Stroke and TIA

Question 1

In stroke, secondary injury results from what?

Answer 1

Edema, mass effect

Question 2

TIA definition

Answer 2

Transient episode of neurological dysfunction by focal brain, spinal cord, or retinal ischemia without acute infarction

Question 3

How long does TIA usually last?

Answer 3

1-2 hours (usually less than 24)

Question 4

What percent of TIA will have ischemic stroke and when?

Answer 4

10% in 90 days

Question 5

get early re-perfusion?

Answer 5

Quick use of thrombolytics and neuroprotective agents

Question 6

Will perfusion return to baseline in hemorrhagic stroke?

Answer 6

No

Question 7

Describe arteries of brain

Answer 7

Question 8

Worst HA of life is what?

Answer 8

SAH

Question 9

What is more common type of hemorrhagic stroke and what are causes?

Answer 9

ICH-
•Elderly, Hx of Stroke; also ETOH and tobacco use
•Anticoagulation, cocaine, vascular malformation, amyloidosis

Question 10

What is most important when diagnosing stroke?

Answer 10

Timing

Question 11

On fundoscopic exam, what may papilledema indicate?

Answer 11

Mass lesion, HTN crisis

Question 12

On fundoscopic exam, what may preretinal hemorrhage indicate?

Answer 12

SAH

Question 13

When is NIHSS stroke scale used?

Answer 13

Baseline and serial exams (post-CT, 2 hours, 24 hours, 7-10 days, 3 mo)

Question 14

What percent of TIA becomes stroke within 2 days of ED presentation?

Answer 14

50%

Question 15

Findings of unilateral ACA infarction:

Answer 15

•Contralateral sensory & motor sx’s in LE’s
•Sparing of hands & face
•Left sided lesions = akinetic mutism (unmoving / unspeaking)
•Transcortical Motor Aphasia (TMA) = comprehension with non-fluent speech
•Right sided lesions = confusion & motor hemi-neglect
–Bilateral = combination of mutism & incontinence; worsened outcomes

Question 16

What is most common infarction?

Answer 16

MCA

Question 17

MCA infarction findings:

Answer 17

• Hemiparesis, facial plegia, contralateral sensory loss
• Face & UE > LE
• Dominant hemisphere = aphasia (receptive, expressive OR both)
• Nondominant hemisphere = inattention, neglect, extinction, dysarthria w/o aphasia, constructional apraxia (difficulty drawing complex 2-D or 3-D objects)
• Homonymous hemianopsia & gaze preference in either

Question 18

How does PCA infarction classically present?

Answer 18

Visual field defects

Question 19

What is most common presenting complaint with PCA?

Answer 19

Unilateral HA

Question 20

Other findings of PCA:

Answer 20

–Light-touch & pinprick deficits
–Alexia w/o agraphia: can’t read but writes
–Cannot name colors & recent memory loss
–Unilateral CN III palsy & hemiballism
–Motor minimally affected: prevents realization that one has had a stroke

Question 21

Most common symptom of vertebrobasilar artery:

Answer 21

Vertigo

Question 22

Other findings of vertebroasilar:

Answer 22

• HA, nausea, visual disturbances & oculomotor palsies
• Ataxia, sensory disturbances, limb weakness, oropharyngeal dysfunction

Question 23

Hallmark presentation of posterior circulation stroke:

Answer 23

•Crossed neurologic deficits
–Ipsilateral CN deficits w/ contralateral motor weakness

Question 24

•Basilar Artery Occlusion

Answer 24

–Severe quadriplegia, coma, locked-in syndrome

Question 25

Cerebellar Infarct findings

Answer 25

–Vertigo, gait disturbance, limb ataxia, HA, dysarthria, n**ausea, vomiting,** CN abnormalities –Mental Status variable & may deteriorate rapidly –MRI/MRA better than CT –Prompt Neurosurgical consultation a must –Obstructing hydrocephalus = BAD

Question 26

Lacunar Infarction findings:

Answer 26

–Pure motor or sensory deficits –Clumsy hands & dysarthria –Unilateral leg paresis & ataxia –Small penetrating artery involvement –**Chronic HTN** and age related –Variable presentation •May be sub-clinical –More favorable prognosis

Question 27

What is commonl in Hx of cervical artery dissection?

Answer 27

Neck trauma, often trivial

Question 28

Internal Carotid Artery Dissection findings:

Answer 28

•**Unilateral head pain (1st symptom)**, face pain, neck pain, partial Horner’s syndrome

Question 29

Vertebral artery dissection findings:

Answer 29

* Posterior neck pain & headache (posterior-occipital) * Can be unilateral or bilateral HA; typically occipital * Unilateral facial paresthesia, dizziness, vertigo, N/V, diplopia, ataxia, limb weakness, numbness, dysarthria, hearing loss

Question 30

What is a PE finding for cerebellar infarct?

Answer 30

Cannot look toward side of bleed

Question 31

What is SAH associated with?

Answer 31

Valsalva

Question 32

Within how long should brain imaging occur upon arrival?

Answer 32

Within 25 min

Question 33

Treatment decision of stroke should occur within how long of arrival?

Answer 33

60 min

Question 34

Treatment approach for stroke

Answer 34

•“Safety Net” – don’t forget the D-stick •Very brief history •ABCs •Diagnostic studies –STAT EKG –PCXR –Your labs –**Non-contrast head CT!!**

Question 35

Who reads CT for stroke?

Answer 35

Most expert interpreter

Question 36

What is therapeutic range of INR?

Answer 36

2-3

Question 37

What is ancillary testing for Stroke/TIA?

Answer 37

•CBC-look at platelets •Chemistry •ECG & Cardiac Enzymes •Coags-If patient is on blood thinner, what should INR be? –Therapeutic Range for INR is between 2.0-3.0 •Type and Screen

Question 38

What should be addressed when ischemic stroke?

Answer 38

•Dehydration: give IV crystalloids •Hypoxia: maintain O2 Sats \> 92% •Hyperpyrexia: search for & treat the cause of the fever (sepsis, PNA, UTI, meningitis) •Hypertension Hyperglycemia

Question 39

What is go-to drug for HTN?

Answer 39

labetalol

Question 40

What is HTN requirement for thrombolytics in ischemic stroke?

Answer 40

Must be 185/110 within 2 doses of labetalol. If takes more than 2 doses then no longer candidate for thrombolytics

Question 41

What is the only acceptable CCB for ischemic stroke?

Answer 41

Nicardipine

Question 42

What may worsen outcome of ischemic stroke?

Answer 42

Vasodilators

Question 43

What thrombolytic is used in ischemic stroke?

Answer 43

Recombinant tissue-type plasminogen activator 0.9mg/kg, max dose of 90mg; 10% given as a bolus, 90% infused over 60 minutes

Question 44

What must you do prior to pushing rTPA?

Answer 44

Consult but don't delay

Question 45

rTPA use requirements:

Answer 45

–Assessment •NIHSS score (4-22)\*\*[may be lower if posterior stroke suspected] –Dose •Total Dose 0.9mg/kg max dose of 90mg; 10% bolus, remainder over 60 minutes –Reassess •Neuro & BP checks Q15min x 2 hrs = ICU Admission

Question 46

Post monitoring for rTPA:

Answer 46

–No ASA or heparin for 24 hours –BP and Neuro exam q 15 minutes for 2hrs post administration –SBP \>180 or DBP\>105 (2 consecutive) •IV Labetalol 10 mg q 10-20 min to 300mg •Nitroprusside infusion (0.5-1.0 mcg/kg) if no improvement with Labetalol –If suspected post-rtPA bleed: CT, CBC, coags, fibrinogen, T & C; urgent Neurosurgery, Neurology, & Hematology consult

Question 47

Antiplatelet therapy for TIA:

Answer 47

•Aspirin alone: start within 24 to 48 hours of TIA –significantly reduces 4 week to 6 month mortality •Dipyridamole & ASA •Clopidogrel (Plavix)