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Neuro > Cerebrovascular Disease - Exam 4 > Flashcards

Cerebrovascular Disease - Exam 4 Flashcards

1
Q

What are the 3 main arteries of the brain? Which one is each?

A

anterior cerebral: black

medial cerebral artery: red

posterior cerebral artery: blue

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2
Q

What are the 2 different types of strokes? What is the prevalence of each?

A

Ischemic stroke: 80% : clot that leads to lack of oxygen

hemorrhagic stroke: 20%

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3
Q

______ is the area of complete loss of flow = death of brain tissue within _____

A

Ischemic core

4–10 min

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4
Q

_____ is the surrounding tissue after an ishemic stroke which has only a reduction in flow and can remain viable for ____ after onset of stroke

A

penumbra

hours

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5
Q

What are the 2 different etiologies of an ischemic stroke? What are each related to?

A

thrombotic: ruptured atherosclerotic plaques leading to platelet activation

embolic: embolus originating from EXTRAcranial source and associated with ATRIAL FIBRILLATION

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6
Q

_____ is the MC place an artherosclerotic plaque ruptures from and causes a stroke

A

biforcation of the carotid artery

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7
Q

a spontaneous rupture of a cerebral artery leads to what 2 things?

A

cerebral ischemia resulting from loss of microvascular perfusion due to acute vasoconstriction and microvascular platelet aggregation

increased intracranial pressure

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8
Q

A hemorrhagic stroke can be due to _______ and _______ hemorrhages

A

intracerebral and subarachnoid hemorrhages

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9
Q

Intracerebral hemorrhage is MC caused by ________. What 3 things cause subarachnoid hemorrhage?

A

prolonged uncontrolled HTN

aneurysm, AV malformation, trauma

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10
Q

What are the 6 risk factors for a hemorrhagic stroke?

A

Advanced age
Hypertension (up to 60% of cases)
Anticoagulant use
Previous history of stroke
Alcohol abuse
Use of illicit drugs (eg, cocaine, other sympathomimetic drugs)

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11
Q

What is the BE FAST acronym stand for?

A
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12
Q

What is the difference between a stroke presentation and Bell’s Palsy?

A

Bells palsy: the entire 1/2 side of the face will be paralyzed (including the forehead)

stroke: more pronounced facial deficits from the eyes down. so the forehead is normal bilaterally

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13
Q

What are some additional s/s that are seen with HEMORRHAGIC strokes?

A

HA
N/V
seizures
syncope
AMS: LOC is more depressed in hemorrhage stroke presentation when compared to ischemic presentation

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14
Q

**What is the most important piece of history to obtain when considered about a stroke? What is that key piece of information is not available?

A

When did it start? need an EXACT time

When was the last known normal?

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15
Q

_____ strokes often deteriorate more rapidly

A

hemorrhagic strokes

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16
Q

What and where are Janeway lesions?

A

irregular, erythematous, nontender macules on the palms or soles

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17
Q

What and where are Osler’s nodes?

A
  • tender, erythematous nodules located on the hands and feet
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18
Q

What are some fundoscopy findings associated with stroke?

A

papilledema (ICP)

retinopathy, retinal emboli, retinal hemorrhage (signs of predisposing conditions)

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19
Q

If you find a tongue laceration on a suspected stroke pt, what are you thinking?

A

they had a recent seizure from the stroke

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20
Q

During the cardio PE you find a carotid bruit, what does that make you think?

A

thrombotic etiology

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21
Q

What 7 categories does the National Institutes of Health Stroke Scale (NIHSS) take into effect before calculating a score?

A

mental status/LOC
vision
motor function
cerebellar function
sensory function
language
neglect

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22
Q

**What is the NIHSS scale of stroke severity?

A
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23
Q

An NIHSS score of greater than ____ correlates with an 80% likelihood of ______

A

10

proximal vessel occlusion

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24
Q

T/F: History and physical can differentiate ischemic from hemorrhagic stroke

A

FALSE!! H&P alone CANNOT differentiate ischemic from hemorrhagic so need imaging!!

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25
Q

What is included in the urgent work-up of a pt presenting with a stroke?

A

fingerstick glucose

brain CT w/o contrast if the patient presents within 6 hours

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26
Q

What is the goal timeframe for a pt to get a CT if a stroke is suspected? If hemorrhage is present, what will it look like on CT? What will an ischemic stroke look like on CT?

A

within 25 minutes of arrival

hemorrhage: acute bleeding appears hyperdense

ishemic: will have NORMAL CT

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26
Q

What will a subarachnoid hemorrhage look like on CT?

A

Will look like a starfish

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27
Q

Under what stroke scenario do you need to avoid ABGs?

A

avoid if considering fibrinolytic therapy

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28
Q

In strokes, what do you need to keep the O2 stat above? Is the pt allowed to eat?

A

supplemental O2 to keep O2 saturation above 94%

NO! NPO with IV fluids

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29
Q

When is a stroke pt allowed to eat?

A

after speech pathology clears them after assessing ability to swallow

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30
Q

When would you want to put the pt in Low Fowler’s position?

A

any s/s of increased ICP

aspiration

cardiopulmonary decompensation/O2 desaturation (chronic CV or Pulm disease)

no more than 30 degrees

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31
Q

in stroke patients ______associated with increased morbidity and mortality

A

Temp >100.4

if hot, cool them off, acetaminophen rectally or IV

if cold, warm them up via warm blankets, bair hugger and warm IV fluids

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32
Q

What is the goal BS in stroke pts?

A

60-180

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33
Q

If a pt is having an hemorrhagic stroke and on a blood thinner, what do you do?

A

give the reversal agent!!

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34
Q

What is the reversal agent for warfarin?

A

4-factor prothrombin complex concentrate (PCC)¹ PLUS vitamin K

35
Q

What is the reversal agent for dabigatran?

A

activated charcoal (only if the pt had just taken the medication within the last 2 hours)

idarucizumab (Praxbind)

PCC (last resort option)

36
Q

What is the reversal agents for rivaroxaban (Xarelto), apixaban (Eliquis), fondaparinux (Arixtra), edoxaban (Savaysa)?

A

activated charcoal (only if the pt had just taken the medication within the last 2 hours)

andexanet alfa (Andexxa)

PCC

37
Q

What is the reversal agent for heparin/LMWH?

A

protamine

38
Q

**What is the goal BP range in order to be eligible for tPA? **If not in range, what do you need to give? What do you need to do if the BP is too low?

A

rt-PA Eligible: BP goal of SBP ≤ 185 and DBP ≤ 110 before rt-PA can be administered (class 1)

IV nicardipine, clevidipine, labetalol

IV fluids to maintain organ perfusion

39
Q

Ischemic stroke **If a pt is NOT eligible for tPA, there blood pressure needs to be ?????? before you should treat it.

A

Do not treat unless SBP >220 or DBP >120

40
Q

Ischemic stroke **if a pt is NOT eligible for tPA, BP should NOT be lowered more than ____ in the _____. Why? What should you give them?

A

15%

first 24 hours

due to risk of hyoperfusion if you drop the BP toooo low toooo fast

IV nicardipine, clevidipine, labetalol

41
Q

**Intracerebral Hemorrhage and a SBP 150-220 mmHg, what do you do?

A

careful titration of therapy to allow for smooth reduction of SBP to a goal of 130-140 mmHg (Class 2a)

42
Q

**Intracerebral Hemorrhage and a SBP >220 mmHg, what do you do?

A

textbook answer: there is currently not enough evidence to provide specific recommendations
“It is common practice to take a similar BP-lowering approach”.

give same first line IV antihypertensives

43
Q

What is the risk vs benefit argument with regards to elevated BP in intracerebral hemorrhage?

A

risk - loss of cerebral perfusion pressure leading to higher level of infarction

benefit - decreased risk of rebleed

44
Q

What was the “reasonable” recommendation for target BP in SAH? What are the preferred medications?

A

a SBP < 160 or MAP < 110

nicardipine, clevidipine, labetalol, or enalapril

45
Q

What is the goal of BP treatment in SAH? What is the goal of choice?

A

to prevent vasospasms in SAH and prevent delayed cerebral ischemia

nimodipine PO or via NG tube for 3 weeks

46
Q

before intiating tPA _____ is the only lab value that must be assessed prior to initiation of therapy. _____ must also be obtained

A

glucose

informed consent

47
Q

What is the major risk for tPA?

A

**risk of hemorrhage, angioedema

48
Q

**What are the 3 tPA inclusion criteria?

A

Clinical diagnosis of ischemic stroke causing measurable neurologic deficit

Onset of symptoms within 4.5 hours before beginning of treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal

Age ≥18 years

49
Q

** is the special circumstance tPA inclusion criteria?

A

if their is an unclear time of onset with an DWI-FLAIR mismatch

50
Q

What are the 4 relative exclusion criteria that shorten the window to less than 3 hours?

A

older than 80

oral anticoag use regardless of INR

NIHSS score of greater than 25 (severe stroke)

Combination of both previous ischemic stroke and diabetes mellitus

51
Q

If tPA is appropriate for a pt, what are the general principles for admistinstration? What does the BP need to be kept under?

A

infuse tPA over 60 minutes

send to stroke ICU

neuro checks q15m for 3 hours, then q30m for 6 hours, then qhr x 15 hours

Keep BP < 180/105 mmHg

avoid microtrauma (no NG tubes, catheters or arterial caths)

obtain CT at 24 hours post-tPA

52
Q

What are the tTPA complications?

A

acute bleeding and angioedema

53
Q

What is the tx for an acute bleed due to tPA? What is the tx for angioedema due to tPA?

A

cryoprecipitate or tranexamic acid (TXA)

IV methylprednisolone, diphenhydramine and famotidine or intubate if edema is rapidly progressing

54
Q

When is Endovascular mechanical thrombectomy an option during a stroke?

A

Alternative if rt-PA is CI or ineffective in a patient with a persistent potentially disabling neuro deficit (NIHSS ≥6)

and.

large artery occlusion in the anterior circulation (dx by CTA or MRA) with small infarct core and no hemorrhage (dx by MRI)

55
Q

When must an endovascular mechanical thrombectomy be performed?

A

Treatment must occur within 24 hours of symptom onset and performed at a stroke center with surgeons experienced in procedure plus a bunch of additional eligibilty requirements

56
Q

What are the neurologic complications that are common with strokes?

A

hematoma
large intracranial hemorrhage
cerebral edema
increased ICP
hydrocephalus
seizures

57
Q

When is hematoma evacuation recommended?

A

Evacuation via minimally invasive surgical procedures is recommended moderate to large ICHs (Class 2a) and large intraventricular extension of ICH’s. (class 1)

58
Q

What is the difference between craniotomy and craniectomy? When are they used?

A

large intracranial hemorrhage as a result of a stroke

59
Q

When does cerebral edema peak? What pt population is it worse in?

A

Peaks on day 2 or 3 - can be present for up to 10 days post stroke

worse in patients with larger infarcts

60
Q

What is the tx for cerebral edema?

A

fluid restriction and IV mannitol - watch for hypotension leading to worse infarct

decompressive craniectomy (reduces mortality by 50%) in younger patient (< 60 y/o)

61
Q

What is the tx for increased ICP due to strokes? What type of stroke are the associated with?

A

elevate head of bed 30°
mild sedation to maintain comfort as needed
osmotic therapy (i.e. mannitol, hypertonic saline) may be considered

more often with hemorrhagic strokes

62
Q

hydrocephalus may occur with _____. What do you need to watch for? What will imaging show? What do you need to do next?

A

SAH

watch for worsening HA and progressively impaired neurological testing

CT/MRI will show enlarged ventricles

consult neurosx and consider shunt placement

63
Q

seizures are seen more commonly with _____ strokes. What do you need to monitor?

A

seizures are seen more commonly with hemorrhagic strokes

64
Q

When do you want to give primary prophylaxis for seizures in a stroke pt?

A

Impaired consciousness and evidence of seizure activity on EEG

Hx of clinical seizures

65
Q

What is the AED of choice for stroke pts? ____ is preferred for active seizure control

A

fosphenytoin is preferred for seizure prevention

IV lorazepam is preferred for active seizures

66
Q

What is considered primary stroke prevention?

A

Screen for and control all modifiable risk factors

67
Q

What is considered secondary stroke prevention?

A

strict BP control!! initiate/restart BP meds for anyone withvBP > or = 140/90
goal: ICH - goal <130/80

statin therapy in ischemic strokes

smoking cessation

DM control

Weight loss/exercise

low fat/low salt diet

avoid heavy alcohol intake

68
Q

Statin therapy is recommended in _____ strokes

A

ischemic strokes

69
Q

What are the additional prevention recommendations for pt with ischemic strokes? What are the starting timeframes depending on if they used tPA or not?

A

antiplatelet therapy for 21 days

(+) tPA - start ASA 24-48 hours after tPA
(-) tPA - start ASA and Plavix within 24 hours

70
Q

When is anticoag therapy indicated in ischemic strokes?

A

Indicated in patients with a potential cardiac source of embolism

MC is atrial fibrillation

71
Q

What is a TIA? When do symptoms resolve?

A

a transient episode of neurologic dysfunction caused by cerebral acute ischemia WITHOUT death of brain cells

most often symptoms resolve within 1-2 hours

72
Q

When assessing someone with a possible TIA, what are you looking for?

A
73
Q

When would you consider tPA in a pt with TIA?

A

if there is a persistent neurologic deficit that is potentially disabling

work-up and tx them the same as if the pt were having a full on stroke

74
Q

What are the high risk features of a TIA?

A
75
Q

What is the medical management for TIA?

A

antiplatelet
antihypertensive
statin therapy
address all modifiable risk factors

76
Q

What is carotid artery stenosis often caused by? Where? What are some s/s? What will the PE reveal?

A

Carotid atherosclerosis is often most severe within 2 cm of the bifurcation of the common carotid artery

Symptoms result from reduced blood flow and/or superimposed thrombus formation

PE: carotid bruit or palpable sclerosis

77
Q

What are the 4 imaging options for carotid artery stenosis?

A

Carotid duplex ultrasound (CDUS)

MRA

CTA

Carotid angiography

78
Q

Which imaging option for CAS (carotid artery stenosis) is the gold standard?

A

Carotid angiography

most accurate in determining severity and collateral blood supply

79
Q

Which CAS imaging?
Pro: least invasive, least expensive, readily accessible, less time consuming
Con: operator dependent; may ______ the degree of stenosis

A

Carotid duplex ultrasound (CDUS)

overestimate

80
Q

Which CAS imaging?
Pro: produces a 3D image, more accurate for detecting high grade stenosis; less operator-dependent
Con: more expensive, more time consuming, tight enclosure in supine position, CI in pacemaker, ferromagnetic implant

A

MRA

81
Q

Which CAS imaging?
Pro: produces a 3D image, more sensitive and specific than US and more specific than MRA
Con: radiation exposure, requires contrast, CI in renal insufficiency

A

CTA

82
Q

What is the management of asymptomatic CAS? What is considered asymptomatic? When would you consider sx?

A

Includes: statins, antiplatelet agents, treatment of hypertension and diabetes, smoking cessation and healthy lifestyle changes

Asymptomatic disease (no hx of stroke or TIA symptoms)

Referral to vascular surgery for a carotid endarterectomy (CEA) is indicated if carotid stenosis is between 60 and 99%

83
Q

What is the tx for symptomatic CAD? What is considered symptomatic?

A

refer for carotid endarterectomy (CEA) and maximize medical management

carotid stenting - second-line alternative to CEA for select patients

Symptomatic disease (hx of TIA or ischemic stroke within previous 6 months)

84
Q
A

Neuro (13 decks)

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