Stroke, TIA, Syncope, Altered mental status Flashcards Preview

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Flashcards in Stroke, TIA, Syncope, Altered mental status Deck (34):
1

_____ is the second most common cause of mortality and 3rd most common cause of disability worldwide

stroke

2

definition of a stroke:

acute neurological injury that occurs as a result of one of many pathologic processes primarily brain ischemia (lack of oxygen) secondary to thrombosis (clotting), embolism or systemic hypoperfusion or brain hemorrhage secondary to ICH or SAH

3

Large Vessel Thrombosis:

Include extracranial and intracranial arterial systems
Extracranial: common / internal carotids
Intracranial system: Circle of Willis and its proximal branches

4

Small vessel disease:

Affects the intracerebral arterial system (penetrating arteries arising from distal vertebral, basilar, MCA and COW)
Common mechanism is Lipohyalinosis which causes necrosis and thickening of small vessel walls with decreased luminal diameter thought in part 2/2 hypertension and or endothelial dysfunction/inflammation.
Atheromas or plaques can block small penetrating arteries as well
All often occur at branch points or 90 degree angles

5

Embolism: Four General Categories

Known cardiac source
Possible cardiac or aortic source based on echocardiographic studies
Arterial source (artery-artery embolism)
Truly unknown source (embolic testing negative / no evidence of cardiac disease)

6

Cortical strokes:

Frontal, parietal, temporal or occipital lobe
Often are large vessel territory infarcts if are not embolic
If occur on pt.’s language center (hemisphere opposite dominant hand) can have aphasia.
agraphia, acalculia, neglect, trouble with visuo/spatial, memory/behavior, gaze preference, or trouble with higher order cognitive function also present
Motor / Sensory Involvement:
Focal motor weakness, Face/Arm > Leg or Leg > Face/Arm
Focal sensory loss

7

Subcortical stroke:

Internal Capsule / Basal Ganglia / Thalamus
Often caused by lacunar infarcts
predominately motor or sensory deficits (Face = Arm = Leg) on the opposite side of the body
Thalamic stroke could cause hemibody sensory deficit often painful after recovery “thalamic pain syndrome”

8

Subcortical Brainstem stroke:

Extraocular muscle impairments
Other cranial nerve findings (facial paresthesias, facial weakness, bulbar symptoms)
Diplopia
Dysphagia
Dysarthria
Nystagmus

9

brainstem strokes present with:

PTs often present with profound nausea/vomiting/headache/double vision/imbalance/ and eye movement problems / other cranial nerve deficits

10

events that can cause brainstem strokes:

Trauma (dissection), chiropractic manipulation, hyperextension maneuvers

11

cerebellar stroke presentation:

Will predominately have gait imbalance / ataxia / nausea / vomiting / vertigo / tremor / nystagmus

12

Watershed ischemia:

cortical blindness, bilateral vision loss, coma, weakness of shoulders/thighs spare face/hands/feet “man in a barrel”

13

gold standard imagining for stroke?

DSA digital subtraction angiography

14

stroke management:

tPA (alteplase) within 3h of stroke

15

Transient ischemic attack (TIA):

A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction

16

TIA clinical presentations:

Most are short lived in duration (minutes) and often resolve prior to presentation
Can be isolated or recurrent
Clinical presentation will often mimic stroke:
Sudden weakness
Slurred speech
Aphasia
Facial droop
Vision changes / vision loss
Paresthesias in a large distribution
Gait instability
Vertigo dizziness (if posterior circulation)

17

TIA Eval:

non contrast CT

18

epidural hematoma:

accumulation of blood in potential space between dura and bone
-convex appearance (football shaped)

19

what is the primary artery involved in epidural hematoma?

middle meningeal

20

epidural hematoma presentation:

Occurs in the setting of trauma
Lucid interval: Period after initial loss of consciousness in which individual recovers partially prior to decompensating again usually 2/2 expansion of hematoma
Other symptoms:
Headache
Nausea/vomiting
Seizures
Focal deficits
Spinal symptoms:
Weakness
Numbness
Bowel/bladder incontinence

21

subdural hematoma:

-collection of blood below inner dura but external to brain
-concave, crescent

22

what veins are involved in subdural hematoma?

bridging veins

23

subarachnoid hemorrhage (SAH):

blood in subarachnoid space
-crab

24

SAH clinical presentation:

Sudden onset severe headache often referred to as “worse headache of life”
Nausea
Vomiting
Photophobia / Double vision
Dizziness
Neck pain (meningismus)
Syncope
Localizing neurological signs
Sentinel leaks: prodrome of sudden head pain may precede rupture by days to months (average is 2 weeks)

Less Common:
Seizures
Trauma
encephalopathy

25

SAH tx:

surgery

26

Intracerebral hemorrhage clinical presentation:

Alterations in consciousness
Nausea and vomiting
Headache
Seizures
Focal neurological deficits
Provoked by:
Episodic hypertension
Drugs

27

Syncope:

nsient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery

28

Pre-syncope

Same symptoms but terminates prior to LOC and may include partial loss of postural tone

29

Vasovagal syncope:

Usually in standing position. Precipitated by fear, emotional stress, pain .
Presentation: Nausea, diaphoresis, fading out, epigastric discomfort, light-headedness precede syncope by minutes
Mechanism: Efferent vasodepressor reflexes results in decreased PVR

30

Situational Syncope:

Known precipitant, reproducible
Causes: micturition, defecation, deglutition, tussive, carotid sinus syncope
Mechanism: precipitants cause autonomic vasodepression which lead to transient cerebral hypoperfusion

31

Orthostatic Syncope:

Secondary to orthostatic hypotension
Autonomic failure in neurodegnerative diseases such as: Parkinson’s disease, supranuclear palsy, MSA, dementia, spinal cord injury etc.
Other causes: drugs, volume depletion (dehydration)
BP Definition:
Drop of systolic BP of 20mmHg or Diastolic BP of 10mmHG when going from lying to standing position within 3 minutes. Often with pulse increase of >10-20

32

factors prior to syncope event:

Fatigue
Sleep/food deprivation
Warm temperature
ETOH consumption
Pain
Strong emotions (ie fear)
Positions
Activities:
Exertion
Shaving
Coughing
Voiding
Prolonged standing

33

clinical presentation of syncope:

Rapid onset LOC that is short in duration with spontaneous complete recovery + loss of postural tone
Faintness
Dizziness
Light-headedness
Vertigo
Weakness
Blurred vision
Pallor
Epigastric discomfort
Nausea
Diaphoresis

34

how long is LOC in syncope?

<1 min