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Surgery 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

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

Internal carotid

A

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

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8
Q

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 stokes

A

Intracerebral
Subarachnoid

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14
Q

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

Ischemic core

A

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

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16
Q

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

Thrombotic stroke is likely related to ___

A

Ruptured atherosclerotic plaques leading to platelet activation

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18
Q

What diseases are thrombotic strokes associated with?

A

HTN
DM
Hyperlipidemia

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19
Q

Embolic stroke originate from ___ source

A

Extracranial

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20
Q

What diseases are embolic strokes associated with?

A

Afib
Cardiac valve disease

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21
Q

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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22
Q

MC cause of intracerebral hemorrhage

A

Prolonged uncontrolled HTN

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23
Q

Causes of subarachnoid hemorrhage

A

Trauma
AV malformation
Aneurysm

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24
Q

Clinical presentation of a stroke

A

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

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25
Q

Most important piece of historical information

A

Onset of symptoms

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26
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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27
Q

Important history information for strokes

A

Anticoagulant use
Drug abuse
Trauma
Epilepsy

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28
Q

Skin PE for stroke

A

Janeway lesions or osler nodes
Livedo reticularis
Purpura

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29
Q

HEENT PE for stroke

A

Retinal hemorrhages
Papilledema

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30
Q

Cardiovascular PE for stroke

A

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

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31
Q

Respiratory PE for stroke

A

Abnormal breath sounds
Assessing for comorbid conditions

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32
Q

Neuro PE for stroke

A

Full neuro exam

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33
Q

NIH 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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34
Q

You should aim to keep the patient’s O2 sat over…

A

94%

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35
Q

Urgent workups for stroke

A

Fingerstick glucose
CT w/o contrast

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36
Q

Goal is to complete the CT within ___ of arrival

A

25 minutes

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37
Q

Brain bleed on CT

A

Lighter than brain tissue

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38
Q

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

A

MRI

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39
Q

Treatment of a stroke

A

ABCs
NPO

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40
Q

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

A

Increased ICP
Aspiration
Cardiopulm decompensation

41
Q

Treatment of a fever with stroke

A

Rectal Tylenol

42
Q

When to treat hyperglycemia and hypoglycemia?

A

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

43
Q

Anticoagulation reversal for stroke patients

A

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

44
Q

Treatment of ischemic stroke

A

Determine eligibility for tPA

45
Q

Management of hypotension in ischemic stroke

A

IV fluids

46
Q

BP goal of ischemic stroke before tPA can be administered

A

SBP over 185 and DBP over 110

47
Q

1st line antihypertensives for ischemic stroke

A

IV labetalol
IV nicardipine
IV clevidipine

48
Q

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

A

220; 120

49
Q

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

A

15%

50
Q

Treatment of elevated BP in intracerebral hemorrhage

A

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

51
Q

Treatment of elevated BP in subarachnoid hemorrhage

A

Reduce BP to < 160

52
Q

First line intervention for ischemic stroke

A

tPA

53
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

54
Q

If there is ischemia on DWI but not FLAIR…

A

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

55
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

56
Q

Relative exclusion criteria for tPA

A

Low glucose
Major surgery in the past 14 days
Pregnancy
Aneurysm

57
Q

Exclusion criteria if onset of stroke is over 3 hours

A

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

58
Q

Management if tPA is administered

A

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

59
Q

Stop tPA infusion and obtain CT if patient develops…

A

HA
N/V
Acute HTN
Neuro deterioration

60
Q

Complications of tPA

A

Acute bleeding
Angioedema

61
Q

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

A

Cryo

62
Q

How do you manage angioedema after tPA?

A

IV methylprednisolone, diphenhydramine, and famotidine

63
Q

Last resort therapy for ischemic stroke

A

Thrombectomy

64
Q

Thrombectomy must occur within ___ of symptom onset

A

24 hours

65
Q

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

A

Transfer to stroke center and consult neuro

66
Q

Management of hematoma due to stroke

A

Evacuation via minimally invasive surgical procedure

67
Q

Management of cerebral edema due to stroke

A

Fluid restriction and IV mannitol
Decompressive craniectomy

68
Q

Treatment of increased ICP due to stroke

A

Elevate head of bed
Mild sedation to maintain comfort
Osmotic therapy

69
Q

Increased ICP often occurs in ___ strokes

A

Hemorrhagic

70
Q

Hydrocephalus

A

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

71
Q

Management of hydrocephalus due to stroke

A

Consult neurosurgery for consideration of shunt placement

72
Q

Imaging of hydrocephalus

A

CT/MRI shows enlarged ventricles

73
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

74
Q

Admission consults within 2 days of stroke

A

Occupational therapy
Physical therapy
Speech therapy

75
Q

Secondary prevention of strokes

A

Strict BP control
Statin therapy
Smoking cessation
DM control

76
Q

Primary prevention of stroke

A

Screen for and control all modifiable risk factors

77
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

78
Q

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

A

Antithrombotic therapy

79
Q

Transient ischemic attack

A

Transient episode of neurologic dysfunction caused by cerebral acute ischemia

80
Q

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

A

True

81
Q

Symptoms of TIA often resolve within ___

A

1-2 hours

82
Q

___% of patients with stroke have a history of TIAs

A

30

83
Q

Acute management of TIA

A

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

84
Q

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

A

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

85
Q

Diagnosis and management if TIA is caused by carotid artery disease

A

Dx: carotid US
Tx: carotid endarterectomy with medical management

86
Q

Diagnosis and management if TIA is caused by cardioembolic etiology

A

Dx: EKG or echo
Tx: treat underlying disorder

87
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 medical management

88
Q

Management if TIA is of unknown origin

A

Medical management

89
Q

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

A

2 cm of the bifurcation

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 for 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

A

Antiplatelet
Antihypertensive
Statin therapy
Address all modifiable risk factors

Surgery EOR (12 decks)

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