TIA and Stroke

Question 1

TIA

Answer 1

Transient ischemic attack; acute focal cerebral insufficiency lasting under 24h (often under 60min)

Question 2

Do TIAs have residual effects?

Answer 2

NO - and no acute infarction

Question 3

Who gets TIAs

Answer 3

more males than females

Question 4

Does TIA cause increased risk of stroke?

Answer 4

Yes - inc risk after one within 1 month

Question 5

Do TIAs recur often?

Answer 5

Yes - often with the same symptoms

Question 6

TIA CM

Answer 6

depend on the affected vessel and follows a vascular “line”

Question 7

TIA CM (specifics)

Answer 7

Like Bell’s palsy
- droopy face, like stroke
- carotid area–weak, numb, heaviness in the contralat arm, leg, face, dysphagia and ipsilateral monocular vision loss
- vertebrobasilar–blurry vision, vertigo, dysphasia, motor or sensory changes, ipsilateral face, contralateral body

Question 8

TIA care

Answer 8

• hx and physical for pattern or vasc problem
• CT, MRI, MRA 1st to r/p hemorr, lacunar infarct or aneurysm
• Carotid doppler study for carotid stenosis
• echo for cardiac causes

Question 9

TIA tx

Answer 9

• anticoag–ASA or clopidogrel or hep/warf if cardiac
• carotid endarectomy w/ over 70% stenosis
• edu on lifestyle meds

Question 10

Names for strokes

Answer 10

CVA aka stroke aka brain attack

Question 11

Risk fx for stroke

Answer 11

HTN, HLD (inc chol), endothelial damage–tobacco and DM, obese, alc, fam, race (AfAm), oral contraceptives, old, men, SCA, physically inactive, arterial disease, hx TIA, a-fib, IV, coke use, HF (EF <25%)

Question 12

Stroke CM

Answer 12

numb/weak unilaterally in face, arm, leg, confuse, trouble speaking, slurred speech (dysarythria), ataxia, severe HA w/o cause (esp hemorr)

Question 13

What to do first after a stroke

Answer 13

CT w/o contrast
- bright white shows hemorrhaging blood
- darkness shows damaged tissue

Question 14

Ischemic stroke

Answer 14

Vessel occlusions stop blood distal to brain occlusion
- occluded cerebral artery
- thrombus or embolus

Question 15

How to treat an ischemic stroke best?

Answer 15

Known the best cause

Question 16

Hemorrhagic stroke

Answer 16

Ruptured vessel in brain parenchyma

Question 17

Hemorrhagic conversion

Answer 17

happens post-stroke, extravasation of blood from peripheral circulation across a disrupted BBB
- occurs after reperfusion is established
- natural or with therapy

Question 18

Stroke patho

Answer 18

dec blood supply, o2 dec, neuro def and sx w/i 1 min, cont loss of supply, irreversible damage

Question 19

Thrombotic stroke

Answer 19

from arterial obstruction from thrombus
- often athero that ruptures
- or clot
- or hypercoag state–cancer, oral cont, COVID

Question 20

Embolic stroke

Answer 20

• often cardiac source like a-fib, mural thrombus
• often arterial on L side
• venous if atrial septal defect or patent foramen ovale
• thrombus of vegetation of valves from mitral valve (IE) and valve replace
• carotid plaque rupture (hear bruit)

Question 21

What is a mural thrombus

Answer 21

in L ventricle a part breaks off

Question 22

penumbra

Answer 22

injured but salvagable tissue around dead area

Question 23

Goal of stroke tx

Answer 23

Tx w/i 3h to save
- maintain perfusion–BP <180/105 w/ TPA; BP <220/120 w/o TPA

Question 24

What are hemorrhagic strokes associated with

Answer 24

• long standing, severe HTN–inc pressure weakens the vessel
• aneurysms

Question 25

Mortality of hemorrhagic stroke

Answer 25

quick--minutes to hours or w/i seconds in the brainstem

Question 26

With a hemorrhagic stroke, ICP...

Answer 26

Increases with inflammation - herniation can occur - tissue death - cranium defines the space

Question 27

Age range for hemorrhagic stroke

Answer 27

30-60Y (younger than ischemic)

Question 28

What does hemorrhagic stroke prognosis depend on

Answer 28

Age (older is better), location and size, how rapid the brain shifts occur

Question 29

Midline shift

Answer 29

blood forces the brain past the cranial midline

Question 30

Where does a hemorrhagic stroke occur?

Answer 30

Below the pia mater

Question 31

Epidural bleed

Answer 31

- skull fracture - arterial bleeds - less severe injury

Question 32

subdural bleeds

Answer 32

injury in bridging veins that carry blood from outer region to larger brain vessels - if severe, rapid decline - brain moves but vessels don't - can be slow--2-10d later (bc venous) - need to relieve pressure

Question 33

Where does a subarachnoid hemorrhage occur?

Answer 33

In the CSF - often due to cerebral aneurysm or AVM - may see blood in the CSF during a lumbar puncture

Question 34

Which bleed will NOT be treated by evacuating the blood build up?

Answer 34

Bleeds in the tissue

Question 35

Hemorrhagic stroke presentation

Answer 35

- worst HA ever - rapid chx in LOC - irritation of the meninges--nuchal rigidity and photophobia (subarachnoid)

Question 36

AVM

Answer 36

abnormal junction with blood flow direct from artery to vein without slowing thru caps - puts at risk of intracranial hemorrhage

Question 37

When is a lumbar puncture most sensitive for detecting a subarachnoid bleed?

Answer 37

12 hours after onset of sx

Question 38

Subarachnoid hemorrhage management

Answer 38

- keep BP steady (withing borders) - bed rest - surgery ASAP for aneurysm--clip or coil - anticonvulsant maybe - CCB post-surg to "narrow BVs to slow BF" - triple H therapy for perfusion--HTN (pressors), hypervolemia, hemodilution

Question 39

When is the risk of rebleed highest?

Answer 39

24 hours after

Question 40

Fibrinolytics

Answer 40

Destroy an already formed clot

Question 41

BE FAST

Answer 41

Balance, HA, dizzy Eyes (vis loss) Face (symmetry) Arm (weak) Speech Time to call 911

Question 42

Endovascular embolization

Answer 42

Insert cath in groin and thread to aneurysm and coil metal inside to block blood flow in aneurysm

Question 43

What is important to know for a stroke?

Answer 43

Last known normal

Question 44

GCS < 8

Answer 44

Intubate--worry about protecting airway

Question 45

Stroke protocol

Answer 45

- ABCs - Glucose and labs - CT

Question 46

How do you r/o hemorr or ischemic?

Answer 46

CT scan w/o contrast

Question 47

tx for hemorrhagic stroke

Answer 47

- Reverse anticoags - Control HTN - Manage ICP - raise HOB, antipyretics, head neutral

Question 48

tx for ischemic stroke

Answer 48

Anticoags or thrombolytics to dec penumbra

Question 49

MRI vs CT for stroke

Answer 49

MRI more detailed but not first choice in emergencies

Question 50

L side head stroke complications

Answer 50

Logic, math, communication

Question 51

R side stroke comps

Answer 51

Pictures, stories, music, art

Question 52

Alteplase class and MOA

Answer 52

- fibrinolytic therapy - Converts plasminogen to plasmin to dissolve clots

Question 53

Alteplase SE and NC

Answer 53

Biggest risk is intracranial bleeding, dysrhythmias with reperfusion, hypotension - give w/i 30-70 min for sx of MI - can give with Hep and clopidogrel - CI with brain bleed - IV - antidote is aminocaproic acid (anti-thrombolytic)--stops the bleed

Question 54

Surgical tx for ischemic stroke

Answer 54

Penumbra procedure--mechanical thrombectomy

Question 55

Other comps of stroke

Answer 55

- dysphagia--need swallow study - motor and sensory - flaccid on contralat side - spasticity w/i 6W and contractures - Contralat vision changes - aphasia--probs with lang reception of reading, speaking

Question 56

Homonymous hemianopia

Answer 56

Lose the r or l side of both visual fields

Question 57

Receptive aphasia

Answer 57

Difficulty understanding but can communicate

Question 58

Dysarthria

Answer 58

Impaired speech

Question 59

Expressive aphasia

Answer 59

Can't express language but can comprehend

Question 60

Cognitive stroke effects

Answer 60

- memory - behavioral--apathetic, emotional, slow rxn time, cautious, underestimate own abilities - depression