Cerebrovascular Flashcards
Definition of a stroke
Destruction of a portion of brain tissue as a result of circulatory failure in the distribution of a specific arterial vessel
Ischemic strokes
Make up 87%
Defined as embolic or thrombotic
Hemorrhagic strokes
13% of strokes
Intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, or intraventricular hemorrhage
Stroke facts
1 in 4 are recurrent
Leading cause of disability
Reduces mobility in over half of survivors 65 and over
80% are preventable
Non- modifiable stroke risk factors
Race
Age
Gender
Genetics
Modifiable stroke risk factors
Hypertension
Heart disease
A-fib
Hypercholesterolemia
PFO
Carotid artery stenosis
Dissection
DM
OSA
Hypercoagulability
Depression
ETOH
Drug use
Smoking
Oral contraceptive pills
Migraine
Smoke exposure
Inactivity
Obesity
Poor nutrition
Post menopausal hormone therapy
Occlusion pathophysiology
Decreased blood flow due to blockage. Neurons are deprived of oxygen and glucose. Within seconds to minutes of loss of perfusion edema and cell death occur
Transient ischemic attack
A transient episode of neurological dysfunction caused by focal brain cell ischemia without acute infarction
Increased risk of stroke within 48 hours of a TIA.
Workup should include HCT, carotid ultrasound, CTA/MRA, echo, lipids, and ECG
Subjective assessment finding after stroke
Headache
Difficulty speaking
Dizziness
Loss of coordination
Falling
Dropping objects
Numbness and/or tingling
Visual abnormalities- blurred, double, or vision loss
Objective assessment findings after stroke
Decreased LOC
Disorientation
Aphasia
Gaze preference toward stroke
Motor weakness
Sensory abnormalities
Cerebellar signs
Possible cranial nerve deficits in strokes
Visual abnormalities: field cut, amaurosis fugax, diploma
EOM palsy
Facial weakness
Decreased cough or gag
Airway compromise
Dysarthria
Stroke timeline
Door to Dr- 10 minutes
Door to stroke team- 15 minutes
Door to CT- 25 minutes
Door to CT results- 45minutes
Door to drug- 60 minutes
Door to floor- 3 hours
Tests done for stroke
Non-contrast CT
Blood glucose
O2 saturation
CBC, BMP, PT/PTT, INR
EKG
Cardiac ischemia markers if doesn’t delay tPA
PRN
BAC
Pregnancy test
Toxicology
Hepatic function
CTA/MRA
Chest x-ray
EEG
BP goals
Pre-TPA <185/<110
Post TPA <180/<105
No-Go TPA <220/<120 lower by 15% within first 25 hours after onset
Anoxic injury
Technically a stroke
Caused by hypoxia/ischemia
Mostly poor prognosis
ICH Causes
Primarily caused by hypertension
BP goal for ICH
Systolic <140
Intraventricular hemorrhage
Usually an extension of ICH and rarely isolated
If risk of hydrocephalus place EVD
Cerebral aneurysm
An abnormal local dilation in the wall and artery in Circle of Willis caused by defect, disease, or injury
Risk factors for cerebral aneurysm
HTN, ETOH abuse, smoking, illicit drug use, connective tissue disease, family genetics
Assessment of cerebral aneurysm
Usually asymptomatic and an incidental finding
Larger aneurysms can cause compression resulting in double vision, ptosis, increased eye pressure, and redness
Cavernous aneurysms can cause cranial nerve 3 or 4 palsy, proptosis, and increased intraoccular pressure
Aneurysmal subarachnoid hemorrhage
Caused by aneurysm rupture resulting in blood in the subarachnoid space
Medical emergency with high morbidity and mortality
Grading systems used for subarachnoid hemorrhage
HUNT and HESS: rates 1-5
World Federation of Neurological Surgeons Grading System: rates 0-5 with 0 being unruptured
What is monitored for after a bleed
Hydrocephalus
Seizures
Vasospasm
Delayed cerebral ischemia
Cerebral edema
Increased cranial pressure
Arrhythmia
ECG changes
Left ventricle dysfunction
Stress cardiomyopathy
Airway protection
Pulmonary edema
Pneumonia
Cerebral salt wasting
SIADH
Arteriovenous Malformation
Congenital mass of abnormal blood vessels
Used Spetzler Martin Classification System
Risk of rupture resulting in ICH or IVH
Assessment findings and interventions of arteriovenous malformations
Presents with seizures, headache, stroke symptoms
Conservative is imaging and monitoring. If causing issues surgical reduction or resection
What is a dural arteriovenous fistula
Pathological shunts between dural arteries and dural venous sinuses, meningeal veins, or cortical veins
Caused by trauma, venous thrombus, venous HTN, or are idiopathic
Due to the drainage pattern they are a hemorrhage risk
Also found in the spine
Assessment findings in dural arteriovenous fistulas
Pulsatile tinnitus, headaches, seizures, progressive neuro deficits, dementia
Spinal may cause pain, lower extremity weakness, and sensory changes
Interventions for dural arteriovenous fistulas
Same as arteriovenous malformations
Cavernous malformations
Also called cavernous hemangiomas, canvernomas, or cavernous angiomas
Low flow, low pressure lesions made up of dilated capillaries with risk of rupturing
Moya moya disease
Progressive large intracranial artery narrowing and the development of small vessel collaterals
Increased risk of ischemic and hemorrhagic strokes
Cerebral venous sinus thrombosis overview and assessment
Thrombosis of cerebral veins or dural sinus causing increase in venous or capillary pressure
Leads to edema, venous infarct, or hemorrhage
Presents with headache, papilledema, and visual problems due to increased intraocular pressure. Can also have focal deficits and seizures
Symptoms of anterior cerebral artery ischemic stroke
Altered mental status
Impaired judgement
Contralateral weakness and hypesthesia
Gait apraxia
Middle cerebral artery ischemic stroke findings
Contralateral hemiparesis
Contralateral hypethesia
Contralateral homonymous hemianopsia
Gaze preference toward side of lesion
Agnosia
Receptive or expressive aphasia
Posterior cerebral artery ischemic stroke symptoms
Homonymous hemianopsia, cortical blindness, visual agnosia
Altered mental status, impaired memory
Dizziness
Limb weakness
Paresthesias
Nausea
Language dysfunction
Vertebrobasilar system ischemic stroke symptoms
Wide variety of cranial nerve, cerebellar, and brain stem deficits
Vertigo, nystagmus, diplopia, visual field deficits, dysphagia, dysarthria, facial hypesthesia, syncope, ataxia
Variety of neurological syndromes
What is Hunt and Hess used for?
Grading of aSAH
Hunt and Hess Grade 1
Asymptomatic
Hunt and Hess grade 2
Severe headache
Stiff neck
No neuro deficit except cranial nerve palsy
Hunt and Hess grade 3
Drowsy
Minimal nerve deficit
Hunt and Hess grade 4
Stuporous
Moderate or severe hemiparesis
Hunt and Hess grade 5
Deep coma
Decerebrate posturing
World federation of neurological surgeons grading system for aSAH
0- unruptured
1- GCS 15
2- GCS 13-15
3- GCS 13-15 with focal neurological deficits
4- GCS 7-12 with or without deficits
5- GCS 3-6 with or without deficits
