Ch 26 Stroke Flashcards
Stroke or CVA
sudden onset of impairment in neurologic functioning due to severe decrease of blood supply to the brain
What a stroke caused by
Ischemia or hemorrhage
What does ischemia do
It provides an infarct in the brain related to occlusion- (thromboembolic)
Transient ischemic attack
Brief episodes of neurologic dysfunction resulting from focal cerebral ischemia
Lasts less than an hour but up to 24 hours
Warning sign of a future stroke
Chronic persistent symptoms of a stroke depend on what factors
Location and size of stroke age hand preference previous stroke time post stroke other med factors
Prenatal stroke
Occurs between 20 weeks gestation to first 28 days of life
Childhood strokes
strokes occurring 1 month - 18 years
Intraventricular hemorrhage is excluded from pediatric stroke
-
Subdural and epidural hemorrhages arising from trauma or excluded in pediatric strokes
-
Most common stroke types in adults
Thromboembolic ischemic stroke 88%
Thromboembolic ischemic stroke can originate from where
Site of occlusion (thrombus)
or at a distance from the occlusion (embolus)
Which part of the brain is typically most affected in thromboembolic ischemic stroke
The anterior circulation in 80%
- anterior cerebral arteries (ACA)
- middle cerebral arteries (MCA)
posterior circulation 20%
- Posterior cerebral artery (PCA)
Middle cerebral artery encompasses what percentage of the brain
50-60
What percentage of strokes are accounted for by hemorrhagic stroke
12%
- 9% intracerebral hemorrhage
- 3% SAH
Mortality rate of subarachnoid hemorrhage
50% in the first 6 mos after stroke
What is affected in the brain usually by intracerebral hemorrhage
They are localized deep in the area and affect small penetrating arteries
Slow leak
gradual symptom onset
Etiology for deep intracerebral hemorrhage
Hypertension
Two common reasons for stroke and younger adults
Aneurysm or AVM
Most common cause of subarachnoid hemorrhage
Aneurysm
Which kind of stroke is more common in children
Ischemic and hemorrhagic stroke or equally common in children
Two major forms of infarct in children
Arterial ischemic stroke (AIS)
- MORE COMMON!!!!
cerebral Sinovenous thrombosis (CSVT)
- more common in neonates than in older kids
The most common location of arterial ischemic stroke for children
MCA territory
subcortical infarction
Which type of stroke is less common in children
Ischemic stroke in posterior circulation < anterior circulation
How long does it take to produce neuronal damage in ischemia
6 to 8 minutes
How long would it take for microscopic changes to be seen after ischemia
Six hours
swelling happens after that
Does the zone of ischemic damage or infarct recover
No
Does the surrounding ischemic penumbra recover after a stroke
Yes, if blood flow is restored within six hours
What leads to better outcome for ischemic stroke
faster treatment
tPA in adults
Dissolves occlusive clot and increase blood flow to the surrounding ischemic penumbra
Needs to be used within 3 to 4 1/2 hours of symptom onset
TPA used in children
Controversial because of lack of strong evidence base
What can happen after a hemorrhagic stroke
Brain herniation and death can occur if intracranial pressure is not managed
Examples of secondary injury after ischemic stroke
vasospasm
Risk factors for stroke
Age - risk doubles every decade after 55 years Hypertension - 3 to 6 x Atrial fibrillation - untreated 3-5x, treated 1.5x Family history - 3 x Prior transient ischemic attacks cocaine use smoking sleep apnea serum lipid abnormality obesity diabetes
Risk factors for stroke in childhood
- Perinatal ischemic stroke
Maternal infertility preeclampsia prolonged rupture of membranes chorioamnionitis congenital heart disease Bacterial meningitis
Most common cause of perinatal CSVT
infection
Risk factors for stroke in childhood
- childhood ischemic stroke
Cardiac disease
sickle cell
infection
Risk factors for stroke in childhood
- hemorrhagic stroke
Trauma - most common cause of intracranial hemorrhage in children
AVM or brain tumors - can cause non-traumatic hemorrhagic stroke
Mortality due to stroke increase or decrease
decrease
stroke prevalence increase or decrease
increase
Strokes more common with what factors
age
females
Gender difference in stroke incidence
Females have higher stroke incidents than males only later in life
Racial difference in stroke incidence
Blacks higher than Whites
Gender difference in incidence of stroke in childhood
Boys more than girls
Mortality rate for a childhood stroke increase or decrease
increase
Mortality rate for ischemic stroke in childhood
10%
Mortality rate for hemorrhagic stroke and children
25-35%
What factor is associated with poor outcomes after childhood stroke
Post stroke epilepsy
recurrence rate for childhood stroke
10-25%
lower for perinatal strokes
What are the determinants of severity in stroke
Age of patient, size and location of infarct or hemorrhage acute treatment (tpa, surgery) medical comorbidities previous stroke secondary medical events
Presentation of hemorrhage
Headache, nausea, vomiting
loss of consciousness, coma
Deficits associated with anterior circulation strokes
Hemiparesis, hemi anesthesia, aphasia, visual spatial deficits, visual field cuts if visual pathway is affected
Deficits associated with middle cerebral artery MCA
Hemiparesis in superior branch of MCA
visual field cuts in inferior branch of MCA and PCA
Left MCA superior infarct deficits
Brocas aphasia
right face and arm weakness
working memory and executive functions
Left MCA inferior infarct deficits
Wernickes aphasia, right visual field deficit, right face and arm sensory loss, limb apraxia, parts of Gertsmann syndrome
Left MCA deep infarct deficits
Right pure motor hemiparesis
large infarcts could produce aphasia
Left MCA stem infarct deficits
Same as left MCA deep territory with R hemiplegia, R hemianesthesia, R hemonymous hemianopia global aphasia Left gaze preference
Right MCA superior branch infarct deficits
Left face and arm weakness
impaired working memory and executive function
some left hemi neglect
Right MCA inferior branch infarct deficits
PROFOUND L hemineglect L visual field and somatosensory deficits L motor neglect anosognosia Vs
Right MCA territory infarct deficits
Left pure motor hemiparesis
large infarcts produce L hemineglect and VS deficits
Right MCA stem infarct deficits
Same as right MCA territory infarct L hemiplegia L hemianesthesia L homonymous hemianopsia profound L hemineglect VS deficits anosognosia right gaze preference
Left ACA infarct deficits
R leg weakness R leg sensory loss grasp reflex executive function deficits transcortical motor aphasia
Right ACA infarct deficits
L leg weakness L leg sensory loss grasp reflex executive function deficits may have left hemiplegia
Left PCA infarct deficits
Right homonymous hemianopsia
Rights PCA infarct deficit
Left homonymous hemianopsia
Most common presentation of AIS in childhood
Seizures #1
Hemiparesis
altered mental status
Focal neurological signs
Posterior strokes presentation
Ataxia
vomiting
vertigo
Hemorrhagic stroke presentation in infants and young children
Non-specific features,
altered mental status,
convulsions,
less common focal neurological signs
Outcome after subarachnoid hemorrhage
85% of adults need supervision
33% continue to have cognitive impairment and impaired ADL after six months
CT is most sensitive to what kind of stroke
Acute intracerebral hemorrhage
CT is not as sensitive to ischemic damage especially in the first 24 hours
Normal CT is a good indicator of whether the stroke produced damage. True or false
F
while MRI can be normal for a few hours after stroke, what can detect infarct within minutes of symptom onset
DW MRI!
What kind of imaging is more sensitive for ischemic stroke
MRI is more sensitive than CT
What type of imaging is sensitive to lacuna infarcts
MRI
Other test to identify etiology of ischemic or hemorrhagic stroke?
cerebral angiography
MRA
CT anteriography
- both can identify aneurysm and AVM in the case of hemorrhage or vessel narrowing in the neck or head for ischemic stroke
How is Doppler ultrasound useful for stroke assessment
-identify carotid artery narrowing in the neck
How is electrocardiograms useful for stroke assessment
evidence of cardiac ischemia
arrhythmias
first thing to assess after stroke in an evaluation
Language
rate of depression in adults after stroke
20-30%
A common mechanism of occlusion due to embolism or thrombosis?
artherosclerosis 动脉硬化
artherosclerosis动脉硬化
a disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls.
Treatment of AVM
surgical endovascular embolization (threading a catheter to the malformation's feeder artery to block blood flow with glue)
treatment of hemorrhage
discontinue anticoagulants
anti hypertensive meds
intraventricular catheter
endovascular coil insertion
treatment of strokes in children
similar to adults
antithrombotic drugs in ischemic stroke
not enough research on tPA
primary goal of LT management of childhood stroke
prevent recurrence
how to prevent secondary stroke
antithrombotic drugs
aspirin
chronic blood transfusion
treatment of cerebral arteriopathy
anti inflammatory and immunosuppresive meds
bone marrow transplant
when does the greatest degree recovery occur
soon after stroke
1-3 mons post > 4- 6 mos post
most recovery would happen by 1 year
independent risk factor for morbidity and mortality of stroke?
depression
Common complication of childhood stroke
Motor weakness, spasticity, dystonia
Do children with acute aphasia improve over time
yes
Patient fully recover after a stroke?
No. 70% of stroke survivors report persistent diffuse or non-use of their upper limb up to four years after stroke
Which type of aphasia is associated with higher incidence of frustration and depression after stroke?
higher incidence of depression and frustration in Broca’s aphasia (possibly because but higher incidence of depression of the left frontal damage)
which age group has the poorest outcome after stroke?
after perinatal stroke
younger children are less likely to demonstrate…
classic aphasia symptoms or aphasia syndromes
focal lesions are NOT necessarily more benign for younger children
but it may result in less localizing and more diffuse pattern of impairment
endarterectomy
most well established intervention for carotid stenosis
lesion in area that is associated with worst cog outcome in childhood AIS (arterial ischemic stroke)
Left temporal and basal ganglia
CT is the least sensitive to
Acute ischemia
most common cause of childhood ischemic stroke?
cerebral arteriopathy #1
congenital heart disease also a common cause
cause of cerebral sinovenous thrombosis?
bacterial meningitis
