3.5/ 3.6 CLIN - Stroke

Question 1

pt admitted to internal medicine inpt services for ischemic stroke. what labs would you order?

Answer 1

CBC, electrolytes, urea, creatinine, glucose, liver function tests, toxicology screen, INR, PT, PTT, sed rate, lipid profile, Alcohol level, Hypercoag panel if younger

Question 2

pt admitted to internal medicine inpt services for ischemic stroke. what imaging would you order?

Answer 2

didn’t get specific here. in ED, 1st order CT w/o contrast. after that can order a variety: MRI, MRA, CT with contrast, venogram, TEE carotid US, etc.

Question 3

HTN can increase stroke risk. why then don’t you want to decrease blood pressure in the 1st 24-hours post stroke? How else can I get blood to the brain right after stroke?

Answer 3

in the first 24 hours post stroke usually don’t treat unless BP >220/120 acutely. Want to keep the brain vascularized in an ischemic stroke and high BP facilitates this. 2. can also decrease angle of head of bed, give IV fluids to increase blood volume.

Question 4

Why do you get increased BP right after stroke?

Answer 4

This is common –> *Primary consequence of stroke - compensatory

Question 5

How do you treat acute ischemic stroke if you get to the ED within 4.5 hours? what medicine?

Answer 5

rt-PA.

Question 6

How do you treat acute ischemic stroke if you arrive at ED after 4.5 hours? what medicine?

Answer 6

asa, clopidogrel, dipyridamole

Question 7

list some 2ndary prevention meds:

Answer 7

antiplatelet/blood thinners: asa, clopidogrel, dipyridamole, warfarin, dabigatran 2. for high cholesterol, HTN, and 2ndary risk reduction: HTN meds, statins

Question 8

What’s the single most important risk factor for stroke?

Answer 8

HTN

Question 9

List some lifestyle mods you can tell your patients about to lower stroke risk:

Answer 9

diet exercise, stop smoking, don’t do illicit drugs, lose weight, increase fiber, exercise, a bit of alcohol consumption,

Question 10

what neurological complications of stroke did we go over?

Answer 10

cerebral edema + ICP

Question 11

Whats the hallmark of cerebral edema + increased ICP ?

Answer 11

*Hallmark is depression of consciousness

Question 12

when cerebral edema + increased ICP risk highest? Why are we worried about this complication?

Answer 12

*Peaks within 72 hours of large vessel strokes or IC hemorrhage 2. this complication is the Leading cause of death

Question 13

what can we do to medically manage Brain Edema and Increased Intracranial Pressure?

Answer 13

• Restrict fluids
• Control fever, hypoxia, hypercarbia
• ->*Hyperventilation - reduces PCO2

Question 14

What the #1 cause of hemorrhagic stroke?

Answer 14

HTN

Question 15

Which imaging technique is best to spot a hemorrhagic stroke?

Answer 15

noncontrast CT of the brain

*Modality of choice for imaging hemorrhagic stroke on emergent basis

Question 16

How do you approach lowering BP in hypertensive pt with ICH?

Answer 16

undetermined. “probably best to lower BP slowly to SBP ~140”

Question 17

in ICH setting, How do you treat the bleed itself?

Answer 17

undetermined. provide supportive care, lower BP, reverse blood thinner if culprit.

Question 18

what’s the one situation when neurosurgery is indicated in hemorrhage?

Answer 18

cerebellar hematoma

Question 19

What are some mixed signs of cerebellar or brainstem involvement in a stroke?

Answer 19

• Gait or limb ataxia.
• Vertigo or tinnitus.
• Crossed signs (ipsilateral face and contralateral body)
• Hemisensory loss, or sensory loss of all 4 limbs.
• Eye movement abnormalities (nystagmus or diplopia).
• Nausea and vomiting.
• Oropharyngeal weakness or dysphagia.

Question 20

What is a TIA?

Answer 20

• Transient Ischemic Stroke.
• All the signs and symptoms of a stroke but resolve usually within an hour.
• Normal MRI.
• Sets the stage for a stroke, if you treat the TIA you can have a good chance at reducing stroke risk.

Question 21

Pt. presents with vision deficits in one eye that resolve quickly, these attacks are indicative of what? What is causing these?

Answer 21

• Transient Monocular Blindness.
• Signals presence of ipsilateral carotid artery disease.
• Feeding ophthalmic artery.

Question 22

What are classic presentations of lacunar infarcts?

Answer 22

• Aphasia and visual field deficits are absent.
• Pure motor stroke/ hemiparesis.
• Pure sensory stroke. Occasionally complaint of pain, burning, or other unpleasant sensations = thalamus.

Question 23

Pt. presents non-verbal, right facial droop, looks left, slightly use R leg, cannot use R arm, L side functional. What is your FIRST move? SECOND move?

Answer 23

• First: send pt straight to get CT.
• Second: Take history and do PE.
  Check pulses, listen to cardiac rhythm, listen for bruits, check skin for signs of endocarditis, check eyes for cholesterol emboli/ papilledema, signs of head trauma, neuro deficits.
• Get labs/ tests.

Question 24

After getting test/ lab/ etc. results back everything is fine, heart is a. fib though. What is your next move?

Answer 24

• Suspect stroke.

- Find out how long ago the symptoms started if possible.

Question 25

Stroke symptoms began 4hrs prior what do you do? Pt. went to bed at 940 and woke up at 7am with symptoms, what do you do?

Answer 25

• Cry tears of joy and start t-PA treatment to reverse clot.

- Get bummed and begin supportive type treatments.