Stroke (Nolte) Flashcards
(37 cards)
1
Q
What are the two different types of stroke?
- ______(87%) - blocked blood flow to the brain
- Thrombus- clot forming in brain artery
- Embolus - clot from somewhere else breaks off and blocks
- ______ - Bleeding into the brain
- SAH (3%) bleeding into skull around brain
- ICH (10%) bleeding directly into brain
A
- Ischemic Stroke
- Hemorrhagic Stroke
2
Q
Evolution of cerebral atherothrombosis -
- What is the most important aspect of the thrombus formation?
A
- The pro-inflammatory matrix - activates T cells, macrophages
3
Q
Etiologies of _________ ?
- Intracranial atherosclerosis, carotid artery/VB artery stenosis
- Valvular disease, paroxysmal afib, intracardiac thrombus
- Paradoxical
- Systemic hypercoagulability
A
Etiology of Embolic Stroke
4
Q
FYI:
Formation of cerebral embolism - distal to the BIFURCATION
A
5
Q
Subarachnoid Hemorrhage:
- Due to? _____ or ______
- What locations are the most common for this?
- What is morbidity due to once the aneurysm is secured?
- What medication is used 60q4hr, TCDs x 21 days
*Risk factors for rupture?
A
- Trauma (cortical) or berry aneurysm
- ACOMM, PCOMM, MCA bifurcation, TICA
- Vasospasm
- Nimodipine
* Tobacco, HTN
6
Q
Intracerebral Hemorrhage
- Most important prognostic factor?
- What are subcortical hemorrhages due to?
- ______ hemorrhages due to
- trauma, ischemia, AVM, Mets, cerebral amyloid angiopathy, cerebral venous thrombosis
A
- LOCATION, LOCATION, LOCATION
- HTN
- Cortical
7
Q
Uncontrollable risk factors for stroke?
- -
- -
- -
- -
- -
A
- Age (>65)
- Race (greater for AA)
- Family history
- Previous MI, stroke, TIA
- Sex
8
Q
Each year, about 55,000 more _____ than ____ have a stoke
- _____ stroke incidence rates are greater at younger ages - but not at older ages
- Male:female 1.25 (55-64), 1.5 (65-74), 1.07 (75-84), 0.76 (85+)
- ESTROGENs - hypercoagulable
A
Women than men
- Men’s
9
Q
Controllable risk factors for stroke include:
- risk 2x
- independent risk factor, increasing risk about 5x
- -
- -
A
- HTN
- DM
- Tobacco abuse
- A fib
- Previous TIA, stroke
- Carotid or other artery disease
10
Q
Secondary controllable risk factors for stroke:
- (high RBC, sickle cell anemia)
- Increased serum ______
- ***
- ***
- Less well known - excessive EtOH intake, drug abuse; infection
A
- Blood disorders
- Cholesterol
- PHYSICAL INACTIVITY
- OBESITY
11
Q
FYI:
- Potential genetic risk factors for stroke:
- mutations that lead to hypercoagulable state - factor V leiden and prothrombin
- increased serum apolipoprotein e4
- elevated homocysteine level
- fabrys, homocysteinuria, ehlers-danlos syndrome, pseudoxanthoma elasticum
A
12
Q
What symptoms should prompt you to think of stroke?
sudden onset of…
A
- vision loss, blurred vision, double vision
- slurred speech, difficulty speaking/understanding language
- difficulties with swallowing
- unilateral weakness or numbness
- difficulties with balance or sensation of vertigo
- severe headache with progressive decline in level of consciousness
13
Q
What neuroimaging is needed for stroke?
A
- CT stroke alert protocol
- “fast brain” MRI
- conventional angiogram
- carotid US
- transcranial dopplers
14
Q
CT “acute stroke” protocol:
- _____: to evaluate for presence of intracerebral hemorrhage or edema associated with underlying tumors
- _____: to evaluate for presence of vascular occlusions or significant stenosis
- ____: to evaluate for presence of areas of brain that are either infarcted “core” (or permanently damaged brain tissue) or “penumbra” (potentially salvageable tissue that is stunned)
A
- Plain head CT
- CTA head and neck with contrast
- CTP
15
Q
What does CTP tell us?
- _____ blood volumes throughout the brain
- _____ identifies the amount of time it takes to get to specific regions of the brain - increased in areas of brain distal to vessel occlusions
A
- CVB: Identifies blood volumes throughout the brain -
- core - decreased cerebral blood volume, so already infarcted
- areas of preserved blood volume are still salvagable
- MTT: identifies the amount of time it takes
16
Q
A. What occurs in the setting of vessel occlusion,
- CBV is preserved!
- MTT is prolonged
- Recanalization of occluded vessel may provide benefit
B. Occurs in the setting of vessel occlusion
- CBV is decreased
- MTT is prolonged
- Recanalization of vessel puts the patient at risk for more adverse events than benefit
A
A. Penumbra
B. Core infarct
17
Q
What is the gold standard for treatment of acute stroke?
- Approved for use within 3 hours of onset of neuro deficits in a defined population of patients
- ASA has recognized the 3-4.5 hour window in selected pts
_____ is approved for use in patients who do not receive the above - with no contraindications, and 24 hours after receiving above if there is no hemorrhage on 24hr post___ CT/MRI scan
A
Recombinant tissue plasminogen activator
Aspirin 325 mg
18
Q
NINDS trial evaluating tPA showed that patients treated with tPA within 90 minutes, had…
(Lazarus effect [rapid improvement within the first 24 hours] was NOT shown to be sig. different)
- Declining return on benefit when taking into account risk of hemorrhage from tPA over time
- ECASS 3 - tPA could be used in a select group of patients outside the 3 hour window, still more benefit than risk
A
… more improvement from baseline neurologic deficit at 90 days than patients treated with ASA alone
19
Q
In order to consider tPA administration…
- _____ stroke onset within 3 hours of drug administration
- Measurable deficit on ______ examination
- _____ does not show hemorrhage or nonstroke cause of deficit
- Age is > __
A
- Ischemic
- NIHSS
- Plain head CT
- > 18
20
Q
FYI: do not give tPA is any below are true:
- Minor symptoms or rapidly improving
- Seizure at onset of stroke
- Had another stroke or serious head trauma within the past 3 mos
- Major surgery within the last 14 days
- Known history or ICH
- Sustained SBP of >185 mmHg, DBP >110 mmHg
- Symptoms of SAH
- GI or Urinary tract hemorrhage within the last 21 days
- Arterial puncture at noncompressible site within last 7 days
- Received heparin within the last 48 hours and elevated PTT
- PT is > 15 seconds or INR >/= 1.7
- Platelet count < 100,000
A
21
Q
Use tPA with caution if…
- Large stroke scale score of ____
- CT shows evidence of _______
How is tPA administered IV?
- dose: 0.9 mg/kg (max dose 90 mg)
- IA?
A
- >22
- Large MCA territory infarction (sulcal effacement or blurring of gray-white junction in greater than 1/3 of MCA territory)
- IV: 10% bolused over first minute, rest of 90% given in IV infusion over 60 minutes
- IA: dependent on physician and situation, can be combined with IV
22
Q
When monitoring after tPA is given,
- what is the BP goal?
- q15 min vitals + neuro checks x2 hrs; q30 min vitals + neuro checks x4 hrs, q1 hour vitals + neuro checks x24 hrs
- 24 hour post tPA head CT or MRI to evaluate for presence of hemorrhagic transformation
- Stat head CT for any acute decline in neuro status
A
- Tight control with goal of < 180/105
23
Q
What are some adverse reactions that can occur following tPA administration?
A
- Local bleeding
- Anaphylaxis - angioedema can occur
- Acute worsening of neuro exam
- Cushing’s triad - HTN, bradycardia, irregular respirations
24
Q
What are some other options besides tPA?
Aspiration pneumonia, DVT, PE, decubitus ulcers, seizures, UTIs, constipations, depression are all examples of ________
A
- ASA, intra-arterial therapy: tPA, solitaire stent retriever, PENUMBRA catheter
- Post stroke complications
25
Stroke Syndromes:
* Anterior circulation: \_\_\_\_\_\_\_\_\_\_, \_\_\_, \_\_\_
* Posterior circulation: ____ (PCA)
* Dominant Hemisphere strokes
* Nondominant Hemisphere strokes
* Internal carotid artery, MCA, ACA
* Vertebrobasilar system, PCA
26
With anterior circulation strokes - what symptoms/exam findings do you see?
* Hemiparesis, hemianesthesia, visual field deficit, slurred speech, ataxia
* **Gaze preference**
* **Aphasia**
* **Neglect**
27
With posterior circulation strokes, what symptoms/exam findings do you see?
* Hemiparesis, hemianesthesia, visual field deficits, slurred speech, ataxia
* **Vertigo**
* **Diplopia**
* **"crossed track" findings**
* **Dysconjugate gaze**
28
* What symptoms are seen in **dominant hemispheric strokes?**
* What symptoms are seen in **nondominant hemispheric strokes?**
* Hemiparesis, hemianesthesia, dysarthria, gaze preference, visual field deficit, **Aphasia**
* Hemiparesis, hemianesthesia, dysarthria, gaze preference, visual field deficit, **neglect**
29
Case 1: Localize lesion, tPA candidate?
80 yof, slurred speech, ams - LKN: 2 hr prior, recent colon resection
* NIHSS 20, R hemiplegia, 1 midline command, nonverbal, can't mimic any one syllable sound, L gaze preference, R homonymous hemianopsia
Anterior circulation (ICA) - dominant hemisphere (aphasia)
Massive area of penumbra - gave tPA
30
What can cause/ appear to cause Altered Mental Status?
* Broca's aphasia
* Wernicke's aphasia
* Mixed aphasia
* Basilar tip psychosis
* ICH with pending herniation
* Bilateral ACA strokes (akinetic mutism)
* Bilateral PCA strokes (Anton's syndrome or cortical blindness)
* Mesial Temporal lobe infarct affecting the limbic structures
31
Case 2: Localize lesion. tPA candidate?
* 61 yom with VRFs of Afib on ASA - previous retroperitoneal hematoma, embolic ischemic stroke within 3 mos, HTN - bradycardia
* LKN: 9 am, 10 am had R hemiparesis, decreased speech
* NIHSS 24, globally aphasic, L gaze deviation, R arm/leg hemiplegia, R facial droop, R homonymous hemianopia
Anterior Circulation (ICA) - gaze preference, aphasia
not a tPA candidate!
32
Case 3: Localize lesion. tPA candidate?
* 56 yof with afib on ASA, previous L MCA embolic ischemic stroke with mild aphasia and dense R hemiparesis, HTN
* LKN: within 2 hr, NIHSS 11, R\>L facial droop, RUE and RLE plegia, LLE plegia, LUE 2/4, dense aphasia with more difficulties with spontaneous speech than comprehension, decreased sensation in L face/arm/leg, R gaze preference
Anterior circulation (aphasia, gaze preference) - R hemisphere (R gaze, L hemiparesis/plegia, R hemianesthesia)
tPA - w/in 3 hours, previous stroke, risk of ICH is 8-10%
33
* 6.4% of all patients who receive IV tPA will have symptomatic \_\_\_\_\_\_\_
* When is the risk for this higher?
Intracranial hemorrhage
* When given later after symptom onset, in older populations, with history of previous stroke, with underlying significant small vessel ischemic changes, with labile BP
34
Case 4: Localize lesion. tPA candidate?
* 44 yom - pmhx - HTM, multiple MI, stents, noncompliance with antiplatelets/statins
* Sudden onset of R face, arm, leg weakness
* NIHSS 4 --\> 10, mild R facial droop, moderate R arm weakness, mild R leg weakness, profound sensory loss on R, severe ataxia in R arm/R leg
Can't tell - initially thought to be a small vessel lacunar syndrome
- clumsy hand dysarthria
- ataxia hemiparesis
Give tPA!! standard of care, his perfusion imaging was concerning for a completed infarct and was no penumbra to save so IAT was not offered.
35
Can IA thrombectomy be performed with core infarcts?
NO!
36
Case 5: Localize lesion. tPA candidate?
* 77 yom with afib, idiopathic parkinson's disease who developed sudden onset R sided face arm leg weakness and decreased verbal output 6 hours prior to arrival
* NIHSS 6, partial forced gaze to L, R facial droop, mild drift in the R arm and leg, mild dysarthria, moderate resting tremor in RUE with marked increased tone in RUE and RLE with moderate bradykinesia
Anterior circulation - ICA, dominant hemisphere
(aphasia, gaze preference)
No tPA - but IA thrombectomy
37
* tPA is an effective means at treating acute stroke and should be offered as ______ if there are no contraindications
* ____ should ALWAYS be anticoagulated unless there is a very compelling reason to withold such medications
* tPA is DANGEROUS!
* standard of care
* Atrial fibrillation
