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Clin Med IIB Pulmonology > Cerebrovascular disease > Flashcards

Cerebrovascular disease Flashcards

1
Q

What is the MC stroke?

A

Iscehmic (like 80%)

Next is hemoragic

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2
Q

Explain an ischemic stroke

A

Acute occlusion o an intracranial vessel that leads to decreased blood flow resulting in hypoxia and neurologic function loss.

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3
Q

Ischemic core vs penumbra

A

Ischemic core is the area of complete loss of flow = death of brain tissue within 4–10 min

Penumbra is the surrounding tissue which has only a reduction in flow and can remain viable for hours after onset of stroke

Penumbra can turn into an ischemic core (time = brain tissue)

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4
Q

What are the 2 pathologies that lead to ischemic stroke

A
  1. Thrombotic - likely related to ruptured atherosclerotic plaques leading to platelet activation
    Associated with: HTN, DM, hyperlipidemia, carotid artery disease, alcohol consumption, and smoking
  2. Embolic - embolus originating from extracranial source
    Associated with: atrial fibrillation (MC), cardiac valve disease, MI, endocarditis and cardiomyopathy
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5
Q

MCC of embolic ischemic stroke

A

A fib

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6
Q

Overview of risk factors of ischemic stroke in older population that are not part of ischemic heart disease

A

FHx of TIA/Stroke

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7
Q

Risk factors of ischemic stroke in younger population

A

Traumatic Brain Injury (TBI)¹
Coagulopathies
Illicit drug use
cocaine
Migraines²
women, oral contraceptive use, age < 45, migraine with aura
Oral contraceptive use
Covid-19

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8
Q

What type of migraines a risk factor for younger patients having ischemic stroke?

A

Migraines with an aura

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9
Q

Explain the general pathophys that leads to hemorrhagic stroke and what it leads to

A

a spontaneous RUPTURE of a cerebral artery leads to:
cerebral ischemia resulting from loss of microvascular perfusion due to acute vasoconstriction and microvascular platelet aggregation
increased intracranial pressure

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10
Q

What are the two specifc patho[hys tha leads to hemmoriagic stroke

A

2 pathologic etiologies

  • Intracerebral hemorrhage (ICH)
  • Subarachnoid hemorrhage (SAH)
    aneurysm, arteriovenous (AV) malformations, trauma
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11
Q

MCC of ICH

A

intracranial hemmorage

Prolonged uncontrolled HTN

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12
Q

Specific risk factors of hemorrhagic stroke

A

Advanced age
Hypertension (up to 60% of cases)
Anticoagulant use
Previous history of stroke
Alcohol abuse
Use of illicit drugs (eg, cocaine, other sympathomimetic drugs)

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13
Q

Stroke prevention mnemonic for average person

A

BE FAST

Balance
Eyes

Face
Arms
Speech
Time

seen in every stroke pretty much

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14
Q

Balance

A

Ataxia
Vertigo (rare)
Disequilibrium

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15
Q

Eyes

A

Visual loss
any type
Visual deffedts

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16
Q

Face

A

MC sign of stroke
facial droop (bells palsy is complete loss in the face, while in stroke, your forehead can move)

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17
Q

Arms

A

unilateral, weakness/sensory

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18
Q

Speech

A

dysarthria/aphasia

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19
Q

Time

A

time is brain tissue

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20
Q

What is the MC symptom of specifically aa hemorrhagic stroke? What are some others

A

Intracranial bleeding, leading to:

HA, thunderclap (MC)

N/V
seizure
syncope
AMS: LOC

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21
Q

What is the most important thing to know history wise for stroke?

A

ONSET - lets you know management

when they were last normal

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22
Q

What is the second most important piece of info for a stroke?

A

Timeline:
progression vs regression

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23
Q

MC stroke mimicker

A

hypoglycemia MC

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24
Q

Important med to take in mind if you think they have a stoke

A

anticoagulants or hypoglycemic defects

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25
Q

What PMH is important to know for stroke

A

epilepsy, drug overdose or abuse, recent trauma

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26
Q

Why do you intubate for 8 or lower?

A

They cannot protect their airway alone

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27
Q

What PE do you perform for suspected stroke and most important

A

ABC
VS
Skin
HEENT
CV
Respiratory
Neuro (most important

28
Q

What is common findings of stroke on PE

A

ABC’s and VS
Assess LOC and determine need for airway assistance
hemorrhagic strokes often deteriorate more rapidly
Skin
petechiae, Janeway lesions¹, Osler’s nodes² (infective endocarditis)
livedo reticularis³/gangrene (cholesterol emboli)
purpura, ecchymoses (bleeding diathesis, anticoagulation)
recent surgical sites/scars (may not be able to have clot busters)

HEENT
signs of trauma
fundoscopy
papilledema (ICP)
retinopathy, retinal emboli, retinal hemorrhage (signs of predisposing conditions)
mouth - tongue laceration (indicative of seizure)

Cardiovascular
Irregular rhythm, murmur, gallop (cardiogenic emboli)
Indicating a.fib, endocarditis, other valvular diseases, cardiomyopathy, MI
Palpate carotid, radial, and femoral pulses
Assessing absence, asymmetry or irregular rate
Auscultation for carotid bruit (thrombotic etiology)
Respiratory
abnormal breath sounds, bronchospasm, fluid overload or stridor

Cranial Nerves
National Institutes of Health Stroke Scale (NIHSS - provides a quantitative measure of stroke-related neurologic deficit)
Mental status and level of consciousness
Vision - visual fields by confrontation
Motor function - arm/leg lift, facial movement
Cerebellar function - F-N, H-S

Sensory function - sharp sensation
Language (expressive and receptive capabilities) ask pt to describe an image or read sentences shown to patient
assessing ability to comprehend task and coordinate speech
Neglect - lack of awareness of disability or visual comprehension

29
Q

What are the different scores for Natinonal Institute of Health Stroke Scale

A

0
No stroke symptoms
1-4
Minor stroke
5-15
Moderate stroke
16-20
Moderate to severe stroke
21-42
Severe stroke

30
Q

What is the first thing you do for stroke and why?

A

Point of care glucose to r/o hypoglycemia, which could be causing the neuro deficits

31
Q

What do you see in a CT w/out contrast for an ischemic stroke?

A

Normal

if it is hemmoragic, you will see the bleeding

32
Q

What is the goal time to get a CT scan for stroke

A
  1. minutes
33
Q

What does a SAH look like on CT?

A

loopy starfish

34
Q

What happens for an ischemic stroke CT with time?

A

See problems with time

35
Q

What do you see on hemorragic stroke CT?

A

Midline shift

36
Q

What labs do you order for stroke?

A

CBC
BMP/CMP
PT/PTT/INR
Direct factor Xa activity assay
Troponin (always)
EKG w/in 10 minutes

37
Q

When do you get advanced imaging for stroke and what imaging might you order?

A

after stabilization and treatment is initiated to look for etiology and severity of stroke damage

CTA, MRA and/or MRI of the brain
Carotid duplex US (always at some point)
Echo (if irregular cardiac rhythm)

38
Q

What additional labs can you order and why?

A

Toxicology screen - suspected drug use (eg. cocaine)
Blood alcohol concentration (BAC) - increases risk of bleeding/stroke mimic
Lumbar puncture
indicated if high suspicion for SAH with a normal CT head
ABG - if hypoxic (avoid if considering fibrinolytic therapy)
hCG - women of childbearing age
ESR/CRP - elevated in infective endocarditis
CXR - if suspected or history of lung disease or (+)fever
EEG - suspected seizure
UA/blood cultures - if (+) fever

39
Q

When do you adminster O2 or stroke?

A

Maintain above 94%

40
Q

Why do you tell a patient to be NPO for stroke?

A

risk of aspiration d/t dysphagia from stroke
consult occupational therapy (for swallowing study)
swallowing has to be assessed prior to advancement of diet
Fluids - IV normal saline

41
Q

If there is signs of ICP, what should the bed be at?

A

elevate head of bed 30°

42
Q

If a patient is >100.4

A

acetaminophen

“PR” (rectal), IV (Ofirmev)

surface cooling¹
Evaporative cooling, Ice water immersion, Whole-body or strategic ice packing
search for cause
common causes: aspiration pneumonia, UTI
Hypothermia can worsen cerebral ischemia in all strokes
tx with warm blankets, bear hugger, warm IV fluids

43
Q

When do you treat hypoglycemia or hypoglycemia?

A

hypoglycemia - treat if BS <60 mg/dL (class 1)
hyperglycemia - treat if BS is >180 mg/dL to a goal of between 140-180 mg/dL (class IIa)

44
Q

What should you do if a patient is on an anticoagulation med and has hemorrhagic stroke

A

reversal agent to allow clogging

45
Q

treatment for ischemic stroke

A
  • Determine eligibility for fibrinolytic therapy (rt-PA)
    Hypotension (2019 update)
    IV fluids to maintain organ perfusion, although a specific goal is not provided
    BP goal of SBP ≤ 185 and DBP ≤ 110 before rt-PA can be administered (class 1)
    First line antihypertensives¹
    IV nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes; max 15 mg/h
    IV clevidipine 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP reached; maximum 21 mg/h
    IV labetalol 10-20 mg IV over 1-2 minutes

want to get BP just barely below SBP <185 and DBP <110

goals is to get them to this level so that they can get tPA

46
Q

If you are not eleible for tPA, what BP do you not want to treat

A

Do not treat unless SBP >220 or DBP >120

47
Q

When do you treat even if BP is <220 or DBP <120

A

Additional indications for tx BP:
malignant hypertension (end organ damage)
comorbid or complicating conditions that require lowering of BP
Ex: active ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or pre-eclampsia/eclampsia
BP should not be lowered more than 15% in the first 24 hours (to preserve cerebral perfusion)
First-line agents same as AIS eligible for rt-PA

nicardipine
clevidipine
labetolol

48
Q

what organs are considered end organs?

A

eyes
heart
kidneys

49
Q

When to treat intracranial hemorrhage and what BP goals and with what

A

SBP 150-220 mmHg - careful titration of therapy to allow for smooth reduction of SBP to a goal of 130-140 mmHg (Class 2a)
SBP >220 mmHg - there is currently not enough evidence to provide specific recommendations
“It is common practice to take a similar BP-lowering approach”.
First line antihypertensives same as AIS
Risk vs benefit of treatment
risk - loss of cerebral perfusion pressure leading to higher level of infarction
benefit - decreased risk of rebleed

50
Q

How to treat a subarachnoid hemmorage

A

No optimal target has been defined - a SBP < 160 or MAP < 110 was a “reasonable” recommendation
preferred agents: labetalol, nicardipine or enalapril
Risk vs Benefit of treatment same as intracranial hemorrhage
Prevent vasospasm in SAH
Goal: prevent delayed cerebral ischemia
Nimodipine is drug of choice - given PO or via NG tube (if not cleared) and continued for 3 weeks

51
Q

What is the only FDA approved therapy for stroke

A

Recombinant tissue-type plasminogen activator (rt-PA) - first line intervention

given over 60 minutes and blocks the blood flow

need to not have hypoglycemia

52
Q

What is a complication of tPA?

A

Death - d/t hemmorage

53
Q

3 inclusion criteria of tPA

A
  1. clinical diagnosis of ischmic stroke
  2. Onset of symptoms within 4.5 hours before beginning of treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal
  3. 18 or older
54
Q

If you give tPA, what is necessary to do?

A

Symptoms should improve w/in 60 minutes

Infuse tPA over 60 minutes
Stop infusion and obtain CT if pt develops HA, N/V, acute HTN, or neurologic deterioration
Admit or transfer to ICU at a stroke center or specialized stroke unit
Neuro checks q15m for 3 hours, then q30m for 6 hours, then qhr x 15 hours
Keep BP < 180/105 mmHg
Avoid NG tube, indwelling catheters or intra arterial catheters if possible
Obtain CT at 24 hours post-tPA, before starting antiplatelets or anticoagulants

55
Q

What to do if a patient has a bleed during tPA

A

cryoprecipitate¹ or tranexamic acid (TXA)²

56
Q

What to do if a patient has Angioedema during tPA?

A

allergic reaction

IV methylprednisolone, diphenhydramine and famotidine
Consider SQ or inhaled epinephrine
prepare to intubate if edema is rapidly progressing

57
Q

interventional treatment of stroke

A

Interventional Treatment for Ischemic Stroke - Reperfusion Therapy Option
Endovascular mechanical thrombectomy
Alternative if rt-PA is CI or ineffective in a patient with a persistent potentially disabling neuro deficit (NIHSS ≥6)
Indication: large artery occlusion in the anterior circulation (dx by CTA or MRA) with small infarct core and no hemorrhage (dx by MRI)
Treatment must occur within 24 hours of symptom onset and performed at a stroke center with surgeons experienced in procedure
Specific eligibility criteria for treatment must be met if < 6 hours since onset and if treatment will occur between 6-24 hours since onset
Reference for eligibility criteria (reference only)

58
Q

complications of stroke

A

Hematoma
Evacuation via minimally invasive surgical procedures is recommended moderate to large ICHs (Class 2a) and large intraventricular extension of ICH’s. (class 1)
Large intracranial hemorrhage
Craniotomy (allow bain to swell) vs craniectomy

Cerebral edema - worse in patients with larger infarct
peaks on day 2 or 3 - can be present for up to 10 days post stroke
monitor for increased ICP
Treatment
fluid restriction and IV mannitol - watch for hypotension leading to worse infarct
decompressive craniectomy (reduces mortality by 50%) in younger patient (< 60 y/o)

59
Q

treating ICP from stroke treatment

A

Increased ICP - occurs most often in hemorrhagic strokes
elevate head of bed 30°
mild sedation to maintain comfort as needed
osmotic therapy (i.e. mannitol, hypertonic saline) may be considered

60
Q

treating hydrocephalus for stroke complications

A

Hydrocephalus - increased fluid in the ventricles of the brain leading to pressure on the surrounding cerebral structures
may occur with SAH
watch for worsening HA and progressively impaired neurological testing
CT/MRI brain will show enlarged ventricles
consult neurosurgery for consideration of shunt placement

61
Q

treating seizures for stroke

A

Seizures - occur most frequently in hemorrhagic strokes
Consider continuous electroencephalographic monitoring for at least 24 hours in hemorrhagic stroke patients
Primary prophylaxis is only recommended if impaired consciousness and evidence of seizure activity on EEG or patient hx of clinical seizures
Secondary prophylaxis for all patients and continued for at least 7 days
Active seizure controlled with IV lorazepam
Prevention with fosphenytoin
avoid phenytoin - evidence shows worsened mortality

62
Q

complications that can occur after a stroke

A

Dysphagia and aspiration
consult speech/occupational therapy for swallowing evaluation
Venous thromboembolism
pneumatic compression stockings or heparin
UTI
Urinary incontinence
GI bleed
consider preventative PPI therapy
Depression

Nutritional deficiency, dehydration
consult nutrition
Pressure /ulcers sores
nursing orders to move patient q2h if patient unable to self adjust
Falls and bone fractures
early education, bed alarms, physical therapy consult

Pulmonary Complications
aspiration pneumonia
keep NPO until swallowing eval
mechanical ventilation
laryngeal injury, vocal cord dysfunction, swallowing impairment, tracheal stenosis, tracheoesophageal fistula, sinusitis
oxygen desaturation
continuous pulse ox, oxygen supplementation to maintain O2 sat above 94%
neurogenic pulmonary edema
unknown pathophysiology; abrupt onset, rapidly progressing pulmonary edema; supportive treatment
abnormal respiratory patterns*
Cheyne-Stoke respiration, periodic breathing, ataxic breathing, apneustic breathing, gasping, apnea

Cardiac Complications - monitor for symptoms, EKG changes and assess cardiac

63
Q

management of stroke after stable

A

Admission
Frequent neuro checks for up to 72 hours post stroke¹
Admission consultations - with in 2 days of stroke
occupational therapy
physical therapy
speech therapy
Additional consultations on a case by case basis
Home health care coordinator
Rehabilitation coordinator
Social worker
Dietitian
Medical specialist (depending on complications)
psych, urology, GI, pulmonary, cardio, ortho

64
Q

Secondary prevention of strokes

A

Strict BP control - once pt is neurologically stable and risk of worsening ischemia has resolved¹
2018 guidelines AIS - restart or initiate BP therapy in any patient with BP > 140/90
2022 guidelines for ICH - goal <130/80

Secondary prevention cont.
Statin therapy²
recommended in ischemic strokes
Smoking cessation
risk of stroke decreases 2-4 years after cessation
Diabetes mellitus control
Weight loss/Exercise
Low-fat/Low-salt diet
Avoid heavy alcohol intake (>4 drinks/d)

65
Q

antiplatelet therapy for ischemic stroke

A

antiplatelet therapy for 21 days ¹ (2019 update)
(+) tPA - start ASA 24-48 hours after tPA²
(-) tPA - start ASA and Plavix within 24 hours
anticoagulant therapy ³
Indicated in patients with a potential cardiac source of embolism
MC - a. fib
other - mechanic heart valve, left ventricular thrombus, dilated cardiomyopathy, rheumatic valve disease

Clin Med IIB Pulmonology (12 decks)

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