Cerebral Vascular Accident: Brain Attack Flashcards
How long do TIA’s symptoms usually last?
< 1 hr
What are risk factors of TIA?
a. Men
b. African American
Causes of TIA and Stroke?
- Atherosclerotic disease
- Cardiac emboli
- Myocardial Infarction
- Congestive Cardiomyopathy
- Valvular disease
- RBC, & Plt disorders
- increased viscosity/hypercoagulable conditions
4) What are red blood cell disorders that can cause a TIA?
a. increased sludging
b. severe anemia
c. polycythemia, sickle cell anemia
5) What platelet disorders that can cause a TIA?
a. thrombocytosis
b. thrombocytopenia
6) Conditions that can mimic stroke or TIA?
a. Hypoglycemia
b. bells palsy
c. migraine
d. seizure
e. structural brain lesions
f. metabolic or toxic disorders
g. infectious disorders
h. Psychological disorders
7) When are people at greatest risk of having a stroke?
a. Within the first two days after a TIA
8) What are risk factors for having a TIA?
a. Hypertension
b. cardiac disease
c. smoking
d. obesity
e. hyperlipidemia
f. age > 60 y/o
g. diabetes mellitus
h. alcohol or recreational drug abuse
9) What TIA symptoms indicate carotid arterial involvement?
a. Transient monocular visual loss
b. aphasia
10) What TIA symptoms indicate vertebrobasilar (brainstem) arterial involvement?
a. Limb weakness
b. ataxia
c. Vertigo
d. dysphasia
e. dysarthria
f. Abnormal ocular motor signs
11) what is the definition of diplopia?
a. double vision
12) what is the definition of dysphasia?
a. difficulty swallowing
13) What is the definition of ataxia?
a. loss full control of bodily movements
14) What is the definition of aphasia?
a. Loss of ability to understand or express speech caused by brain damage
15) What abnormal ocular motor signs may be seen during a TIA?
a. nystagmus
b. lateral gaze
c. diplopia
16) What are general symptoms of a TIA?
a. N/V
b. hemianopia
c. sensory loss to face
d. pain and temperature loss
17) what is hemianopia?
a. Field loss on the left or right side of the vertical midline
18) Which test predicts the initial severity of a TIA or stroke?
a. NIH stroke scale
19) which test is useful in predicting future stroke risk?
a. ABCD2 score
b. age, BP, clinical symptoms, duration of symptoms, diabetes
20) Why would an ECG be done for a TIA patient?
a. to evaluate A-fib
21) What labs are done during a TIA assessment?
a. BG and A1C
b. Troponin
c. CBC w/ plt count
d. Pt/INR
e. BMP
f. Lipid profile
g. Tox screen
22) When should you screen for hypercoagulable states during an assessment of TIA?
a. < 55 y/o with no risk factors
24) Diagnostic tests for TIA?
a. Noncontrast CT of brain
b. CT angiography of brain and neck
c. MRI
d. Magnetic Resonance Angriography (MRA)
e. Carotid US
f. TEE
g. CXR
h. Cerebral angiography
25) Which diagnostic test is used to rule out structural causes (hematoma, intracranial hemorrhage, or brain tumor) of TIA?
a. Non-contrast CT scan of the brain
26) Which diagnostic test is used to evaluate the vessels of the brain and neck in the assessment of a TIA?
a. CT angiography of brain and neck
b. Can be done at same time as CT, uses contrast
27) Which diagnostics test can be done as an alternative to an ultrasound or CT studies for assessment of a TIA?
a. MRA
28) When should a carotid doppler be done when in an assessment of TIA?
a. if MRA and CTA are medically contraindicated
29) Why is a chest X Ray done in an assessment of TIA?
a. To evaluate cardiomyopathy
30) What diagnostic tool is used to evaluate the necessity of anti coagulations in patients with A-fib or a flutter?
a. CHADS2VASC2 score
23) What tests screen for hypercoagulable states?
a. Fibrinogen
b. D-dimer
c. Factor VIII
d. Von Willebrand factor
31) What is the CHADS2VASC2 score ?
a. Diagnostic tool used to evaluate the necessity of anticoagulation in patients with A-fib or a flutter
32) What drugs are direct thrombin inhibitors?
a. Warfarin
b. Dabigatran
c. Rivaroxban
d. apixaban
e. edoxaban
What category of drug are the below:
a. Warfarin
b. Dabigatran
c. Rivaroxban
d. apixaban
e. edoxaban
direct thrombin inhibitors?
33) Patients with A-fib or a flutter lasting > 48hrs or of unknown duration, should receive anticoagulation for what time period before and after cardioversion?
At least 3 weeks before and 4 weeks after cardioversion
34) What is heparins mechanism of action?
a. Factor Xa inhibition
35) What is warfarins mechanism of action?
a. direct thrombin inhibitor
36) What is apixaban’s mechanism of action?
a. Direct thrombin inhibitor
37) Dabigatran, rivaroxaban and edoxaban are contraindicated in pts with A-fib and?
a. End stage chronic kidney disease
38) Which drug is the preferred treatment for the prevention of recurrent stroke in patients with nonvalvular A-fib?
a. Rivaroxaban
39) What is the mechanism of action for aspirin?
a. Antiplatelet agent
40) what drug is the first line therapy for reducing the risk of strokes in pts with TIA?
a. aspirin
41) what is the dosing of aspirin in the prevention of stroke in patients with TIA?
a. 160 mg x 5 days, then 81 mg QD
42) Which drug when given with aspirin or aspirin-dipyridamole within 24 hours of a TIA reduces the risk of recurrent ischemic stroke?
a. Clopidogrel
43) What is the dosing of clopidogrel and aspirin when given to prevent stroke?
a. Day 1: Clopidogrel 600 mg
b. Day ≥ 2: Clopidrogel 75mg and aspirin (50-325mg) QD
44) High intensity statin therapy is recommended for which patients in the prevention of strokes?
a. LDL > 100
b. < 75 y/o
45) What does the Jupiter statin is recommended for patients with LDL > 100 and < 75 y/o, in the prevention of stroke?
a. 80 mg
46) What is defined as the destruction of a portion of the brain parenchyma (tissue) as a result of circulatory failure in the distribution of a specific arterial vessel?
a. Acute stroke or brain attack
47) What are the two types of strokes?
a. Ischemic and hemorrhagic
48) what is the most common type of stroke?
a. Ischemic
49) what are the different types of ischemic strokes?
a. Embolic
b. thrombotic
c. lacunar
d. cryptogenic
What are the types of hemorrhagic stroke?
a. intracerebral and subarachnoid
51) What female population is at increased risk of acute stroke?
a. Those who use oral contraceptives
b. smokers
52) does low or high cholesterol increase the risk of hemorrhagic stroke?
a. Low
53) what are the sudden signs of stroke?
a. Weakness affecting one side of the body
b. numbness affecting one side of the body
c. difficulty with speech or understanding
d. visual difficulties
e. difficulty walking, dizziness, loss of balance or coordination
f. severe headache
What does the acronym F.A.S.T. stand for in relation to stroke?
- Facial drooping
- Arm weakness
- Speech difficulty
- Time of last known well
What is tested for in a BMP?
a. Bicarb
b. BUN
c. Creatinine
d. Calcium
e. Chloride
f. Glucose
g. Potassium
h. Sodium
56) What is tested for in a CMP?
a. Albumin
b. Alkaline phosphatase (ALP)
c. ALT
d. AST
e. Bicarb
f. Bilirubin
g. BUN
h. Creatinine
i. Calcium
j. Chloride
k. Glucose
l. Potassium
m. Sodium
n. Total protein
1) Type of stroke that is caused by thrombus or emboli that occludes a blood vessel in the head or neck?
a. Ischemic stroke
2) How quickly do symptoms present in a thrombotic ischemic stroke?
a. Sudden, or may progress over hours to days
3) How quickly do symptoms present in a embolic ischemic stroke?
a. Very rapid onset of symptoms
4) What are predisposing factors for an embolic ischemic stroke?
a. A-fib
b. mitral stenosis and regurgitation
c. endocarditis
d. mitral valve prolapse
e. hypertension
5) What is the largest vessel that branches off the internal carotid artery?
a. Middle cerebral artery (MCA)
6) What is the most common occlusion site seen in an ischemic stroke?
a. Middle cerebral artery occlusion
What are specific signs and symptoms of a right Middle Cerebral Artery (MCA) stroke?
- Signs of unilateral neglect
- decreased awareness or failure to attend to one side of the body and lack of awareness or concern about the deficit
7) What are signs and symptoms of a complete MCA stroke?
a. hemiplegia of the contralateral side
b. Contralateral sensory loss contralateral (Arms affected > legs)
c. homonymous hemianopsia
11) what is the classic sign of in anterior cerebral artery (ACA) stroke?
a. Contralateral leg weakness and sensory loss
b. leg weakness > arm
8) what is homonymous hemianopsia?
a. Same side field loss on the left or right side of the vertical midline in both eyes
9) What are specific signs and symptoms of a left MCA stroke?
a. Aphasia
b. maybe expressive, receptive or both
12) What is a telltale difference between and MCA and ACA stroke?
a. MCA effects the arms more, while the ACA stroke affects the legs
3) neglect is a symptom of what type of strokes?
a. right MCA and right PCA stroke
14) Which arteries/locations are most often included in cause strokes?
a. Middle cerebral artery (MCA)
b. anterior cerebral artery (ACA)
c. posterior cerebral artery (PCO)
d. vertebral and basilar arteries
e. Cerebellum
f. brainstem
16) what is a common sign of cerebellar stroke?
a. Impaired balance and coordination , look for ataxia
17) What is dysconjugate gaze?
a. failure of the eyes to turn together in the same direction
18) Why is a CT of the head without contrast performed in the assessment of a stroke patient?
a. To rule out cerebral hemorrhage
18) Why is a CT of the head without contrast performed in the assessment of a stroke patient?
a. To rule out cerebral hemorrhage
19) A CT scan of the head without contrast should be completed within what timeframe of arrival to the hospital for a stroke patient?
a. within 20 minutes
20) A brain infarct may not be visible for up to how long on a CT scan of the head?
a. 24 hours
21) What is a penumbra?
a. healthy tissue or area surrounding ischemic infarct
22) Why is an echocardiograph with bubble study performed in the assessment of a stroke patient?
a. To detect the presence of structural cardiac disease
Current stroke treatment guidelines suggest lowering the BP by how much during the first 24 hrs of an acute stroke?
Lower BP by 15% during the first 24 hours after onset of stroke
24) What does tPA stand for?
a. tissue plasminogen activator
25) What should the blood pressure be prior to administering tPA?
a. SBP < 185mmHg and DBP < 110 mmHg
26) What should the blood pressure be during and after tPA administration?
a. SBP < 180
b. DBP < 105
27) How often should vital signs be checked during tPA administration?
a. Q 15 min x 2hr
b. Q 30 min x 6 hr
c. Q 1 hr x 16 hr
28) The current stroke guidelines recommend the use of which medications for blood pressure control?
a. Labetalol and nicardipine
What is the dose and route of administration of labetalol recommended by current stroke guidelines?
10 - 20 mg IV push, can repeat once
What is the dose and route of administration of nicardipine recommended by current stroke guidelines for blood pressure control?
2.5 – 15 mg/hr titratable IV gtt
31) What is the timeframe for starting treatment with IV altepase?
a. Within 4.5 hrs of symptom onset or last known well
What is the exclusion criteria for the use of thrombolytic therapy?
- active bleeding
- serious head trauma, or intracranial/spinal surgery within three months
- AV malformations or aneurysms
- bleeding disorders
- uncontrolled severe hypertension
33) what is the maximum dose of IV altepase?
a. 90 milligrams
34) What is the dosage of IV altepase (t-PA)?
a. 0.9 mg/kg over 60 mins
b. 10% as initial bolus over 1 min
c. 90% infused over 59 min
35) How often should vital signs and neuro checks be completed with IV altepase administration?
a. Q 15 min x 2hr
b. Q 30 min x 6 hr
c. Q 1 hr until 24hr after administration
36) What should be done if the patient develops a severe headache, acute hypertension, N/V, or has worsening neurological exam during and after altepase administration?
stop administration and get emergency head CT
37) What medications are given to treat orolingual angioedema associated with IV altepase?
a. Methyl Prednisolone 125 mg IV
b. diphenhydramine 50 mg IV
c. ranitidine 50 mg or famotidine 20 mg IV
d. Epinephrine (0.1%) 0.3mL SQ or 0.5mL nebulizer with worsening angioedema
38) What Medications are used during thrombolytic therapy of an acute ischemic stroke?
a. Altepase and Tenecteplase
39) What treatment modalities are available for patient with an acute ischemic stroke?
a. Thrombolytic therapy
b. mechanical thrombectomy
c. revascularisation
d. Antiplatelet therapy
e. Anticoagulation therapy
40) Revascularization may be performed how long after the initial ischemic stroke event?
a. 48hrs to 7 days
41) Antiplatelet therapy may be used how long after the initial ischemic stroke event?
a. Within 24 to 48 hours
42) how long is aspirin held following treatment with IV altepase?
a. 24 hours
Which two medications were found to be beneficial in preventing secondary stroke for patients with mild stroke symptoms and were not treated with IV altepase dual antiplatelet therapy?
a. Aspirin and clopidrogel.
b. Start within 24 hrs and continue for 21 day
1) What is the definition of a cryptogenic stroke?
a. An unexplained reason identified for asymptomatic stroke after adequate diagnostic evaluation
b. a diagnosis of exclusion
2) what is the first line treatment for cryptogenic stroke?
a. Antiplatelet therapy , aspirin 325 mg PO
3) Management of cryogenic stroke includes?
a. Antiplatelet therapy
b. HTN control
c. Closure of patent foramen ovale if present
4) What is a patent foramen ovale?
a. opening in the septum between the right and left atrium causing the shunting of blood
1) Where are the causes of a hemorrhagic stroke?
a. Intracranial hemorrhage
b. Subarachnoid hemorrhage
2) What is the definition of a hemorrhagic stroke?
a. bleeding into the subarachnoid space or brain parenchyma
3) What are the common presenting symptoms of a hemorrhagic stroke?
a. Seizures
b. vomiting
c. headache
d. diminished LOC
4) What are risk factors for hemorrhagic stroke?
a. Hypertension
b. cerebral amyloid angiopathy
c. anticoagulant or thrombolytic therapy
d. cocaine , methamphetamine use
e. heavy alcohol consumption
f. over the counter stimulants/energy drinks
5) how does alcohol consumption increase the risk of hemorrhagic stroke?
a. Impairs coagulation and injures cerebral vessels
6) What is suspected when a patient presents with an intense sudden headache that radiates into the posterior neck and is worsened by neck and head movements?
a. subarachnoid hemorrhage , possible hemorrhagic stroke
7) what type of hemorrhage is described as a Thunder clap headache or worst headache of my life?
a. Subarachnoid hemorrhage
8) What are the signs and symptoms of an intracerebral hemorrhage?
a. Uncontrolled HTN
b. Rapidly progressive neurological signs and symptoms
c. headache
d. vomiting
e. seizures
f. decreased LOC
9) Uncontrolled hypertension, conjugate deviation of eyes to the side of the lesion, decreased LOC, contralateral hemiplegia and hemisensory disturbance are signs and symptoms of which type of hemorrhage?
a. Basil ganglia hemorrhage
10) downward deviation of the eyes (looking at the nose), pinpoint pupils with the positive reaction, coma, and flacid quadriplegia are signs and symptoms of which type of hemorrhage?
a. Thalamic hemorrhage
11) ipsilateral horizontal conjugate gaze paresis, inability to stand or walk, facial weakness, ataxia, Vertigo and dysarthria or signs and symptoms of which type of hemorrhage?
a. Cerebral hemorrhage
12) What diagnostic tests are done to find hemorrhagic bleed?
a. brain scans including noncontrast CT, CTA, MRI
Ketamine should be avoided in the management of which type of hemorrhagic stroke patient?
Hypertensive patient
Why should succinylcholine be avoided in the management of the hemorrhagic stroke?
It can cause transient intracranial pressure increase
what is the neuromuscular blocking agent of choice to be used during the intubation of a hemorrhagic stroke patient?
Rocuronium
Why should nitroprusside and nitroglycerin be avoided in the management of a hemorrhagic stroke patient?
they cause cerebral vasodilation and can further increase the ICP
What is the reversal agent for heparin and low molecular weight heparin?
Protamine
what is the reversal agent for warfarin?
Vitamin K
what is the reversal agent for factor Xa inhibitors (apixaban, rivaroxaban)?
Coagulation factor Xa
Why would mannitol be given in the treatment of hemorrhagic shock?
To reduce cerebral edema caused by bleeding
What is cerebral salt wasting?
hyponatremia that develops d/t a CNS disease or aneurysmal Subarachnoid hemorrhage
When does re-bleeding occur following an aneurysmal rupture?
re-bleeding occurs 2-19 days after initial rupture
