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2.1) My Cards > 1. MTB Step 3 - Stroke, TIA, & Arterial Lesions and Symptoms > Flashcards

1. MTB Step 3 - Stroke, TIA, & Arterial Lesions and Symptoms Flashcards

Cards Complete:

1
Q

ETIOLOGY

What is the cause of Stroke and TIA?

A

Altered Cerebral Blood Flow

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2
Q

PRESENTATION

What are (4) common presenting Signs/Symptoms of Stroke & TIA?

A

Sudden Onset:

  1. Weakness on ONE side of the body
  2. Weakness on ONE side of the face
  3. +/- Aphasia
  4. +/- Partial or Total Loss of Vision, which may be Transient
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3
Q

PRESENTATION

How is a Stroke discriminated from a TIA?

A
  • Stroke = permanent residual neurological deficits.
  • TIA = NO permanent residual deficits
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4
Q

STROKE

What are the (2) Types of Stroke, and what are the percentages of each?

A
  1. Ischemic = 80%
    • Embolic - more sudden symptoms
    • Thrombotic - less sudden symptoms
  2. Hemorrhagic = 20%
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5
Q

TIA

What is Amaurosis Fugax?

A

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
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6
Q

TIA

What is the ONLY cause of TIA, and what are its (2) types?

A

TIAs are Ischemic only (never hemorrhagic). The two types are:

  1. Embolic
  2. Thrombotic
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7
Q

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?

A

Head CT w/o contrast

Need to rule out Hemorrhagic stroke prior to treating with Thrombolytics, or even Aspirin.

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8
Q

ARTERIAL LESIONS

What are (4) Symptoms for an ANTERIOR CEREBRAL Artery Lesion?

A
  1. Profound Lower Extremity Weakness (contralateral to lesion)
  2. Mild Upper Extremity Weakness (contralateral to lesion)
  3. Personality Changes or Psychiatric Disturbances
  4. Urinary Incontinence
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9
Q

ARTERIAL LESIONS

What are (5) Symptoms for a MIDDLE CEREBRAL Artery Lesion?

A
  1. Profound Upper Extremity Weakness (contralateral to lesion)
  2. Aphasia
  3. Apraxia / Neglect
  4. The Eyes Deviate towards the same side as lesion
  5. Contralateral Homonymous Hemianopsia, with macular sparing.
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10
Q

ARTERIAL LESIONS

What is (1) Symptom of a POSTERIOR CEREBRAL Artery Lesion?

A

Prosopagnosia

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11
Q

ARTERIAL LESIONS

What are (8) Symptoms for a VERTEBROBASILAR Artery Lesion?

A
  1. Ataxia
  2. Bilateral findings
  3. “Drop Attack” - May be described as a Loss of Consciousness
  4. Dysarthria and Dystonia
  5. Nausea and vomiting
  6. Sensory changes in Face and Scalp
  7. Vertical Nystagmus
  8. Vertigo
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12
Q

ARTERIAL LESIONS

What are (3) Symptoms of a POSTERIOR INFERIOR CEREBELLAR Artery Lesion?

A
  1. Ipsilateral face
  2. Contralateral body
  3. Vertigo and Horner syndrome
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13
Q

ARTERIAL LESIONS

What are (6) Symptoms of a LACUNAR INFARCT?

A
  1. Absence of cortical deficits.
  2. Ataxia
  3. Bulbar signs
  4. Hemiparesis (most notable in the face)
  5. Parkinsonian signs
  6. Sensory deficits
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14
Q

ARTERIAL LESIONS

What is (1) Symptom of an OPHTHALMIC Artery Lesion?

A

Amaurosis Fugax

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15
Q

CEREBRAL VEIN THROMBOSIS

What is the Most Common Presenting Symptom for Cerebral Vein Thrombosis?

A

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.
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16
Q

CEREBRAL VEIN THROMBOSIS

  1. What is the Best INITIAL Test for Cerebral Vein Thrombosis?
  2. What is the Most ACCURATE Test for Cerebral Vein Thrombosis?
A
  1. Lumbar Puncture = Normal. Done to rule out SAH
  2. Magnetic Resonance Venography (MRV)
17
Q

CEREBRAL VEIN THROMBOSIS

What is the 2-Step Treatment for Cerebral Vein Thrombosis?

A
  1. Low Molecular Weight Heparin (LMWH) followed by…
  2. Warfarin for a few months.
18
Q

DIAGNOSIS

  1. What is the Best INITIAL Diagnostic Test for either Stroke or TIA?
  2. What is a MORE Accurate Diagnostic Test?
  3. What is the Most ACCURATE Test?
A
  1. CT Head w/o contrast - Within the first several days, all non-hemorrhagic strokes should be associated with a normal head CT scan.
  2. 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.
  3. MRA Head - Most accurately images the brain for stroke. Can be positive within the hour of the stroke.
19
Q

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?

A

Thrombolytics

20
Q

TREATMENT

What are the (4) Criteria a patient must meet in order to receive Thrombolytic treatment for a Stroke?

A

Criteria:

  • ​​Age < 80
  • Mild to Moderate Stroke (NIH Stroke Scale < 26)
  • NOT a diabetic with a previous stroke
  • NOT currently using anticoagulation
21
Q

TREATMENT

What are (8) Contraindications to Thrombolytic treatment for an Ischemic Stroke?

A
  1. Hemorrhagic Stroke (ever)
  2. Ischemic/Embolic Stroke (within 1 year)
  3. Intracranial Neoplasm/Mass
  4. Cerebral Trauma or Brain Surgery (within 6 months)
  5. Bleeding Disorder
  6. Aortic Dissection
  7. Active Bleeding or Surgery (within 6 weeks)
  8. CPR with chest compression (within 3 weeks)
22
Q

TREATMENT

What are (2) other Therapies for Ischemic Stroke patients who arrive in the ED > 4.5 hours after symptom onset?

A
  1. 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.)
  2. 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.
23
Q

TREATMENT

  1. Under what condition would you either switch from Aspirin to Clopidogrel or add Dipyridamole to Aspirin in a patient with an Ischemic Stroke?
  2. What other therapy should be added to ALL patients with Ischemic Stroke?
A
  1. Switch to Clopidogrel or add Dipyridamole if the patient has developed an Ischemic Stroke while on Aspirin.
  2. Statins
24
Q

TREATMENT

What is the ONLY Difference in Treatment between a Stroke and a TIA?

A

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.
25
Q

FURTHER MANAGEMENT

  1. On subsequent screens, After you have done the head CT and given thrombolytics or aspirin, what is the most important issue for preventing another stroke?
  2. What are (3) Exams that assist in the answer to question 1?
A

Determining the Origin:

  1. Echocardiogram: Anticoagulation for clots, possible surgery for valve vegetations
  2. Carotid Dopplers/Duplex: Endarterectomy for stenosis > 70 percent, but not if it is 100 percent. Carotid imaging should not be done in an asymptomatic person. Stenosis of the carotids, even when the passage is narrowed 70–99 percent, is not an indication for endarterectomy in a patient who is asymptomatic.
  3. EKG and a Holter Monitor if the EKG is normal: Warfarin, dabigatran, or rivaroxaban for atrial fibrillation
26
Q

FURTHER MANAGEMENT

What are (4) additional Tests that young Stroke patients (< 50) with no past medical history (i.e., diabetes, hypertension) should have?

A
  1. Sedimentation Rate (ESR)
  2. Protein C, Protein S, Factor V Leiden mutation, Antiphospholipid Syndromes
  3. ANA, Double-Stranded DNA
  4. RPR or VDRL

The younger the patient, the more likely the cause of the stroke is a vasculitis or hypercoagulable state.

27
Q

FURTHER MANAGEMENT

  1. What is the Therapeutic BP Goal for a Stroke patient?
  2. What is the Therapeutic Glycemic Goal for a Stroke patient?
  3. What is the Therapeutic LDL Goal for a Stroke patient?
A
  1. BP = < 140 / 90 mmHg in a Diabetic
  2. Blood Glucose = same tight control as the general population.
  3. LDL < 100 mg/dL - add statins for all non-hemorrhagic strokes
28
Q

FURTHER MANAGEMENT

Under which (3) Criteria is Closure of Patent Foramen Ovale (PFO) the next step in management?

A
  1. Patient age 60+
  2. An embolic-appearing Cryptogenic Ischemic Stroke
  3. Right-to-Left shunt detected by Bubble Study

PFO closure is conducted in conjunction with antiplatelet therapy and is done with a percutaneous device.​

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