6A. Neurologic Disorders Flashcards
Stroke
Sudden interruption of oxygenated blood to the brain
• Focal necrosis of brain tissue – Motor \_\_\_\_ – Speech impairment – \_\_\_\_ – Death
• \_\_\_\_ etiology • \_\_\_\_(80%) – Mortality rate of approx. 8% • \_\_\_\_(20%) – Mortality rate of approx. 45%
dysfunction paralysis vascular ischemia hemorrhage
Epidemiology
• 3rd most common cause of death in the U.S.
• 700,000 new or recurrent strokes / year – 1 stroke / minute
• ____% of people survive their stroke / year
• ____ have a 38% greater risk of first stroke than Caucasians
– Risk of death is ____x greater than Caucasians
• Risk of stroke increases with ____
– 5% of the population over age 65 has had at least one stroke
75
AA
2-4
age
Ischemic Strokes
• Most commonly caused by: – ____ thrombi
– Emboli of ____ origin
• Extent of infarction determined by: – \_\_\_\_ of occlusion – \_\_\_\_ of the occluded vessel – \_\_\_\_ of the occlusion – Presence of \_\_\_\_ circulation
atherosclerotic
cardiac
site
size
duration
collateral
As an example, the red circle on slide shows an area of clot at ____ cerebral artery (PCA). The change in color (purple) shows that later supply of PCA is cut off, causing an area of ischemia to this posterior part of brain, including ____ area (for speech production) as well as visual and tactile senses.
Part of the reason this clot area would be so devastating is because there is no ____ circulation here. So if we clot the only supply to that area, there will be NO blood supply or ability to get oxygen here, leading to loss of oxygen and loss of function over time.
posterior
broca’s
collateral
Types of ischemic stroke syndromes
- Large Vessel Stroke
• Thrombotic occlusion of a major vessel
• ____ artery
– Most common
• Vertebral artery
• Intracranial arteries
• Often results in extensive ____ damage
carotid
cerebral
ypes of ischemic stroke syndromes
- Small Vessel Stroke
- AKA “____ stroke”
- Refers to size (
lacunar
15
small
high
High Risk Conditions for Cardioembolism Development
- ____ valve(s)
- Atrial fibrillation
- ____ stenosis with atrial fibrillation
- Recent MI (
mechanical
mitral
4
cardiomyopathy
Intracerebral Hemorrhage
• Most common cause is ____
– Microaneurysms of the arterioles
• Rupture leads to:
– Extravasation of ____
– Displaces brain tissue
– Increased ____
This is MRI of brain showing intracerebral hemorrhage. It is ____ bc its liquid and it is filling the space that otherwise brain tissue would occupy.
hypertensive atherosclerosis
blood
intracranial volume
bright
Subarachnoid Hemorrhage
• Rupture of a ____ aneurysm at the bifurcation of a major ____ artery or in the ____
This MRA angiogram shows aneurysm within major vessel with extravasated blood by too much pressure trying to get into division into smaller arterioles.
Too much pressure causes weakness in vessel wall and additional area (aneurysm). As increased pressure continues, unless there’s anything that allows it to go back to normal pressure, this can eventually rupture causing a ____.
berry
cerebral
circle of willis
hemorrhage
This shows a subarachnoid hemorrhage. We have more ____ between brain tissue and skull itself all filled with blood which is compressing the area that brain tissue can take up.
This in turn compresses the ability of brain tissue to function the way it should bc it has less room for all the neurons and microglia and other tissue.
This post-mortem specimen shows the aftereffects of displacement of brain tissue after hemorrhage. This is a localized one with increased amount of blood/blood products.
We can see how a brain is usually symmetrical becomes ____ from the extravasation and compression of brain tissue.
volume
asymmetrical
Neurologic phenomena associated with stroke
• Transient ischemic attack (TIA)
– “____”
• Temporary disturbance in blood supply to a localized area of the brain
– ____
– Weakness
– ____ / numbness
- May last approximately ____ minutes
- Major stroke is preceded by TIAs within several ____ of the first episode
stroke hemiplegia tingling 10 days
Signs and Symptoms of Acute Stroke
- ____
- Aphasia
- ____ loss
- Numbness
- ____
- Double Vision
- ____
- Incoordination
weakness
visual
vertigo
imbalance
In a stroke, ____ is brain tissue (MOST IMPORTANT TAKEAWAY FROM THIS LECTURE)
time
Acute Stroke Management
• Activate EMS – \_\_\_\_ as indicated • Transport to \_\_\_\_ • Administration of \_\_\_\_ within 4.5 hours of stroke – Prevent further thrombosis – Lyse existing thrombi or emboli
- stabilize with ____ medications
• Surgery
• Rehabilitation
BLS/ALCS
hospital
IV tPA
anticoagulant
Laboratory Evaluation • Routine lab tests • Lumbar puncture – Check for \_\_\_\_ in CSF – Altered \_\_\_\_ pressure • Imaging – \_\_\_\_ – MRI – \_\_\_\_
blood/protein
CSF
CT
MRA
Medical Management • Prevention • Modification of risk factors – Screening for \_\_\_\_ • \_\_\_\_ agents • \_\_\_\_ agents
co-morbidities
anticoagulant
antiplatelet
Prevention: Risk Factor Modification
• Non-Modifiable – \_\_\_\_ – Sex – \_\_\_\_ – Heredity
• Modifiable – \_\_\_\_ – Cardiac disease (AFib) – \_\_\_\_ – Hypercholesterolemia – \_\_\_\_ smoking – Excessive alcohol – \_\_\_\_ Inactivity
age
race-ethnicity
hypertension
diabetes
cigarette
physical
Prevention: Anti-thrombotics
• Consider risk of recurrent stroke and hemorrhage in acute setting
• Anticoagulation
– ____ stroke
– ____ states
• Antiplatelet agents
– ____ vessel disease
– ____ vessel disease
cardioembolic
hypercoagulable
large
small
Prevention: Anticoagulation • Warfarin (Coumadin): \_\_\_\_ antagonist – Goal INR \_\_\_\_, dosage individualized – Reversible by \_\_\_\_ – Requires close \_\_\_\_
• Dabigatran (Pradaxa): direct \_\_\_\_ inhibitor • Apixaban (Eliquis): \_\_\_\_ inhibitor • Rivaroxaban (Xarelto): \_\_\_\_ inhibitor – No pharmacologic \_\_\_\_ agent available – Does not require \_\_\_\_
vitamin K
2.0 to 3.0
vitamin K
monitoring
thrombin factor Xa factor Xa reversal monitoring
Prevention: Antiplatelet agents • \_\_\_\_ • Clopidogrel (Plavix) • \_\_\_\_ (Ticlid) • Dipyrimadole (Persantine) • \_\_\_\_/Dipyramidole (Aggrenox)
• Enoxaparin (Lovenox) – LMWH
aspirin
ticlopidine
ASA
Prevention: surgical options
• Carotid endarterectomy
Physically go in and remove plaque from carotid artery
-usually at ____ of carotid artery bc its where blood flow splits up, so more plaque occurs here.
Plaque is removed physically and vessel is stitched up afterwards. Allow normal flow to the brain again. However, plaques can ____ bc although we’re removing what has been built up, we still need to change the ____ of the plaque (diet, physical activity, smoking etc)
• Carotid stenting
imilar goal of opening up area so blood can flow through. Physically place a ____ (medicational or physical) to compress the plaques that’s already been built up to restore a normal size for normal blood flow to happen again.
• Cardiac surgery for valve replacement
bifurcation
reform
cause
stent
Dental Management • Identification of Risk Factors – \_\_\_\_ – DM – \_\_\_\_ – Cigarette smoking – \_\_\_\_ / previous stroke – Advancing age
• Neurology consult – if appropriate
hypertension
coronary atherosclerosis
TIA
• Patients with a history of stroke
– Increased risk of having another ____
– First 6 months s/p event – ____ dental care only
• Patients with active TIAs
– ____ dental care only with proper monitoring
- Monitoring of blood pressure
- Judicious use of local anesthetic with ____
- Physical limitations may require ____ of oral hygiene techniques
stroke emergency emergency epinephrine modifications
Oral Considerations • Loss of \_\_\_\_ of oral tissues • Unilateral paralysis of oro-facial structures • Inability to manage oral \_\_\_\_ • Inability to maintain gag reflex • Tongue \_\_\_\_ • Dysphagia • \_\_\_\_ secondary to medications
sensation
secretions
hypermobility
xerostomia
Periodontal disease and Stroke
• Multiple studies support association of chronic periodontal disease and ____ inflammation
• Positive association of poor dental health with increased incidence of cerebrovascular disease
– Benefit of dental prophylaxis to decrease risk of ____ stroke
• Possible result of etiologic factors common to both disease processes
– ____ smoking
• Further clinical trials needed to substantiate association
cardiovascular
ischemic
cigarette
Occult vascular disease
• 71 patients were found to have ____ calcifications on routine panoramic films
• 23 (34%) reached an ____ - stroke, MI, or death
• Average time to reach an endpoint = ____years
• Dental implications:
• If carotid calcifications are seen on panoramic films, refer patient to ____ to
address vascular risk factors!
carotid
endpoint
2.7
physician
Example of carotid calcifications on panoramic X-ray. Smaller on Right and Larger on Left. (WHERE ARROWS POINT) Correlation between how significant a calcification looks, could be more worried about ____ endpoint. But still not worth to tell patient they’re going to have stroke right away. But rather take them to appropriate care/monitoring by physician to monitor risk factors in carotid artery/buildup.
carotid
Antiplatelet agents / Anticoagulants
• ____ and ____ agents are commonly used to prevent stroke in patients at risk
• Should anticoagulation be ____ prior to invasive dental procedures?
anticoagulants
antiplatelet
discontinued
Anticoagulants Warfarin (Coumadin)
• INR of < 3.5–4.0
– Ok for ____ and non-invasive dental procedures – Manage with ____ hemostatic measures
• INR of > 4.0
– Consult physician for dosage ____ of medication prior to invasive
dental procedures
invasive
local
alteration
Anticoagulants Warfarin (Coumadin)
- drug interactions!
• ____, tetracycline, ____ all decrease coumadin metabolism
– Causes ____ INR, higher ____ risk
– Make sure patient arranges for close INR ____ when these medications are prescribed
erythromycin metronidazole higher bleeding monitoring
Anticoagulants New Oral Anticoagulants
• No definitive guidelines for management of dental patients on these agents
• Consider stopping ____ hours prior to procedures where bleeding may be anticipated (as per manufacturer)
• Consult with physician as needed
24-48
Antiplatelet Agents
• Antiplatelet agents have ____ bleeding risk than anticoagulants
• Antiplatelet agents should not be ____ prior to invasive dental treatment
– Single and dual therapy
lower
discontinued
Risk of Infective Endocarditis
High-risk conditions associated with cardioembolic stroke:
Mitral stenosis or atrial fibrillation –> ____ heart valve
- antibiotic prophylaxis
- current AHA guidelines
mechanical
Epilepsy
►Group of disorders characterized by chronic, recurrent, paroxysmal changes in \_\_\_\_ function caused by abnormal and spontaneous electrical activity in the \_\_\_\_ ►Major manifestation of epilepsy is the occurrence of \_\_\_\_ ►Seizures do not imply \_\_\_\_ – Stress – \_\_\_\_ deprivation – Fever – \_\_\_\_ / Drug withdrawal – Syncope
neurologic brain seizures epilepsy sleep alcohol
► I. Partial (focal, local)
– ____ partial seizures
– ____ partial seizures
– Partial seizures evolving to secondarily ____ seizures
►II. Generalized (convulsive or non-convulsive) – \_\_\_\_ seizures (petit mal) – \_\_\_\_ seizures – \_\_\_\_ seizures (grand mal) – \_\_\_\_ Seizures – Atonic Seizures
►III. ____ epileptic seizures
simple
complex
generalized
absence
myoclonic
tonic-clonic
atonic
unclassified
Epidemiology ►10% of the population will have at least one \_\_\_\_ in a lifetime ►Most common in \_\_\_\_ – Between \_\_\_\_ years of age – Peak incidence between \_\_\_\_ months ►Common in the elderly – 130 / 100,000 per year – Most commonly due to \_\_\_\_ disease
seizure childhood 3 months and 5 years 18 and 24 cerebrovascular
Etiology
►Head ____
►Intracranial neoplasm ►____ / Encephalitis ►Metabolic disturbances ►____ effects
►Idiopathic / Primary Epilepsy
– ____ cause
– Seizures may be evoked by specific stimuli
trauma
meningitis
drug
unknown
Pathophysiology ►Excessive focal neuronal discharge that may spread to areas throughout the brain – Altered neuronal membrane \_\_\_\_ – Altered synaptic \_\_\_\_ – Increased neuronal \_\_\_\_
►____ of brain lesion does not correlate with seizures
potentials
transmission
excitability
type
► Tonic – clonic (grand mal) seizures ► Aura ► “Epileptic cry” ► Tonic phase – Muscle \_\_\_\_ – Pupil \_\_\_\_ – \_\_\_\_ movement – Loss of \_\_\_\_
► Clonic phase – \_\_\_\_ movements ► Post – ictal phase (post neuronal firing) – \_\_\_\_ – Confusion – \_\_\_\_ ► Status epilepticus
rigidity
dilation
eye
consciousness
uncoordinated
headache
sleep
►Absence (petit mal) – \_\_\_\_ of unconsciousness – No loss of \_\_\_\_ – \_\_\_\_ twitching – “\_\_\_\_ dreaming” – Can resume \_\_\_\_ activity
seconds body tone facial day normal
Laboratory Findings
► Diagnosis ► History of seizures ► Blood tests – \_\_\_\_ – Electrolytes – \_\_\_\_ ► Electroencephalogram (EEG) – Abnormal electrical activity ►\_\_\_\_ patterns ►\_\_\_\_
►CT
– Intracranial ____
– Skull ____
►MRI
– ____ malformations
– Tumors
– Acquired ____ damage
CBC
glucose
spike and wave
interictal epileptiform discharges (IEDs)
calcification
fractures
vascular
cortical
Seizure Activity on EEG
Goes from normal amplification to more ____ and more common when seizure begins
amplified
Medical Management ►Drug therapy – \_\_\_\_ risk patients ►Goal – Single drug with minimal side effects ►Discontinue medications after seizure-free interval of at least \_\_\_\_ years ►Up to \_\_\_\_ % of patients achieve complete control – Drug compliance – Adverse effects / toxicity
high
2
80
►Classic Drugs ►\_\_\_\_ ►Phenytoin ►\_\_\_\_ ►Phenobarbital
►Recent Drugs ►\_\_\_\_ ►Lamotrigine ►\_\_\_\_ ►Topirimate
carbamazepine
valproic acid
gabapentin
oxcarbazepine
Take a look at the drug therapy table!
yes!
Side effects of these seizure meds can be ____, redness of lips. This can also have a similar clinical look if there is an ____ to medications.
Look if they get this shortly after starting a new seizure med
erythema multiforme
allergy
Other treatment modalities . . . ►20% of patients are ____ to drugs
►Surgery
– Removal of the ____ and amygdala, temporal lobectomy, or
hemisperectomy
►Vagus nerve stimulation
– Increases seizure ____
resistant
hippocampus
threshold
Dental / Oral Conditions in Seizure Patients
►____ rate of dental and facial trauma compared to general population
►____ oral health and dental status compared to age-matched healthy subjects
►____
►Glossitis
►Mucosal ____
higher
poor
stomatitis
ulcerations
Oral conditions associated with seizure medications
ØGingival overgrowth
– Rinses
►____
►____
►Surgical excision
– ____
– ____
chlorhexidine
folic acid
scalpel
laser
►Xerostomia – Topical \_\_\_\_ – Systemic agents – Topical \_\_\_\_ – Monitor for candidiasis
moisturizers
fluoride
Dental Management ►Pre-treatment evaluation – \_\_\_\_ history – Seizure history – \_\_\_\_ history – Laboratory evaluation – if indicated – Medication levels – if indicated – Neurology consultation – if indicated
medical
medication
►Treatment management ►Consideration of venue – Dental office – Hospital outpatient dental facility – Operating room
►Modifications – Mouth prop with \_\_\_\_ system – \_\_\_\_ agents ►Electrical equipment and VNS – Avoid with \_\_\_\_ 1
retrieval
hemostatic
diathermy
