Stroke, TIA, Syncope, Altered mental status

Question 1

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

Answer 1

stroke

Question 2

definition of a stroke:

Answer 2

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

Question 3

Large Vessel Thrombosis:

Answer 3

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

Question 4

Small vessel disease:

Answer 4

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

Question 5

Embolism: Four General Categories

Answer 5

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)

Question 6

Cortical strokes:

Answer 6

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

Question 7

Subcortical stroke:

Answer 7

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”

Question 8

Subcortical Brainstem stroke:

Answer 8

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

Question 9

brainstem strokes present with:

Answer 9

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

Question 10

events that can cause brainstem strokes:

Answer 10

Trauma (dissection), chiropractic manipulation, hyperextension maneuvers

Question 11

cerebellar stroke presentation:

Answer 11

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

Question 12

Watershed ischemia:

Answer 12

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

Question 13

gold standard imagining for stroke?

Answer 13

DSA digital subtraction angiography

Question 14

stroke management:

Answer 14

tPA (alteplase) within 3h of stroke

Question 15

Transient ischemic attack (TIA):

Answer 15

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

Question 16

TIA clinical presentations:

Answer 16

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)

Question 17

TIA Eval:

Answer 17

non contrast CT

Question 18

epidural hematoma:

Answer 18

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

Question 19

what is the primary artery involved in epidural hematoma?

Answer 19

middle meningeal

Question 20

epidural hematoma presentation:

Answer 20

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

Question 21

subdural hematoma:

Answer 21

• collection of blood below inner dura but external to brain

- concave, crescent

Question 22

what veins are involved in subdural hematoma?

Answer 22

bridging veins

Question 23

subarachnoid hemorrhage (SAH):

Answer 23

blood in subarachnoid space

-crab

Question 24

SAH clinical presentation:

Answer 24

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

Question 25

SAH tx:

Answer 25

surgery

Question 26

Intracerebral hemorrhage clinical presentation:

Answer 26

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

Question 27

Syncope:

Answer 27

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

Question 28

Pre-syncope

Answer 28

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

Question 29

Vasovagal syncope:

Answer 29

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

Question 30

Situational Syncope:

Answer 30

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

Question 31

Orthostatic Syncope:

Answer 31

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

Question 32

factors prior to syncope event:

Answer 32

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

Question 33

clinical presentation of syncope:

Answer 33

``` 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 ```

Question 34

how long is LOC in syncope?

Answer 34

<1 min