Neurological Emergencies Flashcards by cortney davis

What percentage of strokes are preventable

80%

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Name some modifiable risk factors of a stroke

DM, HTN, smoking, ETOH, obesity, Afib, High cholesterol

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Name some non-modifiable risk factors

Age, race (African American, Hispanic, Native American), Gender (Men), Previous TIA/CVA, family Hx

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Signs and symptoms of a stroke

Sudden onset garbled/inability to speak, unilateral arm or leg weakness or numbness, facial droop, severe HA, LOC, loss of balance, visual field cut

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Most common artery to be affected in a stroke

Middle Cerebral artery

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Percentage of Ischemia vs hemorrhagic

84%- Ischemic

16%- hemorrhagic

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Types of Ischemic strokes

Thrombolitic- 53%
Embolic- 31%
Lacunar

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What is the biggest risk factor for having an embolic stroke

A-fib

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What is a TIA

Stroke symptoms that clear within 24 hours

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What is the ischemic penebmbra

The “At risk” portion of the brain that is potentially reversable

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Symptoms of anterior cerebral artery stroke

Most die immediately
Frontal lobe portion, poor judgment, altered MS
Uncommon presentation

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Middle cerebral artery stroke

Contralateral hemiparesis, dysarthria, aphasia/apraxia, homonymous hemianopsia, facial droop

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Posterior cerebral artery stroke

contralateral homonymous hemianopsia
Unilateral cortical blindness
Memory loss
Unilateral 3rd nerve palsy

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Vertebrobasilar stroke

close to brain stem
Unilateral or bilateral CN deficits
Coma, death, respiratory insufficiency 
Tachycardia
Liable BP

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Opthalmic artery strokes

Amaurosis Fugax

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Lucunar infarcts

isolated hemiparesis, dystonia, dysarthria, sensory defects, unilateral parkinsonian signs

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What is the Cincinnati pre-hospital stroke scale

Identifies 3 areas- facial droop, pronator drift, speech

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What is the NIH stroke scale

measures sensory, motor, speech, gaze, LOC to identify stroke outcomes

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Why do we use CT in a stroke

to rule out other causes, or to identify bleeding

Infarcts will not show for 24 hours on CT

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What BP do we need to keep people with a suspected stroke below?

220 or less

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What could mimic a stroke

Hypogycemia

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What are the inclusion criteria to give thrombolitic therapy to a ishemic stroke patient

1) Age of at least 18
2) Within 180 minutes of onset of sx’s—NOW EXPANDED TO 4.5 HOURS FROM 3 IN SOME PTS
3) Stroke sx’s acutely
4) BP systolic less than 185, diastolic less than 110
5) No assoc seizures
6) Not minor sx’s or rapidly resolving sx’s
7) No Coumadin use**CHANGED, NOW RELATIVE
8) PT less than 15, INR less than 1.7
9) No Heparin during last 48 hours, normal APTT
10) Platelet count grt than 100,000
11) Glucose grt than 50, less than 400
12) No MI
13) No hx AVM, aneurysm, ICH in past
14) No major surgeries in last 14 days
15) No CVA or serious head injury within 3 months
16) No GI/GU bleeding in last 21 days
17) No lactation or pregnancy within the last 30 days

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Can you give TPA within 4.5 hours instead of 3?

Yes as long as not…
AGE GRT THAN 80
ORAL ANTICOAGS WHO HAVE INR25
PRIOR CVA OR DIABETES

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What are some adjunct therapies for ischemic stroke treatment

ASA, other antiplatelets, Heparin

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If you use a catheter to administer TPA how long do you have for it to be effective

6 hours

If I have A fib what should you give me?

heparin

What are the steps of endovascular retrieval?

1) Catheter is inserted into groin after angiography showing location of cerebral clot 2) Catheter is fed into cerebral location 3) Clot is snared, and sucked up into balloon 4) Catheter is than removed, and clot removed from body

If you have had a TIA what is the probability you will have another within 24 hours? Within 30 days?

A) 30-50% | B) 75%

What are the types of Hemorrhagic strokes?

ICH (10%) SAH (6%) IVH

What is often the culprit of an SAH

Trauma or Berry Aneurysm

What is the number one cause of Intracranial Hemorrhage?

Hypertension | Other cause= Cocaine

What is the cause of an inraventricular hemorrhage?

Consequence of other bleeding

What is the modality of choice in diagnosing a hemorrhagic stroke?

CT- Non contrast

If you suspect an aneurysm what should you get?

CT/MR angiography r formal cerebral angiogram

Management of a hemorrhagic stroke?

Control BP- SBP less than 180 Seizure meds Frequent neruo monitoring

Should you slowly or rapidly decrease the blood pressure in a hemorrhagic stroke patient?

SLOWLY

What type of medications should you use to decrease the blood pressure in an hemorrhagic stroke?

Titratable BP meds--> cortarone, labetalol, nitropuriside

Can you use a beta blocker ALONE to decrease the blood pressure in a hemorrhagic stroke?

NO- too rapid of a descent

What is a new drug being studied for use in hemorrhagic stroke patients?

Recombinant Factor VIIa/Novo 7

What are the layers of the scalp?

``` S- Skin C- Connective tissue/fat A- Aponerosis (Galea)-- blood vessels L- Loose connective tissue P- Periosteum/pericranium ```

If you do not ensure that the Galea is closed fully while suturing the scalp closed what can result?

Expanding/subgaleal hematoma

IF the temporal bone fractures what are you at risk for?

EDH- Middle menigral artery is deep to this

When do you need surgical intervention for a depressed skull fracture

If is depressed more than the thickness of the skull

What is the danger or a basilar fracture?

CSF leaks out!

What are some signs on clinical exam that indicate a basilar fracture?

Hemotympanum Battle sign CSF oto/rhinorrhea Rccoon eyes

What is a concussion?

Breif LOC secondary to non-penetrating trauma, with GSC greater than 12 and negative CT

Symptoms of a concussion

HA, N?V, brief AMS,

If I have a GCS of 11 could I have a concussion?

No --> can get as low as 13 but thats it

Treatment of concussions

observation in hospital or at home, limited cognitive activity (HW, TV), No sports, cognitive follow up

How long to concussion patients need to be followed up for?

until the symptoms are gone

What is a cerebral contusion?

Brain bruise

What imaging modality is best to look for cerebral contusions, and what would it show

CT- small punctate hemorrhage that may enlarge over time

What is the treatment of a cerebral hemorrhage

close observation | Repeat CT in 24 hrs

What is the prognosis of cerebral contusion

Good prognosis, reabsosrb over time

What is a countercoup injury?

2 injuries- Injury to the brain at area of impact as well as the opposite side of the skull

What is a Diffuse Axonal Injury (DAI)

"Tearing/shearing" of axons diffusely in the brain. primary lesion of rotational, accelerating/descelerating durring trauma

What is the prognosis of DAI?

Bad, low GSC, deeply comatose and death is likely

What is the imaging modality used fo DAI and what does it show

CT- normal followed by areas of small hemorrhages

If I am stabbed in the head should you remove the knife?

No! you can worsen the neuro outcome. Go to OR to do that

Where is an Epidural

Between dura and skull

Classic presentation of an Epidural

1) Brief post trauma LOC, 2) Lucid interval, 3) Obtunded , contalateral hemiparesis, ipsilateral pupillary dilation

What is the main vessel affected in an EDH

Middle Menigeal artery

What is Kernohans phenomenon

Shift of the brain stem away from the mass/bleed with compression of the opposite cerebral peducle- causes ipsilateral hemiparesis

How do you diagnose an EDH

CT- non contrast

On CT does an EDH cross the suture line?

What is the treatment of a small EDH

Follow clinically + repeat neuro checks and CT

Treatment for larger EDH

Surgical evacuation/clot removal, emergent burr holes for increasing ICP, Control BP/PAin

Where is a subdural hematoma

between dura and arachnoid

What is in the space between the dura and arachnoid space?

CSF

What vessel is affected in a subdural hematoma

venous- common in elderly

Diagnosis of SDH

CT- appears hyperdense

Classic presentation of SDH

No lucid period, focal signs later and less prominent than with EDH

Treatment of SDH

Control BP/ICP, reverse anticoagulation drugs, frequent neuro checks, maybe surgical intervention

Chronic SDH

Common in elderly

Symptoms of chronic SDH

HA, confusion, vomiting, AMS, language difficulties

Tx of chronic SDH

maybe burr hole drainage but usually liquifies in 1-2 weeks

Where is a subarachnoid hemorrhage

bleeding in subarachnoid space

Presnetation of SAH

Thunderclap HA

DX of SAH

Tx of SAH

Usually only need observation, no surgical intervention, serial examps and repat CT, consider ventriculostomy/EVD to drain if hydrocephalus presents

TBI evaluation essentials

Meticulous Hx, Curent meds (anticoag), VS, head to tow PE, neuro exam

What does a positive babinski indicate

Upper motor neuron lesion