22- stroke Flashcards
orthostasis
A reduction of systolic or diastolic blood pressure of at least 20 or 10 mmHg respectively, measured three minutes after a patient who has accommodated to the supine position assumes a standing or sitting position.
Timed Up and Go Test
Measures mobility and fall risk in people who are able to walk on their own.
- Sit in the chair with your back to the chair and your arms resting in your lap.
- Without using your arms, stand up from the chair and walk 10 ft. (3m).
- Turn around, walk back to the chair, and sit down again.
scoring of time up and go test
<10 sec Freely mobile < 20 Mostly independent 20-29 Variable mobility > 30 Impaired mobility
physical exam findings of stroke
Weakness or asymmetry of the muscles of facial expression
carotid bruits as emboli from carotid arteries
romberg
murmurs or irregular rhythms on the cardiovascular exam may signal valvular disease and intra-cardiac mural thrombi as sources for cardiac emboli.
transient monocular blindness or visual field defects.
Proprioceptive and spatial deficits
mental status change
EKG abnl
one of the most sensitive tests for upper extremity weakness.
The pronator drift
The patient is asked to flex their arms 90 degrees at the shoulders, supinate their forearms, close their eyes, and hold the position. If a forearm pronates, then the patient is said to have pronator drift on that side.
Face Arm Speech (FAST) test
sed by ambulance paramedics and physicians for the rapid clinical assessment of patients with suspected transient ischemic or stroke symptoms.
Common deficits that should alert medical professionals and the general public to the possibility of stroke include:
sudden unilateral numbness or weakness of face, arm, or leg; sudden confusion, dysarthria; sudden visual disturbance; sudden gait disturbance, dizziness, loss of balance or coordination; and sudden severe headache with no known cause.
can TIAs impair consciousness?
nope
medications that can cause stroke-like effects
thiazides- hypokalemia
estrogens and neuroleptics –> stroke risk
antihypertensives –> lightheaded, dizzy
alpha blockers –> syncope
Severe hypoglycemia may present with
sweating, altered consciousness, loss of coordination, parasthesias and focal neurologic findings.
irreversible neuro damage
amaurosis fugax
transient monocular loss of vision)
appears in Temporal arteritis
Hypokalemic periodic paralysis
rare syndrome characterized by episodes of general or focal weakness.
Episodes usually begin in childhood or adolescence.
Paralysis most often occurs during the rest period following vigorous physical activity.
Hemiplegic migraine
rare form of migraine that can present as headache associated with hemiparesis with sensory deficits and motor weakness.
most common during childhood and adolescence with the cessation of symptoms by mid-adult life.
paroxysmal chronic a fib (versus persistent)
atrial fibrillation may recur and then revert back to normal rhythm spontaneously, with variable periods of normal sinus rhythm between episodes.
Mechanisms of TIAs or Possible Stroke
Embolic
Thrombotic- 85%
Cardiogenic
Hemorrhagic
cardiogenic mechanism for stroke
Secondary to a decrease in cerebral perfusion caused by decreased cardiac output (e.g.: anginal event associated with coronary artery disease), severe hypotension, or hypoxemia related to severe anemia or poor oxygen saturation
hemorrhagic mechanism for stroke
Secondary to pathologic cerebrovascular changes within the brain attributable to aging, smoking, hypertension, and hyperlipidemia.
Intra-arterial therapy improves functional outcomes if it can be given within
6 hrs
Recommended Tests for the Initial Emergency Evaluation of a Patient with Suspected Acute Ischemic Stroke
Noncontrast brain CT or brain MRI
E. Serum electrolytes/renal function tests
F. ECG
G. Markers of cardiac ischemia
H. Complete blood count, including platelet count
I. Prothrombin time/international normalized ratio (INR)
J. Activated partial thromboplastin time
K. Oxygen saturation
L. Chest radiography- if have lung disease
B-type Natriuretic Peptide (BNP)
secreted by the cardiac ventricles in response to ventricular volume expansion and pressure overload. The levels of BNP are elevated in patients with left ventricular dysfunction, and the levels correlate with both the severity of symptoms and the prognosis.
Rate control:
Controlling the heart rate with intravenous diltiazem, beta-blockers, or verapamil improves blood flow and does not delay immediate need for emergency stroke treatment.
Rhythm control:
Cardioversion either via electric shock to the heart with the patient under sedation or via medications given orally or intravenously.
Both methods carry a risk of stroke which is greatest in patients who have had atrial fibrillation for more than 48 hours, or who have not been given three weeks of prior anticoagulant therapy.
CT can detect
hemorrhage, tumor, infarct
Symptoms of Right Parietal Infarct
Left hemiplegia May attempt to read while holding books upside down (spatial inabilities) Inattention to areas of a room Denial of stroke disability Left facial weakness
where is stroke that would cause respiratory impairment and affect vital functions of blood pressure, heartbeat and consciousness.
brainstem
which artery stroke would cause Expressive and receptive aphasia and right facial weakness
left middle cerebral artery
Prevention of a First Stroke
- Antiplatelet therapy with aspirin- low risk
- Adjusted-dose warfarin (target INR, 2.0-3.0)- mod risk
- Dual-antiplatelet therapy with clopidogrel and aspirin- higher risk
Prevention of Stroke in Patients With a History of Stroke or TIA
Anticoagulation with a vitamin K antagonist
For patients unable to take oral anticoagulants
aspirin alone
Common Stroke Complications
Aspiration pneumonia
Malnutrition/dehydration
Pressure sores
Stroke Rehabilitation Therapy
begins 24-48 hrs after stroke
first steps involve promoting independent movement because many patients are paralyzed or seriously weakened.
CHADS2 score
validated instrument that applies known cardiovascular risk factors to provide calculated guidance to help weigh the benefits and risks of anticoagulation.
BADLs vs. IADLs
Basic: eg. bathing, dressing, toilet, walking
instrumental but not necessary: manage money, meds, housework
Secondary Stroke Prevention
high-intensity statin such as atorvastatin 40 or 80 mg or rosuvastatin 20 mg.
thiazide diuretic or a calcium channel blocker
stop smoking, mediterranean diet, exercise, education
what % of stroke survivors experience post-stroke depression.
one third
treatment for post stroke depression
SSRIs
TIAs last less than
24 hrs
In the secondary prevention of ischemic stroke, when using Aspirin alone as anti-platelet therapy, which doses is recommended?`
Low dose aspirin; confers equivalent benefit to high dose, and less bleeding risk
When evaluating a person with a possible stroke, when is it acceptable to administer t-PA?
onset of neurologic symptoms has been within three hours of the onset of symptoms,
emergent CT head does not show an intracranial bleed, an early acute infarct, or a brain mass.
Why is it important to distinguish between cardioembolic etiologies of stroke versus atherothrombotic?
Affects treatment!
cardioembolic cause : coumadin therapy.
atherothrombotic stroke: anti-platelet agent.
