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Internal Med EOR > cerebrovascular disease > Flashcards

cerebrovascular disease Flashcards

1
Q

right hemisphere controls…

A
  • creativity
  • spatial ability
  • facial recognition
  • artistic/musical skills
  • left sided muscle control
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2
Q

left hemisphere controls…

A
  • speech
  • comprehension
  • arithmetic
  • writing
  • memorization
  • right sided muscle control
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3
Q

basal ganglia controls…

A

motor control to facilitate movement and inhibits competing movements

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4
Q

anterior cerebral artery supplies…

A
  • medial aspect of the frontal and parietal lobes
  • anterior basal ganglia
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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
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6
Q

posterior cerebral artery supplies…

A
  • thalamus
  • brainstem
  • posterior and medial aspects of the temporal lobe
  • occipital lobe
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7
Q

where is the internal carotid

A

branched into the middle cerebral and connects to the anterior and posterior cerebral arteries

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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

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9
Q

cell death can occur within ______ of loss of blood flow

A

5 minutes

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10
Q

t/f risk of stroke is higher following covid

A

true

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11
Q

types of stroke

A
  • ischemic (MC)
  • hemorrhagic
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12
Q

types of ischemic strokes

A
  • thrombotic
  • embolic
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13
Q

types of hemorrhagic strokes

A
  • intercerebral
  • subarachnoid
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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

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15
Q

what is an ischemic core

A
  • area of complete loss of flow
  • death of brain tissue occurs within 4-10 minutes
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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

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17
Q

what diseases are thrombotic strokes associated with?

A
  • HTN
  • DM
  • hyperlipidemia
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17
Q

thrombotic stroke is likely related to…

A

ruptured atherosclerotic plaques leading to platelet activation

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18
Q

embolic stroke originate from what source

A

extracranial

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19
Q

what diseases are embolic strokes associated with?

A
  • afib
  • cardiac valve disease
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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

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21
Q

what is the MC cause of intracerebral hemorrhage

A

prolonged uncontrolled HTN

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22
Q

Causes of subarachnoid hemorrhage

A
  • trauma
  • AV malformation
  • aneurysm
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23
Q

clinical presentation of a stroke

A
  • weakness on one side
  • facial droop
  • visual changes
  • auditory changes
  • ataxia
  • aphasia
  • HA
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24
Q

most important piece of historical information

A

onset of symptoms

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25
Q

if onset is unknown…

A

symptoms onset is defined as the last time the patient was known to be normal

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26
Q

important history information for strokes

A
  • anticoagulant use
  • drug abuse
  • trauma
  • epilepsy
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27
Q

what should you look for on skin PE for stroke

A
  • janeway lesions or osler nodes
  • livedo retinularis
  • purpura
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28
Q

what should you look for on HEENT PE for stroke

A
  • retinal hemorrhages
  • papilledema
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29
Q

What should be looked for on Cardiovascular PE for stroke

A
  • irregular rhythm (cardiogenic emboli)
  • carotid bruit (thrombotic etiology)
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30
Q

what should be looked for on respiratory PE for stroke

A
  • abnormal breath sounds
  • assessing for comorbid conditions
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31
Q

what should be looked for on neuro PE for stroke

A

you should do a full neuro exam

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32
Q

what is the national institutes of health stroke scale

A
  • no stroke symptoms= 0
  • minor stroke= 1-4
  • moderate stroke= 5-15
  • moderate to severe stroke= 16-20
  • severe stroke= 21-42
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33
Q

you should aim to keep the patient’s o2 sat over …

A

94%

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34
Q

what are the urgent workups for stroke

A
  • fingerstick glucose
  • CT w/o contrast
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35
Q

goal is to complete the CT within how long of arrival for stroke patients

A

25 min

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36
Q

how will a brain bleed appear on CT

A

lighter than the brain tissue

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37
Q

if the CT is negative, what further imaging could you do?

A

MRI

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38
Q

what is the treatment of a stroke

A
  • ABC’s
  • NPO
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39
Q

Elevate the head of the bed 30 degrees if risk of…

A
  • increased ICP
  • aspiration
  • cardiopulm decompensation
40
Q

treatment of a fever with stroke

A

rectal tylenol

41
Q

when to treat hyperglycemia and hypoglycemia?

A

hyper: BS >180 mg/dL
hypo: BS<60 mg/dL

42
Q

anticoagulation reversal for stroke patients:
-warfarin
-pradaxa
-factor Xa
-heparin

A
  • 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
Q

what is the treatment of ischemic stroke

A

determine eligibility for tPA

44
Q

management of hypotension in ischemic stroke

A

IV Fluids

45
Q

BP goal of ischemic stroke before tPA can be administered

A

SBP over 185 and DBP over 110

46
Q

1st line antihypertensives for ischemic stroke

A
  • IV labetalol
  • IV nicardipine
  • IV clevidipine
47
Q

what is the cutoff for blood pressure in administration of tPA in an ischemic stroke

A

if SBP is > 220 and DBP is > 120, then tPA cannot be administered

48
Q

How quickly should BP be lowered in an ischemic stroke

A

no more than 15% in the first 24 hours

49
Q

what is the treatment of elevated BP in intracerebral hemorrhage

A

SBP 150-220: careful titration of therapy to reduce to 130-140

50
Q

treatment of elevated BP in subarachnoid hemorrhage

A

reduce BP to <160

51
Q

first line intervention for ischemic stroke

A

tPA

52
Q

Inclusion criteria for tPA

A
  • clinical diagnosis of ischemic stroke
  • onset of symptoms within 4.5 hours
  • over 18
  • if there is no ischemia on FLAIR
53
Q

if there is ischemia on DWI but not FLAIR…

A

its been less than 4.5 hours and patient can be considered for tPA

54
Q

exclusion criteria for tPA

A
  • previous hemorrhage
  • head trauma in previous 3 months
  • malignancy
  • mild stroke
  • elevated BP
  • internal bleeding
  • infective endocarditis
  • low platelets
  • current anticoagulation use
55
Q

relative exclusion criteria for tPA

A
  • low glucose
  • major surgery in the past 14 days
  • pregnancy
  • aneurysm
56
Q

exclusion criteria if onset of stroke is over 3 hours

A
  • over 80
  • anticoagulant use
  • severe stroke
  • combination of prior stroke and DM
57
Q

management if tPA is administered

A
  • admit to ICU
  • neuro checks
  • keep BP under 180/105
  • avoid inserting tubes
58
Q

stop tPA infusion and obtain CT if patient develops…

A
  • HA
  • n/v
  • acute HTN
  • neuro deterioration
59
Q

complications of tPA

A
  • acute bleeding
  • angioedema
60
Q

what do you give to patients actively bleeding after tPA administration?

A

cryo

61
Q

how do you manage angioedema after tPA?

A

IV methylpredisolone, diphenhydramine, and famotidine

62
Q

last resort therapy for ischemic stroke

A

thrombectomy

63
Q

thrombectomy must occur within _____ of symptom onset

A

24 hours

64
Q

once the patient is stable and treatment has been decided on and administered…

A

transfer to stroke center and consult neuro

65
Q

management of hematoma due to stroke

A

evacuation via minimally invasive surgical procedure

66
Q

management or cerebral edema due to stroke

A
  • fluid restriction and IV mannitol
  • decompressive craniectomy
67
Q

treatment of increased ICP due to stroke

A
  • elevate head of bed
  • mild sedation to maintain comfort
  • osmotic therapy
68
Q

increased ICP often occurs in which strokes

A

hemorrhagic

69
Q

what is hydrocephalus

A

increased fluid in the ventricles of the brain leading to pressure on the surrounding cerebral structures

70
Q

management of hydrocephalus due to stroke

A

consult neurosurgery for consideration of shunt placement

71
Q

imaging of hydrocephalus

A

CT/MRI shows enlarged ventricles

72
Q

management of seizures with stroke

A
  • primary prophylaxis for impaired consciousness, evidence of seizure activity on EEG, or hx of clinical seizures
  • IV lorazepam
73
Q

admission consults within 2 days of stroke

A
  • occupational therapy
  • physical therapy
  • speech therapy
74
Q

secondary prevention of strokes

A
  • strict BP control
  • statin therapy
  • smoking cessation
  • DM control
75
Q

primary prevention of stroke

A

screen for and control all modifiable risk factors

76
Q

discharge therapy for stroke

A
  • start ASA 24-48 hours after tPA
  • if tPA was not administered, start ASA and plavix within 24 hours
77
Q

what is indicated in patients with a potential cardiac source of embolism

A

antithrombotic therapy

78
Q

what is a transient ischemic attack

A

transient episode of neurologic dysfunction caused by cerebral acute ischemia

79
Q

t/f TIA can be embolic or thrombotic in nature

A

true

80
Q

symptoms of TIA often resolve within how long

A

1-2 hours

81
Q

what percent of patients with stoke have a history of TIAs

A

30%

82
Q

acute management of TIA

A
  • same as stroke
  • tPA is included if there is a persistent neurologic deficit that is potentially disabling
83
Q

admit TIA patient if onset is within 72 hours and they have any of …

A
  • 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
Q

diagnosis and management if TIA is caused by carotid artery disease

A
  • dx: carotid US
  • tx: carotid endarterectomy with medical management
85
Q

diagnosis and management if TIA is caused by cardioembolic etiology

A
  • dx: EKG or echo
  • tx: treat underlying disorder
86
Q

diagnosis and management if TIA is caused by large or small vessel disease

A
  • dx: MRA/CTA
  • tx: revascularization with stent placement for large vessels and medial management
87
Q

management if TIA is of unknown origin

A

medical management

88
Q

carotid atherosclerosis if often most severe within ______ of the common carotid

A

2cm of the bifurcation

89
Q

carotid atherosclerosis if often most severe within what area

A

within 2cm of the bifurcation of the common carotid

90
Q

what causes the symptoms of carotid artery stenosis?

A

reduced blood flow and/or superimposed thrombus formation

91
Q

PE of carotid artery stenosis

A

carotid bruit or palpable sclerosis

92
Q

least invasive and least expensive imaging for carotid artery stenosis

A

ultrasound

93
Q

cons of carotid duplex US

A

overestimate the degree of stenosis

94
Q

gold standard imaging for carotid artery stenosis

A

carotid angiography

95
Q

management if asymptomatic carotid artery stenosis

A
  • medical management
  • referral fr vascular surgery for carotid endarterectomy
96
Q

who is a carotid endarterectomy indicated for ?

A

stenosis between 60-99%

97
Q

management for symptomatic carotid artery stenosis

A

-refer for carotid endarterectomy
-carotid stenting

98
Q

medical management of carotid artery stenosis

A
  • antiplatelet
  • antihypertensive
  • statin therapy
  • address all modifiable risk factors

Internal Med EOR (18 decks)

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