Cerebrovascular Disease Flashcards
Right hemisphere controls…
Creativity
Spatial ability
Facial recognition
Artistic/musical skills
Left-sided muscle control
Left hemisphere controls…
Speech
Comprehension
Arithmetic
Writing
Memorization
Right-sided muscle control
Basal ganglia
Motor control to facilitate movement and inhibits competing movements
Anterior cerebral artery supplies…
Medial aspect of the frontal and parietal lobes
Anterior basal ganglia
Medial cerebral artery supplies…
Lateral aspect of the frontal and parietal lobe
Anterior and lateral aspect of temporal lobes
Remaining basal ganglia
Posterior cerebral artery supplies…
Thalamus
Brainstem
Posterior and medial aspects of the temporal lobe
Occipital lobe
Internal carotid
Branches into the middle cerebral and connects to the anterior and posterior cerebral arteries
Stroke
Sudden onset of neurologic deficit resulting from a loss of blood flow to a part of the brain resulting in brain infarction
Cell death can occur within ___ of loss of blood flow
5 minutes
T/F - risk of stroke is higher following COVID
True
Types of stroke
Ischemic (MC)
Hemorrhagic
Types of ischemic strokes
Thrombotic
Embolic
Types of hemorrhagic stokes
Intracerebral
Subarachnoid
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
Ischemic core
Area of complete loss of flow
Death of brain tissue occurs within 4-10 minutes
Penumbra
Surrounding tissue which has only a reduction in flow and can remain viable for hours after onset of stroke
Thrombotic stroke is likely related to ___
Ruptured atherosclerotic plaques leading to platelet activation
What diseases are thrombotic strokes associated with?
HTN
DM
Hyperlipidemia
Embolic stroke originate from ___ source
Extracranial
What diseases are embolic strokes associated with?
Afib
Cardiac valve disease
Hemorrhagic stroke
Spontaneous rupture of a cerebral artery leading to loss of perfusion due to vasoconstriction and platelet aggregation and increased ICP
MC cause of intracerebral hemorrhage
Prolonged uncontrolled HTN
Causes of subarachnoid hemorrhage
Trauma
AV malformation
Aneurysm
Clinical presentation of a stroke
Weakness on one side
Facial droop
Visual changes
Auditory changes
Ataxia
Aphasia
HA
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
30
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
