cerebrovascular disease Flashcards
1
Q
list risk factors for stroke
A
- HTN
- DM
- smoking
- dyslipidemia
2
Q
a stroke occurs as a result of one of what two pathologic processes
A
- ischemia
- hemorrhage
3
Q
what happens in an ischemic stroke
A
- thrombosis: local in situ obstruction
- embolism: debris originating elsewhere that block artery
- systemic hypoperfusion
4
Q
how might signs/symptoms of a ischemic stroke caused by hypoperfusion be different than one caused by a clot
A
- symptoms of brain dysfunction diffuse
- circulatory compromise -> tachycardia, kidney dysfunction
- neurological signs are bilateral
5
Q
What are watershed infarcts
A
- occur at the border between cerebral vascular territories with no or little anastomosis
- secondary to low flow states from hypotension
6
Q
brain hemorrhage can either be or
A
- intracerebral hemorrhage: bleeding directly into brain tissue
- subarachnoid hemorrhage: bleeding into CSF
7
Q
two types of large vessel strokes
A
- anterior circulation (carotid artery supply)
- posterior circulation (vertebrobasilar system)
8
Q
anterior circulation (carotid artery supply) involves what main branches
A
- middle cerebral arteries
- anterior cerebral arteries
- anterior communicating artery
9
Q
Posterior circulation involves what main branches
A
- vertebral arteries
- basilar artery
- posterior cerebral arteries
10
Q
most common CVA involes what artery
A
middle cerebral artery
11
Q
clinical presentation
- contralateral hemiplegia/hemianaesthesia (weakness/numbness) affecting face and arm greater than leg
A
stroke in middle cerebral artery
12
Q
if dominant hemisphere is affected in stroke in middle cerebral artery, what will patient often present with
A
global aphasia
13
Q
if nondominant hemisphere is affected in stroke in middle cerebral artery, what will patient often present with
A
hemineglect
14
Q
clinical presentation
- contralateral weakness and loss of sensation in the leg greater than arm
- abulia: delay in verbal and motor response or perseverating speech (repeating questions)
A
stroke in the anterior cerebral artery
15
Q
clinical presentation
- impingement of cranial nerves
- visual field deficits
A
- anterior communicating artery
- most common circle of willis aneursym
16
Q
clinical presentation
- contralateral homonymous hemianopia: blindness over half the field of vision
- light touch and pinprink sensation reduced
A
- posterior cerebral artery stroke
- affects occipital cortex
17
Q
wallenberg syndrome
A
- patient has a constellation of neurologic symptoms due to injury to the lateral part of the medulla in the brain
18
Q
lateral medulla recieves blood supply from
A
posterior inferior cerebellar artery (PICA)
19
Q
clinical presentation
- ipsilateral loss of facial pain and temperature sensation with contralateral loss of these senses over the body
- vertigo, vomiting, ipsilateral ataxia, nystagmus, dysarthria, ipsilateral horner’s syndrome
A
- stroke in posterior inferior cerebellar artery (PICA)
20
Q
clinical presentation
- “locked-in syndrome”
- preserved consciousness
- quadriplegia and facial weakness
- lateral gaze weakness
A
- stroke in basilar artery
- affects pons
21
Q
What are lacunar strokes and what symptoms are they associated with
A
- small vessel strokes
- associated with chronic HTN
- pure motor OR pure sensory
22
Q
why are you concerned about needing to intubate a stroke patient
A
- Increased ICP -> decreased respiratory drive
- decreased level of consciousness
23
Q
why does mean arterial pressure (MAP) usually elevate in a stroke
A
- an appropriate response to maintain brain perfusion
24
Q
When should a high BP in a patient with an ischemic stroke be treated
A
- do not start treating until BP > 220/120
- *exception: treating with thrombolytics
25
When should a high BP in a patient with a hemorrhagic stroke be treated
* keep BP \< **160/90**
* ****don't want too low (\<140) or else cause ischemia in other areas
* antihypertensive: nicardipine drip commonly used
26
first diagnostic test in the assessment of a stroke
* **noncontrast CT scan of brain**
27
Noncontrast CT brain results in hemorrhagic vs ischemic stroke
* hemorrhagic: CT will show blood
* ischemic: CT may be normal; ischemia takes a certain length of time to be evident on CT
28
what situations are likely to cause a "normal" noncontrast CT in an ischemic stroke
* symptoms present \< 6 hours
* affected area small
* located in area of brain not well seen on CT
## Footnote
**diagnosis of stroke in this situation is clinical**
29
What is the only antiplatelet that is effective for the **early** treatment of acute ischemic stroke? When should it be given?
* Aspirin
* if brain CT shows **no bleed**, full dose ASA should be given **within 48 hours**
30
which antiplatelet medications are acceptable for secondary stroke prevention
* aspirin
* clopidogrel (plavix)
31
desired blood pressure in patients with ischemic stroke who are recieving tPA
* BP \<**185/110**
32
tPA can be used for acute ischemic stroke in what time period
* \< 3-4.5 hours
* CT scan of brain must be normal
33
Therapy for hemorrhagic CVA
* anticoagulant (warfarin) and antiplatelet (Asa) drugs discontinued immediately
* anticoagulant effects reveresed immediately
* FFP, vit K and prothrombic complex concentrates (PCC)
* lower ICP
34
what are some methods to lower ICP in hemorrhagic CVA
* elevated head on bed to 30 deg
* analgesia, sedation
* osmotic diuretics: mannitol
* neuromuscular blockade
* hyperventilation (short term)
35
any brain hemorrhage warrants immediate consult with
neurosurgery
36
secondary prevention of ischemic CVA
* antiplatelets
* warfarin in AFIB or prosthetic heart valve
37
define transient ischemic attack (TIA)
* transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia **without acute infarction**
38
why are TIAs concerning
* relatively brief ischemia can cause permanent brain injury
* stroke risk in first two days after TIA is 4-10%
39
TIA-stroke prevention includes what
* daily asa therapy
* EKG: r/o afib
* carotid US
* lipid lowering med
* antihypertensive med
* diet/lifestyle modification
40
if patient who is on daily ASA still suffers a TIA, then what might possibly be added to treatment regimen
* clopidogrel (plavix)
41
stepwise approach to patient with high risk headache
1. noncontrast brain CT
2. lumbar puncture
* look for RBCs -\> SAH
42
clinical presentation
* "worst headache of my life"
* "thunderclap" HA
* subarachnoid hemorrhage
43
most subarachnoid hemorrhage are caused by
* **ruptured saccular aneurysms**
* trauma
44
number 1 risk factor for subarachnoid hemorrhage
smoking
45
what is the leading cause of death and disability after an aneurysm rupture
* vasospasm
* aneurysm bleeds a little and surrounding vessels that supply that vessel clamp down to decrease amount of blood sent there -\> ischemia
46
champagne tap
defined as zero RBCs in the first and last tubes
47
how can you differentiate between SAH and a traumatic tap
* traumatic tap
* RBC #s decrease from 1st tube - 4th tube
* SAH:
* RBC #s stay the same
* **xanthochromia** (pink or yellow tint): most sensitive indicator
48
what medication is used to prevent vasospasm after SAH
* nimodipine
49
management of SAH
* ICU
* nimodipine: prevent vasospasm
* stop blood thinners
* sz prophylaxis
* surgery: clipping or coiling
