Cerebrovascular Disease Flashcards by Makenzie Cook

Right hemisphere controls…

Creativity
Spatial ability
Facial recognition
Artistic/musical skills
Left-sided muscle control

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Left hemisphere controls…

Speech
Comprehension
Arithmetic
Writing
Memorization
Right-sided muscle control

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Basal ganglia

Motor control to facilitate movement and inhibits competing movements

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Anterior cerebral artery supplies…

Medial aspect of the frontal and parietal lobes
Anterior basal ganglia

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Medial cerebral artery supplies…

Lateral aspect of the frontal and parietal lobe
Anterior and lateral aspect of temporal lobes
Remaining basal ganglia

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Posterior cerebral artery supplies…

Thalamus
Brainstem
Posterior and medial aspects of the temporal lobe
Occipital lobe

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Internal carotid

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

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Stroke

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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Cell death can occur within ___ of loss of blood flow

5 minutes

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T/F - risk of stroke is higher following COVID

True

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Types of stroke

Ischemic (MC)
Hemorrhagic

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Types of ischemic strokes

Thrombotic
Embolic

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Types of hemorrhagic stokes

Intracerebral
Subarachnoid

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Ischemic stroke

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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Ischemic core

Area of complete loss of flow
Death of brain tissue occurs within 4-10 minutes

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Penumbra

Surrounding tissue which has only a reduction in flow and can remain viable for hours after onset of stroke

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Thrombotic stroke is likely related to ___

Ruptured atherosclerotic plaques leading to platelet activation

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What diseases are thrombotic strokes associated with?

HTN
DM
Hyperlipidemia

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Embolic stroke originate from ___ source

Extracranial

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What diseases are embolic strokes associated with?

Afib
Cardiac valve disease

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Hemorrhagic stroke

Spontaneous rupture of a cerebral artery leading to loss of perfusion due to vasoconstriction and platelet aggregation and increased ICP

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MC cause of intracerebral hemorrhage

Prolonged uncontrolled HTN

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Causes of subarachnoid hemorrhage

Trauma
AV malformation
Aneurysm

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Clinical presentation of a stroke

Weakness on one side
Facial droop
Visual changes
Auditory changes
Ataxia
Aphasia
HA

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Most important piece of historical information

Onset of symptoms

If onset is unknown...

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

Important history information for strokes

Anticoagulant use Drug abuse Trauma Epilepsy

Skin PE for stroke

Janeway lesions or osler nodes Livedo reticularis Purpura

HEENT PE for stroke

Retinal hemorrhages Papilledema

Cardiovascular PE for stroke

Irregular rhythm (cardiogenic emboli) Carotid bruit (thrombotic etiology)

Respiratory PE for stroke

Abnormal breath sounds Assessing for comorbid conditions

Neuro PE for stroke

Full neuro exam

NIH stroke scale

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

You should aim to keep the patient's O2 sat over...

94%

Urgent workups for stroke

Fingerstick glucose CT w/o contrast

Goal is to complete the CT within ___ of arrival

25 minutes

Brain bleed on CT

Lighter than brain tissue

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

MRI

Treatment of a stroke

ABCs NPO

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

Increased ICP Aspiration Cardiopulm decompensation

Treatment of a fever with stroke

Rectal Tylenol

When to treat hyperglycemia and hypoglycemia?

BS > 180 mg/dL BS < 60 mg/dL

Anticoagulation reversal for stroke patients

Warfarin: vitamin K and 4-factor prothrombin complex concentrate (PCC) Pradaxa: activated charcoal (if it's been within 2 hours) or Praxbind or PCC Factor Xa: activated charcoal (if it's been within 2 hours) or Andexxa or PCC Heparin: Protamine

Treatment of ischemic stroke

Determine eligibility for tPA

Management of hypotension in ischemic stroke

IV fluids

BP goal of ischemic stroke before tPA can be administered

SBP over 185 and DBP over 110

1st line antihypertensives for ischemic stroke

IV labetalol IV nicardipine IV clevidipine

If SBP is > ___ and DBP is > ___, then tPA cannot be administered (in an ischemic stroke)

220; 120

BP should not be lowered more than ___ in the first 24 hours

15%

Treatment of elevated BP in intracerebral hemorrhage

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

Treatment of elevated BP in subarachnoid hemorrhage

Reduce BP to < 160

First line intervention for ischemic stroke

tPA

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

If there is ischemia on DWI but not FLAIR...

It's been less than 4.5 hours and patient can be considered for tPA

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

Relative exclusion criteria for tPA

Low glucose Major surgery in the past 14 days Pregnancy Aneurysm

Exclusion criteria if onset of stroke is over 3 hours

Over 80 Anticoagulant use Severe stroke Combinations of prior stroke and DM

Management if tPA is administered

Admit to ICU Neuro checks Keep BP under 180/105 Avoid inserting tubes

Stop tPA infusion and obtain CT if patient develops...

HA N/V Acute HTN Neuro deterioration

Complications of tPA

Acute bleeding Angioedema

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

Cryo

How do you manage angioedema after tPA?

IV methylprednisolone, diphenhydramine, and famotidine

Last resort therapy for ischemic stroke

Thrombectomy

Thrombectomy must occur within ___ of symptom onset

24 hours

Once the patient is stable and treatment has been decided on and administered...

Transfer to stroke center and consult neuro

Management of hematoma due to stroke

Evacuation via minimally invasive surgical procedure

Management of cerebral edema due to stroke

Fluid restriction and IV mannitol Decompressive craniectomy

Treatment of increased ICP due to stroke

Elevate head of bed Mild sedation to maintain comfort Osmotic therapy

Increased ICP often occurs in ___ strokes

Hemorrhagic

Hydrocephalus

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

Management of hydrocephalus due to stroke

Consult neurosurgery for consideration of shunt placement

Imaging of hydrocephalus

CT/MRI shows enlarged ventricles

Management of seizures with stroke

Primary prophylaxis for impaired consciousness, evidence of seizure activity on EEG, or hx of clinical seizures IV lorazepam

Admission consults within 2 days of stroke

Occupational therapy Physical therapy Speech therapy

Secondary prevention of strokes

Strict BP control Statin therapy Smoking cessation DM control

Primary prevention of stroke

Screen for and control all modifiable risk factors

Discharge therapy for stroke

Start ASA 24-48 hours after tPA If tPA was not administered, start ASA and Plavix within 24 hours

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

Antithrombotic therapy

Transient ischemic attack

Transient episode of neurologic dysfunction caused by cerebral acute ischemia

T/F - TIA can be embolic or thrombotic in nature

True

Symptoms of TIA often resolve within ___

1-2 hours

___% of patients with stroke have a history of TIAs

Acute management of TIA

Same as stroke tPA is included if there is a persistent neurologic deficit that is potentially disabling

Admit TIA patient if onset is within 72 hours and they have any of...

ABCD2 score over 3 ABCD2 score of 0-2 and uncertainty if workup can be done within 48 hours ABCD2 score 0-2 and event was caused by focal ischemia

Diagnosis and management if TIA is caused by carotid artery disease

Dx: carotid US Tx: carotid endarterectomy with medical management

Diagnosis and management if TIA is caused by cardioembolic etiology

Dx: EKG or echo Tx: treat underlying disorder

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 medical management

Management if TIA is of unknown origin

Medical management

Carotid atherosclerosis if often most severe within ___ of the common carotid

2 cm of the bifurcation

What causes the symptoms of carotid artery stenosis?

Reduced blood flow and/or superimposed thrombus formation

PE of carotid artery stenosis

Carotid bruit or palpable sclerosis

Least invasive and least expensive imaging for carotid artery stenosis

Ultrasound

Cons of carotid duplex US

Overestimate the degree of stenosis

Gold standard imaging for carotid artery stenosis

Carotid angiography

Management if asymptomatic carotid artery stenosis

Medical management Referral for vascular surgery for carotid endarterectomy

Who is a carotid endarterectomy indicated for?

Stenosis between 60-99%

Management for symptomatic carotid artery stenosis

Refer for carotid endarterectomy Carotid stenting

Medical management

Antiplatelet Antihypertensive Statin therapy Address all modifiable risk factors