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Flashcards in Stroke Deck (76):
1

How common is stroke?

-most common cause disability
-4th leading COD

2

Lifetime cost of ischemic stroke

$140k

3

MC type of stroke

87% are ischemic, usually cerebral thrombus

4

Two types of ischemic stroke

-thrombotic
-embolic

5

Two types of hemorrhagic stroke

-SAH (in skull around brain)
-intracerebral (in brain)

6

Four layers of vessel

lumen --> endothelium --> SM --> adventitia

7

Unmodifiable risk factors for stroke: (5)

-65+ years old
-african americans
-previous
-female
-family hx

8

Preventable risk factors for stroke: (7)

-HTN
-DM
-Tobacco
-Afib, carotid disease
-previous
-obesity, inactivity
-hypercholesterolemia

9

Secondary blood disorders contributing to stroke risk:

-high RBCs
-sickle cell anemia

10

Genetic risk factors for stroke: (5)

-FV Leiden,prothrombin
-^ApoE4, homocysteine
-Fabrys
-ED
-Pseudoxanthoma elasticum

11

Acute Neuroimaging during stroke alert:

1) CT
2) fast brain MRI
3) conventional angio
4) carotid US
5) transcranial dopplers

12

CTP evaluates for? How?

-core/penumbra
-penumbra has preserved blood volume (CBV)

13

Define MTT:

-mean transit time
-increased in areas of brain distal to vessel occlusions (penumbra + core)

14

Define CBV:

-cerebral blood volume
-preserved in penumbra, decreased in core

15

Compare recanalization of vessels in penumbra v core:

-May be beneficial in penumbra
-risk for more ADRs than benefit in core

16

Timing for tPA administration

-FDA: 3 hours
-ASA: 3-4.5 hours

17

ASA dose for stroke pts:
Who recieves ASA?

-325 mg
-do not recieve tPA
-24 hours after tPA if no hemorrhage present

18

When are benefits of tPA seen?

-tPA better than ASA at 90 days out, 24 improvement no different

19

In addition to 3 hr window + CT free of hemorrhage, what must be true of pt to consider tPA?

-measurable deficit on NIH stroke scale
-patient 18+ years old

20

What "conditions" are absolute CIs to tPA? (5)

-stroke/ trauma within 3 months
-GI/GU hemorrhage within 21 days
-surgery within 2 weeks
-artery puncture within 1 wk
-history of ICH

21

What blood pressures are absolute contraindications to tPA?

-185/110 after efforts to manage

22

What symptoms are absolute contraindications to TPA?

-sx suggestive of SAH even with clear CT scan

23

What bleding conditions are abs contraindications to TPA?

-heparin + elevated PTT w/in last 48 hours
-PT higher than 15 s
-INR higher than 1.7

24

Platelet count CI in TPA?

-less than 100k uL

25

What glucose is abs CI in TPA?

-less than 50
-higher than 400

26

Four "relative" CI to TPA?

-large/MCA stroke
-sx are minor or rapidly improving
-seizure at onset of stroke
-aggressive tx needed to meet BP goals

27

FDA approved method of TPA administration

systemic IV dosing

28

Cushings triad

-HTN
-brady
-irregular respirations

29

Three symptoms specific of Anterior circulation stroke

-gaze preference
-aphasia
-neglect

30

Four symptoms specific for posterior circulation stroke

-vertigo
-diplopia
-crossed track findings
-dysconjugate gaze

31

Four symptoms that may be seen in either anterior or posterior stroke

-hemiparesis, anesthesia
-visual field deficit
-slurred speech
-ataxia

32

Symptom specific to dominant hemispheric strokes:

1) dominant: aphasia
2) nondominant: neglect, apraxia

33

Cause of akinetic mutism

Bilateral ACA strokes

34

Cause of Antons Syndrome + What is antons syndrome

-bilateral PCA strokes
-cortical blindness

35

mesial temporal lobe infarct affects what structures?

-limbic

36

MC Cause of AMS assc with stroke

-Aphasias

37

How common is symptomatic ICH following IV TPA?

6.4% of patients

38

4 risk factors for ICH following tPA

-older
-previous stroke
-small vessel ischemia
-labile BP

39

How can emboli reach the brain?

-heart: afib, valve disease, PFO
-carotid stenosis

40

Visual defect assc with left sided MCA stroke?

-loss of the rt visual fields
-eyes look towards lesion

41

Speech is controlled by the same side of the brain as:

handedness
(right hand dominant, left brain dominant language)

42

3 classic ACA infarct symptoms

-leg more than arm weakness
-personality or cognitive defects
-urinary incontinence

43

Limb ataxia is assc with stroke of what artery?

-PCA (per master the boards, Kaplan) (per Nolte, can be anterior OR posterior circulation...)

44

How soon does CT show stroke? MRI? Why is CT done acutely?

-CT: 4-5 days to reach 95% sensitivity
-MRI: 24-48 hrs
-CT done acutely to exclude hemorrhage

45

What characterizes nonhemorrhagic stroke on CT?

-edema without blood (may see midline shift, ventricular compression)

46

If ischemic stroke patient is already taking aspirin at time of symptom onset, what is the next best anticoagulant option? (assuming pt is not tpa candidate or has already received is a day ago)

-add dipyridamole
-switch to clopidogrel

47

Treatment for TIA

aspirin +/- dipyridamole OR clopidogrel

48

Treatment for hemorrhagic stroke

-none
-may surgically drain only if limited to posterior fossa

49

If tPA is given within 3-4.5 of sx onset, what is required?

-written consent, this time period is not FDA approved and is considered experimental

50

In addition to being anticoagulated, every patient with a stroke should take?

STATINS

51

LDL goal for stroke patients?

-70-100

52

Appearance of blood on CT

bright white hyperdense lesion

53

Treatment of thrombi throwing clots to brain:

-heparin --> warfarin

54

Goal INR for pt with hx of embolic strokes

2-3

55

How is afib treated to prevent stroke?

-heparin --> warfarin to INR of 2-3

56

Workout to evaluate causes of stroke?

-echo
-EKG (telemetry, holter)
-Carotid US

57

When is carotid endarterectomy advised?

70%-90% stenosis
**Cannot intervene is blockage is 100% occluded.

58

Endarterectomy vs carotid angioplasty and stenting: which is superior?

-endarterectomy, stenting is of no proven value to stroke patients

59

4 risk factors to control for stroke prevention

-HTN
-keep a1c under 7
-reduce LDL to under 100
-smoking cessation

60

Definition of TIA

sx resolve within 24 hours

61

Two main pathways resulting in cellular death from stroke:

-necrosis (energy failure, cell swelling)
-apoptosis (penumbra over days)

62

PCA #1 defect

-contralateral visual field cut

63

Signs of lacunar infarct:

-motor/sensory deficit WITHOUT cortical signs

64

Signs of basilar artery stroke

crossed face and body findings + oculomotor deficits

65

Signs of vertebral artery stroke

crossed face and body findings + lower cranial nerve deficits

66

Define: anosognosia

unawareness of illness and its clinical manifestations

(similar to insight?)

67

MC cause neglect (2)

-right MCA territory stroke (non-dominant parietal lobe, premotor cortex of frontal lobe)

68

Why must be determined before diagnosing apraxia

-pt understands the command, is cooperative, and has learned the task

69

Deficit assc with stroke of dominant occipital cortex/adjacent corpus callosum

agnosia: visual information disconnected from language centers
-patient cannot read own writing, has color agnosia

70

Define:
-asomatognosia
-prosopagnosia

-asomatognosia: does recognize body as part of own (Mrs. Mayo)
-prosopagnosia: cannot recognize faces

71

Labs drawn during Stroke Alert (4)

-CBC
-CMP
-PTT
-INR

72

How long should imaging take during code stroke?

-CT + CTA less than 10 minutes

73

MRI sequence needed for for assessing stroke?

DWI (intense in stroke)

74

TPA MOA

-binds fibrin, converts plasminogen to plasmin

75

How common is hemorrhage in TPA administration?

-6-7%; 1/16

76

Large artery strokes are often _____ while lacunar infarcts are _____.

large: embolic
lacunar: HTN related