11) Stroke Flashcards
CVA
Sudden loss of neurological fxn as the result of a disruption to blood flow resulting in tissue death
Ischemia
Decr blood flow resulting in tissue death
Thrombosis
Aggregation of platelets & fibrin in a cerebral artery resulting in occlusion
*Has a gradual onset & pt often awakes w/sx’s
Embolus
Thrombus originates elsewhere, breaks off, & travels through the bloodstream to a narrowing region
*Onset is abrupt & happens w/activity
Lacunar Infarct
Occlusion of small vessels
*Gradual onset
What is lacunar infarct associated w/?
HTN or DM
TIA
Sx’s are gone w/in24hrs
Ischemic Penumbra
Rim of mild-moderate ischemic tissue around the area of infarct
How long can an ischemic penumbra remain viable for & why?
Several hours bc of collaterals
What happens if reperfusion isn’t quickly established w/a penumbra?
Necrosis
What % of normal blood flow does the brain need to survive?
20-25%
Antiplatelet drugs
Aspirin, Plavix, & Aggrenox
Anticoagulants
Heparin, Coumadin, & Lovenox
What are statins?
Block the enzyme that produces LDL
Hypertensives
Beta-blockers & Ace-inhibitors
How to differentiate a beta-blocker from an ace-inhibitor
Beta-blockers end in “ol”
Ace-inhibitors end in “il”
Intercerebral Hemorrhage
Arterial bleeding into the brain
Does an intercerebral hemorrhage have a high or low mortality rate?
High
What accounts for 15% of all CVA?
intercerebral hemorrhage
Etiology of intercerebral hemorrhage
- Atherosclerosis weakens small arterial walls
- Sudden BP incr
- > 65y/o
Clinical manifestations of intercerebral hemorrhage
*Specific to region
*Sx’s incr as hematoma enlarges
Seizure activity is possible
What does intercerebral hemorrhage result in?
- Structural distortion
- Incr ICP
- Devo of severe edema causing a midline shift
Subarachnoid Hemorrhage
Blood in the subarachnoid space
Sx’s of subarachnoid hemorrhage
Sudden onset of:
- Severe HA
- Nausea
- Vomiting
- Syncope
- Neck pain
- Confusion
- Lethargy
- Coma
Causes of subarachnoid hemorrhage
- AVM
- Age
- Trauma
- Neoplasm
- Infection
- HTN
- Vascular malformation
- Smoking
- Alcohol
Subdural Hematoma
Tearing of bridging veins between the brain & dura bc of truma
Who is subdural hematoma especially common in?
The elderly
How do elderly pt’s w/subdural hematoma present?
W/cognitive decline
Management of subdural hematoma
Small gets absorbed by the body; Large needs to be evacuated
Epidural Hematoma
Traumatic tearing of meningeal arteries
Describe epidural hematoma
Medical emergency requiring evacuation
What happens if an epidural hematoma is not evacuated quickly?
Can cause brainstem compression
Risk factors for CVA
- HTN
- Smoking
- Hyperlipidemia
- Cardiac disease
- DM
- Abdominal obesity
- Sedentary lifestyle
- Excessive alcohol consumption
- Age
- Sex
- FHx
- Race
- Geography
What is the gene associated w/CVA
NOTCH3
What are the warning signs of CVA?
- Sudden numbness/weakness in face, arm, or leg
- Sudden difficulty w/speech or comprehension
- Confusion
- Sudden vision problems
- Sudden trouble amb
- Sudden balance/coordination problems
- Sudden HA w/no known cause
Who less disability 3 months post-CVA?
Pt’s who get to the ER w/in 3hrs
Diagnostic Tests for CVA
- Non-contrast CT
- MRI
- MRA
- EKG
- Echo w/bubble
- TEE
- Telemetry
- Carotid Doppler
Tissue Plasminogen Activator (tPA)
Used w/ischemic strokes to lyse fibrin
Mechanical Embolus Retrieval for Cerebral Ischemia (MERCI)
Has 8hr window for larger occluded arteries
Diagnostic Scales
- Oxford ABC Scale
* NIH Stroke Scale
Oxford ABC Scale
Done in MD’s office to predict risk of stroke after TIA
NIH Stroke Scale
Standardized tool to assess impairment & if pt needs tPA
Medical management of CVA
- CT/MRI
- Angiogram
- Tox screen
- Monitor INR time
- Monitor & maintain BP
- Seizure prophylaxis
- Induced coma
- Medically induced hypothermia
- Hyperventilation
- Diuretics
- Surgical drainage
What lobes do the carotid arteries supply?
- Frontal–>Reasoning, planning, speech, movement, emotions, & problem-solving
- Parietal–>Movement, orientation, recognition, stimulus perception
- Temporal–>Perception & recognition of auditory stimuli, memory, & speech
- Basal Ganglia–>Regulates movement
- Internal Capsule–>Where large #’s of motor & sensory fibers travel to & from the cortex
What is the most common location of lacunar infarcts?
Internal Capsule
What happens if a CVA occurs in the ACA?
- Hemiplegia/Paresis
- Hemisensory Deficits
- Difficulty w/bimanual tasks or imitation
- Aphasia if in dominant hemisphere
- Apraxia if in non-dominant hemisphere
- Personality/behavioral changes
- Urinary incontinence
What is the most common region for CVA’s?
MCA
What is the common cause of MCA CVA?
Internal carotid thrombus
What can happen as the result of a vertebrobasilar artery CVA?
Wallenberg Syndrome & Horner’s Syndrome
Wallenberg Syndrome
- Dysphagia
- Dysphonia
- Vertigo
- Nystagmus
- Ipsilateral Ataxia
- Dyskinesia
- Intention Tremor
- Impaired sensation
Horner’s Syndrome
- Ptosis of eyelids
- Pupillary constriction
- Loss of ipsilateral facial sweating
- Dysphagia/Dysphonia
- Loss of pain/temp sensation in contralateral torso/extremities
What is the result of a complete basilar artery occlusion?
Locked-in Syndrome
What is the prognosis for locked-in syndrome?
High mortality rate; Those that survive are severely disabled
What happens as a result of locked-in syndrome
- Tetraplegia
- Bilateral CN palsy so horizontal eye movement
- Mute
- Cognition is spared
Complications associated w/stroke
- Altered consciousness & cognition
- Speech & swallowing problems
- Motor deficits
- Tone changes
- Reflex problems
- Balance & coordination deficits
- Emotional changes
Pusher Syndrome
Equitable split between L & R hemisphere so pt perceives their midline as 18 to the ipsilesional side
Sx’s of Pusher Syndrome
- Spontaneous body posture towards the involved side
- Incr pushing force by spreading the non-paretic limbs
- Resistance to passive posture correction
- Noted in sitting & standing
Tx for Pusher Syndrome
Combines visual, somatosensory, & motor learning
- Allow pt to “fall: from pushing
- Use vision to attain posture to mimic vertical objects
- Sitting weight shifts progressed to STS
- Single-leg activities
- Fxnl training to uninvolved side
- BW-supported gait training
What device is good for training a pt w/pusher syndrome?
A mirror w/a line down the middle
Aphasia
Difficulties w/expression &/or language comprehension
Broca’s Aphasia
Difficulty w/expression
Wernicke’s Aphasia
Difficulty w/understanding
Global Aphasia
Combo; Happens w/full MCA infarct through the frontal & parietal lobes
Alexia
Reading impairment; Pt doesn’t know what letters mean
Agraphia
Writing impairment
Agnosia
Can’t perceive auditory, visual, & tactile input even though sensory systems are intact
Apraxia
Inability to execute voluntary motor tasks despite having muscle fxn & understanding the task
Anosognosia
Lack of awareness of illness; Means parietal lobe lesion
Dysarthria
Motor speech disorder affecting respiration, articulation, & phonation
Dysphagia
Inability/difficulty w/swallowing bc of CN involvement (5,7, 9-12)
Perseveration
Unable to refrain from certain behaviors
Spatial Perception
Ability to sense the size, shape, movement, distance, & orientation of objects & awareness of oneself in space & in relation to other objects
