1. MTB Step 3 - Stroke, TIA, & Arterial Lesions and Symptoms Flashcards
Cards Complete:
ETIOLOGY
What is the cause of Stroke and TIA?
Altered Cerebral Blood Flow
PRESENTATION
What are (4) common presenting Signs/Symptoms of Stroke & TIA?
Sudden Onset:
- Weakness on ONE side of the body
- Weakness on ONE side of the face
- +/- Aphasia
- +/- Partial or Total Loss of Vision, which may be Transient
PRESENTATION
How is a Stroke discriminated from a TIA?
- Stroke = permanent residual neurological deficits.
- TIA = NO permanent residual deficits
STROKE
What are the (2) Types of Stroke, and what are the percentages of each?
-
Ischemic = 80%
- Embolic - more sudden symptoms
- Thrombotic - less sudden symptoms
- Hemorrhagic = 20%
TIA
What is Amaurosis Fugax?
Transient Loss of Vision sometimes experienced along with Transient Ischemic Attacks (TIAs).
- This happens in TIA because the 1st branch of the Internal Carotid Artery is the Ophthalmic Artery
TIA
What is the ONLY cause of TIA, and what are its (2) types?
TIAs are Ischemic only (never hemorrhagic). The two types are:
- Embolic
- Thrombotic
SAMPLE QUESTION
“A 67-year old man with a history of hypertension and diabetes comes to the ED with a sudden onset of weakness in the right arm and leg over the last hour. On exam, he cannot lift the bottom half of the right side of his face.”
What is the Best INITIAL Step?
Head CT w/o contrast
Need to rule out Hemorrhagic stroke prior to treating with Thrombolytics, or even Aspirin.
ARTERIAL LESIONS
What are (4) Symptoms for an ANTERIOR CEREBRAL Artery Lesion?
- Profound Lower Extremity Weakness (contralateral to lesion)
- Mild Upper Extremity Weakness (contralateral to lesion)
- Personality Changes or Psychiatric Disturbances
- Urinary Incontinence
ARTERIAL LESIONS
What are (5) Symptoms for a MIDDLE CEREBRAL Artery Lesion?
- Profound Upper Extremity Weakness (contralateral to lesion)
- Aphasia
- Apraxia / Neglect
- The Eyes Deviate towards the same side as lesion
- Contralateral Homonymous Hemianopsia, with macular sparing.
ARTERIAL LESIONS
What is (1) Symptom of a POSTERIOR CEREBRAL Artery Lesion?
Prosopagnosia
ARTERIAL LESIONS
What are (8) Symptoms for a VERTEBROBASILAR Artery Lesion?
- Ataxia
- Bilateral findings
- “Drop Attack” - May be described as a Loss of Consciousness
- Dysarthria and Dystonia
- Nausea and vomiting
- Sensory changes in Face and Scalp
- Vertical Nystagmus
- Vertigo
ARTERIAL LESIONS
What are (3) Symptoms of a POSTERIOR INFERIOR CEREBELLAR Artery Lesion?
- Ipsilateral face
- Contralateral body
- Vertigo and Horner syndrome
ARTERIAL LESIONS
What are (6) Symptoms of a LACUNAR INFARCT?
- Absence of cortical deficits.
- Ataxia
- Bulbar signs
- Hemiparesis (most notable in the face)
- Parkinsonian signs
- Sensory deficits
ARTERIAL LESIONS
What is (1) Symptom of an OPHTHALMIC Artery Lesion?
Amaurosis Fugax
CEREBRAL VEIN THROMBOSIS
What is the Most Common Presenting Symptom for Cerebral Vein Thrombosis?
Headache
…developing over several days.
- This is why it can mimic subarachnoid hemorrhage.
- Many patients with CVT present with the same weakness and speech difficulty seen in stroke.
CEREBRAL VEIN THROMBOSIS
- What is the Best INITIAL Test for Cerebral Vein Thrombosis?
- What is the Most ACCURATE Test for Cerebral Vein Thrombosis?
- Lumbar Puncture = Normal. Done to rule out SAH
- Magnetic Resonance Venography (MRV)
CEREBRAL VEIN THROMBOSIS
What is the 2-Step Treatment for Cerebral Vein Thrombosis?
- Low Molecular Weight Heparin (LMWH) followed by…
- Warfarin for a few months.
DIAGNOSIS
- What is the Best INITIAL Diagnostic Test for either Stroke or TIA?
- What is a MORE Accurate Diagnostic Test?
- What is the Most ACCURATE Test?
- CT Head w/o contrast - Within the first several days, all non-hemorrhagic strokes should be associated with a normal head CT scan.
- MRI Head - Achieves 99 percent sensitivity for a non-hemorrhagic stroke within 24 hours. MRI is not done first, because the CT is more widely available, less expensive, and more sensitive for blood.
- MRA Head - Most accurately images the brain for stroke. Can be positive within the hour of the stroke.
TREATMENT
What is the recommended Treatment for an Ischemic Stroke, ONLY after a hemorrhagic stroke has been ruled out with Head CT, and in a patient with no contraindications?
Thrombolytics
TREATMENT
What are the (4) Criteria a patient must meet in order to receive Thrombolytic treatment for a Stroke?
Criteria:
- Age < 80
- Mild to Moderate Stroke (NIH Stroke Scale < 26)
- NOT a diabetic with a previous stroke
- NOT currently using anticoagulation
TREATMENT
What are (8) Contraindications to Thrombolytic treatment for an Ischemic Stroke?
- Hemorrhagic Stroke (ever)
- Ischemic/Embolic Stroke (within 1 year)
- Intracranial Neoplasm/Mass
- Cerebral Trauma or Brain Surgery (within 6 months)
- Bleeding Disorder
- Aortic Dissection
- Active Bleeding or Surgery (within 6 weeks)
- CPR with chest compression (within 3 weeks)
TREATMENT
What are (2) other Therapies for Ischemic Stroke patients who arrive in the ED > 4.5 hours after symptom onset?
-
Aspirin
- Best INITIAL Therapy if symptoms onset > 4.5 hours ago.
- Aspirin or clopidogrel or aspirin combined with dipyridamole is acceptable as initial antiplatelet medication to prevent subsequent stroke (However, at the present time, aspirin first is still the standard of care.)
-
Catheter Retrieval of Clot
- provides a definite benefit up to 6 hours after symptom onset.
- It decreases both focal neurological findings and mortality.
- The benefit persists for years after the stroke.
TREATMENT
- Under what condition would you either switch from Aspirin to Clopidogrel or add Dipyridamole to Aspirin in a patient with an Ischemic Stroke?
- What other therapy should be added to ALL patients with Ischemic Stroke?
- Switch to Clopidogrel or add Dipyridamole if the patient has developed an Ischemic Stroke while on Aspirin.
- Statins
TREATMENT
What is the ONLY Difference in Treatment between a Stroke and a TIA?
In TIA, Thrombolytics are NOT indicated.
- The object of administering a thrombolytic is to achieve a resolution of symptoms. If the symptoms have already resolved, then there is no point in giving thrombolytics.
