a stroke?
Swallowing/facial movements/ gait note: recovery tends to begin proximally
75
What abilities recover more slowily after a stroke?
Language, spatial attention, dominant hand movement
76
What are signs of an intracranial hemorrhage?
Very rapid onset Intracranial pessure symptoms: Headache, vomiting, decreased conciousness CT scan will show blood fast
77
T or F, you can tell an ischemic and hemorrhagic stroke apart using a physical exam
F U need imaging
78
What are the causes of an intracerebral hemorrhage? Most common?
Most common: Hypertension Trauma Rupture of Arteriovenous malformation aneurysm tumor hemorrhagic conversion
79
Common locations of an intracerebral hemorrhage?
Putamen, cerebral hemisphere, thalamus, cerebellum, pons
80
A higher score on the glasgow coma scale means what?
More conscious note: 3 is minimum score
81
How to treat intracerebral hemorrhage?
Treat intracranial pressure (Craniotomy/ectomy) Intubate reversal of antiplatelet or anticoagulation Aggressive BP management
82
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
83
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
84
What kind of stroke is the leading cause of death and disability
Aneurysmal subarachnoid hemorrhage
85
How can vasospasm from a hemorrhage lead to an ischemic stroke?
The blood irritates the smooth muscles of vessels and leads to vasospasm
86
Signs of a venous stroke?
Headache Focal neurological signs Hemorrhage Altered mental state/seizures Diagnose w/ CT or MRI
87
Who does a venous stroke usually occur in?
Pregnant woman/ women on birth control
88
new vs old strokes imaging?

Caroline Summer 25 2.0 (19 decks)

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