stroke Flashcards Preview

CSI > stroke > Flashcards

Flashcards in stroke Deck (84):
1

can do what in 5 secs of walking in room

ABCs (pt speaking)
when did this start?
-if woke up with stroke not eligible for tPA
-vitals: BP!
-oriented/confused
-family present

2

if on coumadin

not candidate for tPA

3

family can...

sign for tPA consent
verify onset

4

stroke vs. bells

stroke spares the forehead, can wrinkle

5

stroke brkdwn

80% ischemic, 20% hemorrhagic

global: low CO (MI, a fib)
focal: occlusion (thrombotic, emolic)

*3rd leading cause of death

6

strokes can be caused by

emobolism, thrombus,
hypoxic etiologys: hypoperf, or hypoxemia
happens during cerebrovasc. sx: affects watershed areas

7

risk factors for ischemic stroke

DM
HTN
smoking
fam hx
high cholesterol
afib
drugs (cocaine)
hx of TIA or recent MI
hx of CHF
OCPs

8

ant. vs posterior circulation

will affect what type stroke

9

watershed zones: area covered by 2 arteries

ant and mid cerebral aa
post and mid cerebral aa

usually from hypotension
upper leg and upper arm weakness
defects in higher order visual processing

10

autoregulation

maintains constant level of CBF despite changing perfusion pressure

11

CPP normally driven by

pCO2, ICP dec. as CO2 dec. via vasoconstriction
*hypervent theory in trauma, CVA*
-can actually cause more damage

12

hypoxemia will

inc. CPP IF PO2

13

CPP=

MAP (BP)-ICP
if CPP=0-->brain dead
via blood flow study
a dec. in BP or inc. in ICP results in lowering of CPP

14

know charts

pg 463

15

chronic HTN

lower/upper levels of autoreg are raised-->tolerance of higher blood pressures, but more *intolerance* to lower BP
*used to give clonidine to reduce high BP-won't stroke out-->but they do from low BP!
*now we do NOT abruptly lower BP in asymptomatic chronic HTN pts* it's relative
put on antiHTN, not rapid

16

cerebral ischemia will lead to

liquefactive necrosis
emo/throm: focal OR
dim. syst: global OR
hypoxia

prolonged ischemia-->infaction
young or old

17

penumbra

transition zone between normal tissue and infarcted tissue

need to save!

18

ischemic histo timeline

12-48 hr—red neurons
24-72 hr—necrosis w neutrophils
3-5 days—macrophages (microglia)
1-2 wks—reactive gliosis w vascular proliferation
>2ks—glial scar

19

irrev. damage

after 5 min hypoxia

20

most vulnerable areas

*hippocampus, neocortex, cerebellum, watershed areas

21

cerebral edema accumulates..

over 3-5 days after stroke-->death

22

2/3 ischemic strokes

cerebral atherosclerosis

23

1/3 ischemic strokes

cardiogenic emboli
afib
patent foramen ovale-DVT

24

etiology in younger pts: things that make you clot

arterial dissections
DRUGS: *cocaine, OCPs(pro-coag), heroin(hypoximic)
endocardidtis
protein C or S deficiency
antithrombin III deficiency
anti-PL AB
SCD
SLE
PFO: patent foramen ovale

25

stroke prevention

control risk factors/reverse them
diet
smoking
HTN-don't take of BP meds
DM
high cholesterol
afib

26

a fib inc. CVA risk

17x
coum/warf therapy: INR 2-3x basement

Chad's score/Chad 2 score/*Chad vasc score* know
-who with a fib need anticoags?

27

carotid stenosis

>70% carotid endarterectomy(cleaned out) if high risk-->stunting

60--70% early carotid endarectomy best rather then deferring

28

TIA

transient neuro deficit
NO infection, neg MRI*

Lasting usually

29

lacunar stroke

Small lesions

30

anterior strokes

MCA, ACA, lateral striate, ophthalmic

31

Ophthalmic artery stroke

amaurosis fugax: sudden vis loss 1 eye, usually transient

32

ant cerebral art

(Motor and sensory cortex of lower limb)
Weakness + sensory loss contralateral leg
Urinary incontinence possible

Abulia: state of akinetic mutism (inability to make a decision) via B/L frontal lobe dysfunction.


33

mid cerebral art

embolic typically
contralat wkness loss of sense: face, arm, leg (arm>leg) via motor/sensory cortex lesion

gaze pref AWAY from side of weakness

temporal lobe lesion: Wernicke
frontal lobe lesion: Broca

aphasia if in dominant (typ. left) and hemineglet in nondominant side

34

mid cerebral artery dominant hem

global aphasia (expr and receptive)

35

mid cerebral artery nondominant hem

anosognosia-unawareness of weakness
-hemineglect

36

lateral striate art

lesion in striatum, int capsul
contralat wkness

common location of lacunar infarcts bc of uncontrl HTN

37

comm artery strokes

lesions typ. aneurysms impinging on CNS, not strokes
acomm-visual field def, aneurysm most common, can lead to stroke

Pcomm: down and out: CNIII palsy ptosis and mydriasis, saccular aneurysm

38

posterior strokes

ASA, PICA, AICA, PCA, basilary artery

39

vertebrobasilar ischemia

dissiness , fluctuating drowsiness, diplopia, ataxia, bilat sens/motor symptoms
may be mistaken as vertigo

40

basilar art stroke

occlusion of bl vertebral arteries
massive BS damage

coma, pinpoint pups, flaccid quadrip/sens loss
often fatal
spares medulla-->dysarthr,

*locked in syndrome*, somnolence, amnesia

pons, med, lower mdbran, CST and corticobulbar tracts, ocular cranial nerve nuc, paramedian pontine retic. formation

blinking and consciousness unaffected

41

post cerebral art

lesion at occipital and visual cortex

thalamic synd: contralat hemisens distr-->pain, hyperpathia

contralat wkness
contralat homonymous heminopsia
*macular vision may be spared-central*

42

ant spinal art strke

contralat hemiparesis of arm and leg, (LCST)

dec. contralat proprioception (ML)

ipsilat hypoglossal dysfuntion-->tongue deviates ipsilat* (hypoglos. nerv)

lesion of lat corticospinal tract; medial lemniscus; caudal medulla-hypoglossal nerve

43

PICA

vomiting, vertigo, nystagmus, ataxia

dec. pain temp
ipsilat face, contralt body:
*crossed findings**

hoarse, dysphagia, dec. gag

ipsilate Horner's
lateral medullary (wallenberg) syndrome

lesion at inf cerebellar peduncle, lateral medullat, sp Trigem nuc, **nuc ambiguus**sp. to PICA, sympathetic fibers

44

Horner's

ptosis
miosis
dec. sweating ipsilat face
*with PICA stroke

45

Wallenberg's

loss of pain/temp
contralto body, ipsilat face
*crossed finding dx for this syndrome
*PICA

46

AICA stroke
-ant inf cerebellar

vomit, vert, nystag, ataxia
paralysis of face, dec pain/temp ipsilat
contralat dec. pain/temp of body

*dec. lacrimation, salivation*
*dec. tast ant 2/3 tongue*
dec. corneal reflex

ipsilat Horner's
dec. hearing ipsilat
lesion at middle and inferior cerebellar peduncles, lateral pons—cranial nerve nuclei, vestibular nuclei, *facial nucleus* (*specific for AICA*), spinal trigeminal nucleus, cochlear nuclei, sympthetic fibers

47

cerebral venous thrombosis

*occlusion of saggital sinus*
usually: difficult to dx, hyperviscosis, hypercoag, preg, maxillofacial inf. SCD

symp: ha**, seizure, papilledema, focal neurolog def

dx: CT w. IV contrast or MRA
tx: steroid to lower ICP, anticoag

typ. present as ha not going away *typically pregnant*
if do CT w.OUT contrast, will not see unless v. large

48

aphasia

higher order inab. to speak

49

dysarthria

motor inab to speak

50

Broca

nonfluent aphasia, broken up, comprehension intact-understanding, can't speak effectively, impaired repetition
*inferior frontal gyrus of frontal lobe
most commonly seen*

51

Wernike

fluent aphasia, impaired comprehension and repetition; very wordy, w.out making sense
*superior temporal gyrus of temporal lobe

52

Broca's aphasia

"expressive" cannot get words out, know what to say, start crying, intact comprehension

53

Wernicke's aphasia

"receptive"
fluent speech, meaningless
impaired comprehension, don't know something is wrong

54

conduction aphasia

Poor repetition
Fluent speech
Intact comprehension
Lesion: arcuate fasciculus

Can't repeat phrases such as “no ifs ands or buts”

55

global aphasia

Both wernicke and broca
Nonfluent aphasia
Impaired comprehension

56

what kind of stroke? ischemic or hemorrhagic?? can tell from

CT

57

thom or emolic?

H/P, cardiac echo, EKG

58

where in brain?

CT: might not rev CVA for 6-24 hrs***

MRI/MRA: not available acutely? 3-30 min after CVA (takes about 45 min!)

doppler: ant only: carotids

cardiac echo

59

carotid duplex

US of carotids, shows how much blockage: %

60

hyperdense MCA sign

Indicative of acute thrombus within the middle cerebral artery

Seen on CT brain usually by 90 minutes
99% sensitivity, 30% specificity

see white arch in MCA
-determine density

61

stroke dx

cardiac workup
CBC, PT/INR, PTT, lipids, BMP, cardiac enzymes, ekg, CT head without contrast, CXR

hypercoag studies? not in ER, but if young will do

UDS ??: not unless young-->cocaine, etc

62

ddx stroke

Todd's paralysis: unilat paralysis after seizure, typ. benign, determine seizure etiology

complicated migraine: involves neuro symps: unilat paralysis, numb, tingling, visual defects

63

stroke tx : general

ABCs
DVT prophylaxis (inpatient)
Early OT, PT, Speech tx, and Swallowing Evaluation
Blood pressure and glucose control
Temperature control
Management of depression

64

stroke tx: anticaog: Heparin?

Heparin: used to be used, no evidence to support routine use for acute stroke, MIGHT reduce risk of recurrent stroke, offset by risk of ICH
*select pts

65

stroke tx: antiplatelet tx?

tx of choice to prevent recurrent thromboembolism
-everyone gets ASA or plavix

66

stroke tx: thrombolysis (tPA)

+1 signature, from family*

death

Benefits…stroke and symptoms resolve

67

antidote to tPA?

aminocaprioic acid

68

exclusions to tPA

Cva or head *trauma*
BP >185/110, reduce 1st if want to give, sacrifice perfusion
sx 15 seconds
glucose 400 could be having non-thrombotic stroke (hypo/hyperglycemic stroke)

69

cerebral edema management

Worry about brain shift and herniation; only with large hemispheric infarctions

airway control-intubate
hypervent?? not really
mannitol: diuretic for brain
craniotomy

70

HTN management in acute CVA

If SBP 220 or DBP>120-too high!
Titratable short acting IV drugs

Labetalol, nitroprusside, nicardipine
BP goal?: 180-200/100

180/110 for tPA

-protect the penumbra!, do not lower BP dramatically

71

if give nitro

BP improves, stroke may get worse, edema, penumbra enlargers, involves consciousness

72

ICH: "bleeding stroke"

Diffuse (SAH)
Focal (intraparenchymal)
20% of all strokes

73

causes of ICH

HTN—undiagnosed, noncompliant
AVM
drugs
aneurysm
bleeding disorders
trauma/tumor

74

intraparenchymal hemorrhage

"paintball to brain"
HTN causes it
goal: reduce mass effect:
mannitol or sx (last-ditch, hydrocephalus, high risk herniation)

putamen most common site: 40%
dec. LOC: mass effect,
rise in ICP, or direct BS involvement
high BP, AMS
may extend into ventricles-->hydrocephalus

75

SAH

usually berry aneurysm rupture
strenuous activity: sex, exercise
thundeclap, HA, post. neck pain
LOC, N/V
CT/LP: blood or xanthochromia
2-3 days later: vasospasm -->rebleeding

76

SAH: sentinel hemorrhages

baby SAHs: sm. aneurysmal leak, resolve after 1-2 days

(like a TIA-precursor)

77

Charcot-Bouchard

chronic HTN
small vessels: basal gang, thalamus
microaneurysm

78

saccular berry aneurysm

bifurcation in circle of Willis:
-bifurcation of anterior comm. and anterior cerebral aa
rupture most common comp: SAH, hem. stroke

bitemp hemianopia via optic chiasm compression
risk: older, HTN, tobacco, african amer
marfan's, Ehlers danlos, polycystic kidney disease (ADPKD)

79

AVM

tangles of arteries connected dir. to vv w.out intervening capillaries**-->bleeding
cause: congenital

HA, seizures, tinnitus, blurry vision, or *hemorrhage*

younger pts: sx excision, embolization, irradiation
>55: conservative

80

right MCA sign

left arm>left leg weakness, slurred speech

81

subarachnoid hemorrhage, diffuse on both sides

complications: vasospasm/rebleed

82

slide 95 pics

blood in ventricles, hydrocephalus
poor px
intraparenchymal hemorrhage, typ. from uncontrolled HTN

83

first aid

pg 466

84

Chads2Vas score

65-74: 1
>75: 2

female: 1
CHF hx: 1
HTN hx: 1
stroke/TIA/thromboembolism hx: 2
vasc. disease hx: 1
DM: 1