stroke Flashcards
(84 cards)
1
Q
can do what in 5 secs of walking in room
A
ABCs (pt speaking) when did this start? -if woke up with stroke not eligible for tPA -vitals: BP! -oriented/confused -family present
2
Q
if on coumadin
A
not candidate for tPA
3
Q
family can…
A
sign for tPA consent
verify onset
4
Q
stroke vs. bells
A
stroke spares the forehead, can wrinkle
5
Q
stroke brkdwn
A
80% ischemic, 20% hemorrhagic
global: low CO (MI, a fib)
focal: occlusion (thrombotic, emolic)
*3rd leading cause of death
6
Q
strokes can be caused by
A
emobolism, thrombus,
hypoxic etiologys: hypoperf, or hypoxemia
happens during cerebrovasc. sx: affects watershed areas
7
Q
risk factors for ischemic stroke
A
DM HTN smoking fam hx high cholesterol afib drugs (cocaine) hx of TIA or recent MI hx of CHF OCPs
8
Q
ant. vs posterior circulation
A
will affect what type stroke
9
Q
watershed zones: area covered by 2 arteries
A
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
Q
autoregulation
A
maintains constant level of CBF despite changing perfusion pressure
11
Q
CPP normally driven by
A
pCO2, ICP dec. as CO2 dec. via vasoconstriction
- hypervent theory in trauma, CVA*
- can actually cause more damage
12
Q
hypoxemia will
A
inc. CPP IF PO2
13
Q
CPP=
A
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
Q
know charts
A
pg 463
15
Q
chronic HTN
A
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
Q
cerebral ischemia will lead to
A
liquefactive necrosis
emo/throm: focal OR
dim. syst: global OR
hypoxia
prolonged ischemia–>infaction
young or old
17
Q
penumbra
A
transition zone between normal tissue and infarcted tissue
need to save!
18
Q
ischemic histo timeline
A
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
Q
irrev. damage
A
after 5 min hypoxia
20
Q
most vulnerable areas
A
*hippocampus, neocortex, cerebellum, watershed areas
21
Q
cerebral edema accumulates..
A
over 3-5 days after stroke–>death
22
Q
2/3 ischemic strokes
A
cerebral atherosclerosis
23
Q
1/3 ischemic strokes
A
cardiogenic emboli
afib
patent foramen ovale-DVT
24
Q
etiology in younger pts: things that make you clot
A
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
```
