cerebrovascular disease Flashcards
1
Q
right hemisphere controls…
A
- creativity
- spatial ability
- facial recognition
- artistic/musical skills
- left sided muscle control
2
Q
left hemisphere controls…
A
- speech
- comprehension
- arithmetic
- writing
- memorization
- right sided muscle control
3
Q
basal ganglia controls…
A
motor control to facilitate movement and inhibits competing movements
4
Q
anterior cerebral artery supplies…
A
- medial aspect of the frontal and parietal lobes
- anterior basal ganglia
5
Q
medial cerebral artery supplies…
A
- lateral aspect of the frontal and parietal lobe
- anterior and lateral aspect of temporal lobes
- remaining basal ganglia
6
Q
posterior cerebral artery supplies…
A
- thalamus
- brainstem
- posterior and medial aspects of the temporal lobe
- occipital lobe
7
Q
where is the internal carotid
A
branched into the middle cerebral and connects to the anterior and posterior cerebral arteries
8
Q
what is a stroke
A
sudden onset of neurologic deficit resulting from a loss of blood flow to a part of the brain resulting in brain infarction
9
Q
cell death can occur within ______ of loss of blood flow
A
5 minutes
10
Q
t/f risk of stroke is higher following covid
A
true
11
Q
types of stroke
A
- ischemic (MC)
- hemorrhagic
12
Q
types of ischemic strokes
A
- thrombotic
- embolic
13
Q
types of hemorrhagic strokes
A
- intercerebral
- subarachnoid
14
Q
what is an ischemic stroke
A
acute occlusion of an intracranial vessel leading to a reduction of blood flow resulting in cell hypoxia and a loss of neurologic function
15
Q
what is an ischemic core
A
- area of complete loss of flow
- death of brain tissue occurs within 4-10 minutes
16
Q
what is a penumbra
A
surrounding tissue which has only a reduction in flow and can remain viable for hours after onset of stroke
17
Q
what diseases are thrombotic strokes associated with?
A
- HTN
- DM
- hyperlipidemia
17
Q
thrombotic stroke is likely related to…
A
ruptured atherosclerotic plaques leading to platelet activation
18
Q
embolic stroke originate from what source
A
extracranial
19
Q
what diseases are embolic strokes associated with?
A
- afib
- cardiac valve disease
20
Q
what is a hemorrhagic stroke
A
spontaneous rupture of a cerebral artery leading to loss of perfusion due to vasoconstriction and platelet aggregation and increased ICP
21
Q
what is the MC cause of intracerebral hemorrhage
A
prolonged uncontrolled HTN
22
Q
Causes of subarachnoid hemorrhage
A
- trauma
- AV malformation
- aneurysm
23
Q
clinical presentation of a stroke
A
- weakness on one side
- facial droop
- visual changes
- auditory changes
- ataxia
- aphasia
- HA
24
most important piece of historical information
onset of symptoms
25
if onset is unknown...
symptoms onset is defined as the last time the patient was known to be normal
26
important history information for strokes
* anticoagulant use
* drug abuse
* trauma
* epilepsy
27
what should you look for on skin PE for stroke
* janeway lesions or osler nodes
* livedo retinularis
* purpura
28
what should you look for on HEENT PE for stroke
* retinal hemorrhages
* papilledema
29
What should be looked for on Cardiovascular PE for stroke
* irregular rhythm (cardiogenic emboli)
* carotid bruit (thrombotic etiology)
30
what should be looked for on respiratory PE for stroke
* abnormal breath sounds
* assessing for comorbid conditions
31
what should be looked for on neuro PE for stroke
you should do a full neuro exam
32
what is the national institutes of health stroke scale
* no stroke symptoms= 0
* minor stroke= 1-4
* moderate stroke= 5-15
* moderate to severe stroke= 16-20
* severe stroke= 21-42
33
you should aim to keep the patient's o2 sat over ...
94%
34
what are the urgent workups for stroke
* fingerstick glucose
* CT w/o contrast
35
goal is to complete the CT within how long of arrival for stroke patients
25 min
36
how will a brain bleed appear on CT
lighter than the brain tissue
37
if the CT is negative, what further imaging could you do?
MRI
38
what is the treatment of a stroke
* ABC's
* NPO
39
Elevate the head of the bed 30 degrees if risk of...
* increased ICP
* aspiration
* cardiopulm decompensation
40
treatment of a fever with stroke
rectal tylenol
41
when to treat hyperglycemia and hypoglycemia?
hyper: BS >180 mg/dL
hypo: BS<60 mg/dL
42
anticoagulation reversal for stroke patients:
-warfarin
-pradaxa
-factor Xa
-heparin
* warfarin: vitamin K and 4-factor prothrombin complex concentrate (PCC)
* Pradaxa: activated charcoal(if its been within 2 hours) or praxbind or PCC
* factor Xa: activated charcoal (if its been within 2 hours) or andexxa or PCC
* heparin: protamine
43
what is the treatment of ischemic stroke
determine eligibility for tPA
44
management of hypotension in ischemic stroke
IV Fluids
45
BP goal of ischemic stroke before tPA can be administered
SBP over 185 and DBP over 110
46
1st line antihypertensives for ischemic stroke
* IV labetalol
* IV nicardipine
* IV clevidipine
47
what is the cutoff for blood pressure in administration of tPA in an ischemic stroke
if SBP is > 220 and DBP is > 120, then tPA cannot be administered
48
How quickly should BP be lowered in an ischemic stroke
no more than 15% in the first 24 hours
49
what is the treatment of elevated BP in intracerebral hemorrhage
SBP 150-220: careful titration of therapy to reduce to 130-140
50
treatment of elevated BP in subarachnoid hemorrhage
reduce BP to <160
51
first line intervention for ischemic stroke
tPA
52
Inclusion criteria for tPA
* clinical diagnosis of ischemic stroke
* onset of symptoms within 4.5 hours
* over 18
* if there is no ischemia on FLAIR
53
if there is ischemia on DWI but not FLAIR...
its been less than 4.5 hours and patient can be considered for tPA
54
exclusion criteria for tPA
* previous hemorrhage
* head trauma in previous 3 months
* malignancy
* mild stroke
* elevated BP
* internal bleeding
* infective endocarditis
* low platelets
* current anticoagulation use
55
relative exclusion criteria for tPA
* low glucose
* major surgery in the past 14 days
* pregnancy
* aneurysm
56
exclusion criteria if onset of stroke is over 3 hours
* over 80
* anticoagulant use
* severe stroke
* combination of prior stroke and DM
57
management if tPA is administered
* admit to ICU
* neuro checks
* keep BP under 180/105
* avoid inserting tubes
58
stop tPA infusion and obtain CT if patient develops...
* HA
* n/v
* acute HTN
* neuro deterioration
59
complications of tPA
* acute bleeding
* angioedema
60
what do you give to patients actively bleeding after tPA administration?
cryo
61
how do you manage angioedema after tPA?
IV methylpredisolone, diphenhydramine, and famotidine
62
last resort therapy for ischemic stroke
thrombectomy
63
thrombectomy must occur within _____ of symptom onset
24 hours
64
once the patient is stable and treatment has been decided on and administered...
transfer to stroke center and consult neuro
65
management of hematoma due to stroke
evacuation via minimally invasive surgical procedure
66
management or cerebral edema due to stroke
* fluid restriction and IV mannitol
* decompressive craniectomy
67
treatment of increased ICP due to stroke
* elevate head of bed
* mild sedation to maintain comfort
* osmotic therapy
68
increased ICP often occurs in which strokes
hemorrhagic
69
what is hydrocephalus
increased fluid in the ventricles of the brain leading to pressure on the surrounding cerebral structures
70
management of hydrocephalus due to stroke
consult neurosurgery for consideration of shunt placement
71
imaging of hydrocephalus
CT/MRI shows enlarged ventricles
72
management of seizures with stroke
* primary prophylaxis for impaired consciousness, evidence of seizure activity on EEG, or hx of clinical seizures
* IV lorazepam
73
admission consults within 2 days of stroke
* occupational therapy
* physical therapy
* speech therapy
74
secondary prevention of strokes
* strict BP control
* statin therapy
* smoking cessation
* DM control
75
primary prevention of stroke
screen for and control all modifiable risk factors
76
discharge therapy for stroke
* start ASA 24-48 hours after tPA
* if tPA was not administered, start ASA and plavix within 24 hours
77
what is indicated in patients with a potential cardiac source of embolism
antithrombotic therapy
78
what is a transient ischemic attack
transient episode of neurologic dysfunction caused by cerebral acute ischemia
79
t/f TIA can be embolic or thrombotic in nature
true
80
symptoms of TIA often resolve within how long
1-2 hours
81
what percent of patients with stoke have a history of TIAs
30%
82
acute management of TIA
* same as stroke
* tPA is included if there is a persistent neurologic deficit that is potentially disabling
83
admit TIA patient if onset is within 72 hours and they have any of ...
* ABCD2 score over 3
* ABCD2 score 0-2 and uncertainty if workup can be done within 48 hours
* ABCD2 score 0-2 and event was caused by focal ischemia
84
diagnosis and management if TIA is caused by carotid artery disease
* dx: carotid US
* tx: carotid endarterectomy with medical management
85
diagnosis and management if TIA is caused by cardioembolic etiology
* dx: EKG or echo
* tx: treat underlying disorder
86
diagnosis and management if TIA is caused by large or small vessel disease
* dx: MRA/CTA
* tx: revascularization with stent placement for large vessels and medial management
87
management if TIA is of unknown origin
medical management
88
carotid atherosclerosis if often most severe within ______ of the common carotid
2cm of the bifurcation
89
carotid atherosclerosis if often most severe within what area
within 2cm of the bifurcation of the common carotid
90
what causes the symptoms of carotid artery stenosis?
reduced blood flow and/or superimposed thrombus formation
91
PE of carotid artery stenosis
carotid bruit or palpable sclerosis
92
least invasive and least expensive imaging for carotid artery stenosis
ultrasound
93
cons of carotid duplex US
overestimate the degree of stenosis
94
gold standard imaging for carotid artery stenosis
carotid angiography
95
management if asymptomatic carotid artery stenosis
* medical management
* referral fr vascular surgery for carotid endarterectomy
96
who is a carotid endarterectomy indicated for ?
stenosis between 60-99%
97
management for symptomatic carotid artery stenosis
-refer for carotid endarterectomy
-carotid stenting
98
medical management of carotid artery stenosis
* antiplatelet
* antihypertensive
* statin therapy
* address all modifiable risk factors
