4 - Stroke Syndromes Flashcards
Sroke is defined as:
Any disease process that interrupts blood flow to the brain
What causes the injury with strokes?
The injury is cause by:
- The loss of O2 and glucose substrates necessary for high-energy phosphate production
- The presence of mediators of secondary cellular injury
- Edema and mass effect exacerbate the insult
Subtypes of stroke?
Ischemia
Hemorrhagic
Types of ischemic stroke
- thrombotic
- embolic
- hypoperfusion
Chart on slide 7
He said ignore the chart and just know that it is clot and hypo-perfusion
Types of hemorrhagic stroke?
Intracerebral
Subarachnoid
Key component to stroke?
Early detection
- bc time is the critical component in care of stroke patients
General and subtle stroke symptoms?
General:
- facial droop
- arm drift
- abnormal speech
Subtle symtoms:
- generalized weakness
- lightheadedness
- vague sensory changes
- altered mental status
Though they account for over 1/2 or strokes who presents in an atypical manner?
Women
Embolic and hemorrhagic strokes present?
Suddenly
Thrombotic or hypoperfusion strokes presentation?
Waxing and waning or stuttering
Cerebral aneurysm rupture presentation, a HX of?
Valsalva maneuver with immediate ha or sudden onset of symptoms
Cervical artery dissection presentation, a HX of?
Recent neck trauma or manipulation
Hx that presents a risk for thrombus?
HTN
DM
CAD
Transient neuro deficits in the same vascular distribution
Hx that presents risk factors for Embolus?
Afib
Valvular replacement
Recent MI
Transient neurologic deficits in different vascular distribution
If you get a hx and r/o stroke mimics and it is likely acute stroke what must you do?
Consider the time limits for thrombolytic therapy
Look for inclusion or exclusion criteria for treatment
Stroke mimics (list)
- Seizures/postictal paralysis
- Syncope
- Meningitis/encephalitis
- Complicated migraine
- Brain neoplasm/abscess
- Subarachnoid hemorrhage
- Hypoglycemia
- Hyponatremia
- Hypertensive encephalopathy
- hyperosmotic coma
- Wernicke’s encephalopathy
- Labyrinthistis
- Drug tox
- Bell’s palsy
- Meinere’s disease
- Demyelinating disease (MS)
- Conversion d/o
Slide 16 for more info
What needs to be checked during PE for stroke?
ABC (top priority) Confirm stroke ID comorbids Eval for cardica or vascular disease Perform a good neuro
Neuro exam for stroke needs to include?
NIHSS
The national institute of heal stroke scale
See slides 18-22
NIHSS scores and their meaning
0 -0 - no stroke 1-4 - minor stroke 5-15 - moderate stroke 16-20 - moderate to severe 21-42 - severe stroke
What vessel is MC involved in stroke?
Middle cerebral artery infarction
This is a type of ischemic stroke syndrome
Middle cerebral artery infarction presentation
Vary based on which hemisphere is dominant and where exactly the lesion is (typically L hemisphere is dominant)
Typically:
- hemiparesis
- facial plegia
- sensory loss (contralateral)
Homonymous hemianopsia and gaze preference toward the side of the infarct
Middle cerebral artery infarction
If the dominant hemisphere is involved?
If the non-dominant hemisphere is involved?
Dominant
- Aphasia (receptive, expressive or both)
Non-dominant
- Inattention
- Neglect
- Extinction on double-simultaneous stimulation
- Dysarthria w/o aphasia
- Constructional apraxia (drawing complex shit)
Symptoms of posterior cerebral artery infarction?
Classic symptoms:
- ataxia
- nystagmus
- altered mental
- vertigo
- visual field loss
- unilateral limb weakness
- CN VII signs
- lethargy
- sensory deficits
Crossed neurological deficits may indicate?
Brainstem lesion
Examples:
- ipsilateral CN deficits with contralateral motor weakness
What sign is thought to be specific for distal posterior circulation stroke?
Why?
Visual field loss
- described as contralateral homonymous heminopsia and unilateral cortical blindness
B/c the visual centers of the brain are supplied by posterior cerebral artery
PE for posterior cerebral artery infarction may find?
- Light-touch and pinprick sensation loss
- Alexia w/o agraphia (loss of reading w/o loss of writing)
- inability to name colors
- unilateral 3rd nerve palsy
- hemiballismus (type of chorea)
Presentation of basilar artery infarction stroke
MC symptoms
- unilateral limb weakness
- dizziness
- dysarthria
- diplopia
- HA
MC signs
- CN VII signs
- dysarthira
- babinski sign
- oculomor signs
Dysphagia, n/v, dizziness and horner’s syndrome are positively correlated with?
Basilar artery occlusion
Rare but serious presentation of basilar artery infarction?
Locked in syndrome
Characterized by complete muscle paralysis except for upward gaze and blinking, lack of communication but are completely aware of surroundings
Which type of stroke is associated with more favorable prognosis?
Lacunar infarction
What is lacunar infarction?
“Mini stroke”
Pure motor and sensory deficits caused by infarction of small penetrating arteries
Commonly associated with chronic hypertension and increasing age
Who gets carotid and vertebral artery dissections?
Young and middle aged pts usually
With a hx of recent minor neck trauma
How does carotid and vertebral artery dissection present?
Unilateral HA
Neck pain
Face pain
Symptoms may be transient or persistent
New onset HA or neck pain of unclear etiology should get?
Imagin of neck vessels
Presentation of carotid artery dissection?
Fronto-temporal HA
- thunderclap ha
Temporal arteritis
Preexisting migraine
Partial horners syndrome (miosis and ptosis)
Carotid dissection can progress to?
Cerebral ischemia Retinal infarction (rare)
Symptoms of vertebral artery dissection?
Neck pain (66%) HA (65%) (usually occipital)
Other S/S
- unilateral facial parestheisa
- dizziness
- vertigo
- N/V
- diplopia
- visual disturbances
- ataxia
- limb weakness
- numbness
- dysarthria
- hearing loss
Test of choice for carotid, vertebra or basilar artery dissection?
MRI angiography
CT/CT angiography
Neurology will tell you which one is best
Color duplex US?
May not detect important vascular lesions
Untreated vertebral artery dissection may result in infarction in the regions of the brain supplied by?
Posterior circulation
Intracerebral hemorrhage and ischemic infarction are both?
Very different in terms of management but may be clinically indistinguishable
Get a noncontrast CT to differentiate them
If a intracerebral hemorrhage pt has HA, N/V you should?
Be concerned, these often precede neurologic deficit and they go downhill quickly
Subarachnoid HA have the “worst HA of my life” and careful hx taking will usually ID?
An association with valsalva type activities
Examples of activities associated with the valsalva maneuver?
Defecation
Sex
Weight lifting
Coughing
What is the goal timeline for stroke?
Decide treatment w/in 60 min
Study of choice for suspected acute stroke?
Non-contrast CT
Ideally should be reviewed by the most senior person w/in 45 min
Problem with non-contrast CT in stroke patients?
Most acute ischemic strokes are not visualized by non-contract brain CT in the early hours of a stroke
Though not the preferred study what study is the most accurate for detection of acute infarction?
Diffusion-weighted MRI
Thought the AHA/ASA recommend either CT or MRI what is the only study necessary to administer rtPA?
Non-contrast CT
Hydration for strokes?
Correct dehydration
Euvolemic pts get maintenance fluids
Dont use volume expansion or hemodilution
2013 AHA/ASA O2 sat recommendations?
> 94%
No hyperbaric O2
Fever and stroke?
Associated w higher morbidity and mortality - find and fix
Ischemic HTN is a concern when?
Pts are candidates for reperfusion intervention
Permissive HTN for pts?
- candidates
- Not candidates
for reperfusion therapy?
Not candidates for reperfusion:
SBP < 220
DBP < 120
Candidates for Reperfusion therapy:
SBP <185
DBP <110
If needed reduce by 15% over 24hrs
If target BP of <185/110 cannot be met?
The pt is no longer a candidate for rePA therapy
BP meds for stroke?
Labetalol 10-20mg IV over 1-2 min
- can repeat once
Nicardipine 5mg/hr
- titrate up 2.5mg/hr q 5-15 min
- when target reached reduce to 3mg/hr
____ is common in acute stroke?
Ischemic hyperglycemia
Stroke glucose level recommendations?
Keep blood glucose between 140 mg/dl and 180mg/dl
No need to stress the brain further
Aspirin and stroke?
Current AHA/ASA guidelines recommend 325mg w/in 24-48hrs
But…
No antiplatelets w/in 24hrs of rtPA
Inclusion criteria for IV Recombinant Tissue Plasminogen Activator (rtPA) in acute ischemic stroke?
Measurable diagnosis of acute ischemic stroke
- NIHSS score
Onset of symptoms <3hrs
- ideally witnessed
Age >/= 18
Exclusion criteria for rtPA?
- Head trauma w/in 3 mo
- Poss subarachnoid
- Noncompressible bleed <7 days ago
- Hx of intracranial hemorrhage
- Intracranial neoplasm
- Arteriovenous malformation
- Aneurysm
- Recent head/spinal surg
- Uncontrolled BP
- Active internal bleed
- platelets < 100,000
- heparin w/in 48hrs w prolonged aPTT
- INR >1.7
- use of thrombin inhibitors or factor Xa
- glucose <50
- multiloba infarction
Relative exclusion criteria for rtPA?
- minor stroke
- pregnancy
- seizure at onset
- maj surg/trauma w/in 14 days
- GI/urinary tract hemorrhage w/in 21 days
- MI w/in 3 o
If a pt wakes up with stroke symptoms when do you “clock” their stroke time?
Should be “clocked” from the time at which the pt was last known to be w/out symptoms (so probably before bed)
IOT administer rtPA you must know?
Time of symptom onset
NIHSS score needed to give rtPA?
Between 4 and 22
Dont withold rtPA for labs except on?
Glucose
Good thing its bedside, take that lab people
Dose of rtPA?
0.9mg/kg IV
Max dose of 90mg
Admin 10% bolus over 1 min
Remaining 90% over 60 min
What must be monitored ruing admin of rtPA?
BP q 15 min for 1st 2 hrs
So admit them to ICU
Post-rtPA bleeding suspected?
Stop rtPA
Order CBC with platelet count
Fibrinogen level
Typing and cross-match for blood
Emergent neuro, neurosurgery and hematology consults needed
Pts with massive middle cerebral artery infarct?
No rtPA (80% mortality) - thrombolytics are contraindicated with hemorrhagic stroke
May be candidates for Decompression
What are endovascular therapies for ischemic stroke?
Mechanical clot disruption/extraction
What are some advantages to mechanical clot removal?
- Expanded tx window
- pts w contraindications for thrombolytics
- eval the vein
- lower thrombolytic drug use
What is the time limit for mechanical clot removal?
None have been established
What is a TIA?
Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia w/out acute infarction
Consider Analogous to unstable angina
TIA-ABCD2 score?
7 point score given based on:
- Age (>60)
- BP (>140/90)
- clinical stroke features
- duration (> 1 hr)
- diabetes
See slide 68
TIA ABCD2 score interoperation?
2 day risk:
- 0-3: 1%
- 4-5: 4.1%
- 6-7: 8.1%
7 day risk:
- 0-3: 1.2%
- 4-5: 5.9%
- 6-7: 11.7%
<4 maybe admit
>4 admit
TIA tx?
Aspirin Or Aspirin + dipyridamole And Warfarin
Benefits of heparins outweigh the risk of intracranial bleeds
MC cause of ischemic stroke in kids?
Sickle cell disease
Tx for SCD stroke?
Same as regular except you must put them on O2 and get them emergency consult with hematology and stroke neurologist
Women are at an increased stroke risk when?
They are pregnant and postpartum (+6weeks)
Greatest risk is during postpartum
Pregnant stroke tx?
rtPA doesnt cross placenta
ED tx: call obstetrics, stroke neuro, and neonatologist
Stroke clinical features
- traditional symptoms
- Sudden numbness (arm, leg, whatever)
- Sudden altered mental (WOMEN)
- Sudden aphasia
- Sudden memory deficit, spacial orientation, perceptions
- Sudden visual deficit or diplopia (MEN)
- Sudden Dizziness, gait, ataxia (MEN)
- Sudden severe HA
Stroke clinical features
- nontraditional symptoms
- LOC/syncope
- Generalized weakness (WOMEN)
- SOB
- Sudden pain face, chest, wherever
- Seizure
- Falls/accidents
- Sudden hiccups
- Sudden fatigue
- Sudden palpitations
- Altered mental
Stroke symptoms more common in WOMEN?
Sudden altered mental status
Generalized weakness
Stroke symptoms more common in MEN?
Sudden numbness/weakness face, arm, leg
Sudden visual deficit or diplopia
Sudden dizziness, gait disturbances, ataxia
Men more commonly present with traditional symptoms
Which artery typically caused very minimal motor dysfunction which can mask awareness of the stroke?
Posterior cerebral artery
Which type of stroke has a high risk of death and poor outcome?
Basilar artery occlusions
I will give you three seconds, exactly three fucking secinds, to wipe that stupid grin off your face
or I will gouge out your eyeballs and skull-fuck you!
