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Block 3: Neuro > Clin Med: Stroke > Flashcards

Clin Med: Stroke Flashcards

1
Q

Stroke aka?

A

cerebrovascular accident

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2
Q

What is a stroke?

A

an acute neurologic deficit due to damage to the brain tissue from a vascular cause

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3
Q

Stroke is one of the leading causes of___ in the US & worldwide.

A

debility & mortality

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4
Q

What do transient ischemic attacks involve?

A

acute neurologic deficits that resolve w/o evidence of brain tissue damage.

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5
Q

What often precedes an CVA?

A

a TIA

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6
Q

What does primary and secondary prevention of stroke invovle?

A

modifying RFs

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7
Q

Global stroke facts:
__leading cause of death
__% lifetime risk after age __

A
  • 2nd
  • 25%, 25
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8
Q

US Stroke facts
__leading cause of death
Higher incidence among___
Gender prevalence

A
  • 5th
  • blacks/hispanics/asians
  • men > women at younger but not older
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9
Q

States in the “stroke belt”

A

TX, LA, AR, MS, AL, GA, NC, TN, MO, KY, WV, SC

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10
Q

SC Stroke death per 100,000
Laurens
Gwd
Gville
Spartanburg

A

Laurens = 92
Gwd = 86
Gville = 76
Spartanburg = 91

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11
Q

Two types of stroke?

A

Ischemic & Hemorrhagic

Ischemic (85-9-%) > Hemorrhagic (10-15%)

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12
Q

What is an ischemic stroke?

A

Damage to brain tissue occurs b/c of reduced blood flow to brain tissue

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13
Q

Causes of an ischemic stroke

A
  • clot
  • plaque rupture
  • embolus
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14
Q

What is a hemorrhagic stroke?

A

Intracranial hemorrhage causes damage to brain tissue due to toxic effects of blood or mass effect due to incr pressure

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15
Q

Causes of a hemorrhagic stroke

A
  • trauma
  • aneurysm
  • AVMs (arteriovenous malformations)
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16
Q

How are TIAs different from ischemic strokes?

A

the occluded vessel reopens prior to infarction

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17
Q

TIA symptoms last…

A

< 1hr up to 24hrs

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18
Q

What is the risk of stroke after a TIA?

A

10-15% usually w/n 2 days & up to 3 months

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19
Q

What is a workup for TIAs

A

Eval & workup should be similar to ischemic stroke w/ emphasis on prevention of stroke

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20
Q

Parts of the cerebrum?

A
  • Frontal lobe
  • Parietal lobe
  • Temporal lobe
  • Occipital lobe
  • Insula lobe
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21
Q

Functions of the cerebellum

A
  • Motor coordination
  • Proprioception
  • Eye movement control
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22
Q

Spinocerebellum Function

A

coordination of motor signals out to muscles

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23
Q

Spinocerebellum: medial portion Function

A

= vermis; control of axial muscles

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24
Q

Spinocerebellum: lateral sides Function

A

(adjacent to vermis)

control of arm and leg muscles

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25
Q

Cerebrocerebellum function

A

interact w/ motor cortex of cerebrum to plan muscle movements

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26
Q

Vestibulocerebellum (flocculonodular lobe) function

A
  • balance & eye movements; - receives signals from vestibulocochlear nerve & sends signals to muscles involved w/ posture
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27
Q

NOTE

A

Cerebellum receives signals from the CONTRALATERAL cerebrum & sends signals to IPSILATERAL body

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28
Q

Parts of the basal ganglia

A
  • Thalamus
  • Globus pallidus
  • Putamen
  • Caudate nucleus
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78
Q

What are the 3 causes of an ischemia stroke/TIA?

A
  1. Thrombosis
  2. Embolus
  3. Systemic hypoperfusion (watershed)
79
Q

What is the thrombosis?

A

Clot formation in a vessel leads to stenosis or occlusion

80
Q

Clot formation is promoted by:

A
  • Athersclerosis*
  • Lipohyalinosis*

Less common causes:
- Infx (COVID!)
- Vasculitis
- Dissection
- Vasoconstriction
- Coagulation disorders
- Inflammatory disorders

81
Q

What is Lipohyalinosis?

A

thickening & narrowing of smaller BVs of the brain, likely due to HTN and/or inflammation

82
Q

Thrombosis: large vessel thrombus

A
  • usually due to stenosis from atherosclerosis

–> Usually affect the cerebrum

83
Q

Thrombosis: small vessel thrombus

A
  • usually due to narrowing from lipohyalinosis

–> Usually affect deep internal structures (basal ganglia, internal capsule, thalamus)
–> “lacunar” strokes

84
Q

What is an embolus?

A

Material from another site travels & occludes a vessel

85
Q

Causes of an embolus

A
  • Thrombus/ plaque debris (most common)
    –> Cardiogenic
    –> Arterial (usually aortic or carotid)
    –> Cryptogenic (unknown)
  • Infx (endocarditis)
  • Cholesterol, fat (bone fracture)
  • Air or other gas
86
Q

Cardiogenic factors that cause embolus

A
  • Afib
  • Mechanical heart valves
  • Patent foramen ovale
  • Rheumatic aortic valves
  • Systolic CHF w/ EF< 30%
  • Dilated cardiomyopathy
  • CABG surgery
  • Left atrial myxoma
  • Endocarditis
87
Q

What is systemic hypoperfusion (watershed)?

A

Areas b/t arterial systems are vulnerable to poor perfusion if BP drops too low

88
Q

Causes of systemic hypoperfusion

A
  • Low cardiac EF / MI
  • Dehydration
  • Sepsis
  • Hemorrhage
  • Surgery
89
Q

Describe TOAST classification

A
  • Large vessel atherosclerosis (30%)
  • Cardioembolic (20%)
  • Small vessel occlusion (15%)
  • Stroke of other determined etiology (10%)
  • Stroke of unknown etiology (25%)
    –> 2 or more possible causes
    –> No workup or Incomplete workup
    –> Complete workup w/o definitive cause (Cryptogenic)
90
Q

Ischemic Stroke/TIA thrombosis symptoms description

A

fluctuating course, often more gradual

91
Q

Ischemic Stroke/TIA embolus symptoms description

A

sudden onset, severity of symptoms steady

92
Q

Symptoms of an ischemic stroke/TIA

A
  • Behavioral changes
  • Confusion
  • Coma
  • Cranial nerve deficits
  • Gaze preference
  • Language issues
  • Loss of coordination
  • Nausea/vomiting
  • Neglect
  • Numbness/tingling
  • Visual field loss
  • Vertigo
  • Weakness
93
Q

Ischemic Stroke/TIA watershed symptoms description

A

fluctuating course

94
Q

Steps when a pt comes in w/ a stroke.

A
  • Early recognition & tx is key!
  • “Code Stroke”
  • 1st step: airway, breathing, circulation
  • Next step: stroke or not stroke
95
Q

Ischemic Stroke/TIA DDx

A
  • Metabolic issue (hypoglycemia)
  • Hypertensive encephalopathy
  • Migraine
  • Seizure
  • Venous sinus thrombus
  • Conversion disorder
  • Encephalitis
  • Tumor
  • Abscess
  • Multiple sclerosis
96
Q

Ischemic Stroke/TIA History

A
  • Specific symptoms
  • Course of symptoms
  • Time of onset (last known normal)
  • Activity at onset
  • Assoc. symptoms
  • Hx of prior CVA/TIA
  • Hx of prior CAD/PVD
  • Hx of heart dz
  • RFs
  • Meds
97
Q

Ischemic Stroke/TIA PE

A
  • General assessment (ABCs)
  • Vital signs
  • Cardiovascular
    –> Neck bruits
    –> Murmurs
    –> Irregular HR
    –> Pulses
    –> Edema
  • Lungs
    –> Fluid overload
  • Skin
    –> Evidence of endocarditis or vasculitis
  • Neurologic – thorough!
98
Q

What is often elevated with in CVA?

99
Q

When do ischemic & hemorrhagic strokes tend to occur?

A
  • ischemic stroke–> while sleeping when blood flow is slower
  • hemorrhagic–> tend to occur when awake
100
Q

Various location a stroke can occur

A
  • Anterior cerebral artery
  • Medial cerebral artery - main
  • Medial cerebral artery - Lenticulostriate arteries
  • Internal carotid
  • Posterior cerebral artery
  • Vertebrobasilar
101
Q

Describe presentation of symptoms w/ an anterior cerebral artery stroke?

A
  • Contralateral motor &/or sensory deficits
    –> Leg > arm/face
  • behavioral changes
102
Q

Describe presentation of symptoms with a medial cerebral artery - main stroke?

A
  • Contralateral Arm/ lower face motor &/or sensory deficits
  • homonymous hemianopsia
  • Ipsilateral eye deviation
  • Dominant hemisphere: language deficits
    –> Broca’s vs Weirnicke’s
  • Nondominant hemisphere: contralateral neglect & confusion
103
Q

What nerve controls muscles in the upper & lower face?

A

facial nerve

104
Q

Where does the facial nerve receive it’s input?

A

contralateral and ipsilateral input so forehead movement is preserved bilaterally in a cerebral infarct

105
Q

Describe presentation of symptoms with a medial cerebral artery - lenticulostriate arteries stroke?

A
  • Pure motor – contralateral face/arm/leg (all 3 - hemiparesis)
  • Pure sensory
  • Mixed sensory/motor
  • Ataxia + pure motor
  • Clumsy hand
106
Q

Describe presentation of symptoms w/ an internal carotid stroke?

A
  • Both MCA & ACA symptoms
  • Amaurosis fugax (Ophthalmic a.)
107
Q

Describe presentation of symptoms w/ a posterior cerebral artery stroke?

A
  • Vision issues
  • Homonymous hemianopsia w/ preserved macular vision
  • Memory issues
  • Sensory loss -contralateral face/arm/leg
108
Q

Describe presentation of symptoms w/ a vertebrobasilar stroke?

A
  • Cranial nerve palsies
  • Crossed sensory deficits (ipsilateral forehead & contralateral arm/leg
  • Dysphagia
  • Vertigo, n/v
  • Hiccups
  • Limb ataxia
  • Coma
  • Locked-in syndrome
109
Q

The pons controls which cranial nerves?

A

CN V, VI, VII, VIII

110
Q

The medulla controls which cranial nerves?

A

CN IX, X, XII, XII

111
Q

Describe Horner’s syndrome

A
  • ipsilateral miosis
  • ptosis
  • anhidrosis
112
Q

Describe Wallenburg stroke

A

vertigo, nausea/vomiting, hiccups

113
Q

What is the name of the stroke scale used?

A

NIH Stroke Scale (NIHSS)

114
Q

Describe interpretation of the NIH stroke scale (NIHSS)

A
  • 11 standardized tests, in order
  • Higher score = worse deficits
  • Good reproducibility when done correctly by trained admin
  • Administered on arrival, w/ any acute neurologic change, after tx, on discharge
115
Q

Ischemic Stroke/TIA Initial workup: ER

A
  • NIHSS / exam
  • Labs:
    –> blood glucose, CBC, BMP, PT/INR, PTT, troponin
    –> If female – pregnancy test
    –> Consider - toxicology screen, alcohol level, infectious workup

Imaging:
- EKG
- CT head, non-contrast STAT (Goal: door-to-imaging time < 25 min)
–> Evaluates for causes besides ischemia & helps rule out hemorrhage
—-> Hemorrhage, mass, abscess
–> Most common finding = nothing abnormal

116
Q

If initial workup suggest probable ischemic stroke, what’s the next step?

A

Is patient a candidate for reperfusion therapies?
–> Thrombolysis or Thrombectomy

117
Q

What is the goal of reperfusion therapies?

A

restore blood flow

118
Q

If pt is a potential candidate for reperfusion therapy, next step?

A

obtain additional imaging studies

119
Q

If pt is NOT a potential candidate for reperfusion therapy, next step?

A

proceed w/ further evaluation for cause & acute management

120
Q

Additional studies needed once patient is a candidate for reperfusion therapy

A

CTA or MRA
- Visualize if thrombus amenable to thrombectomy

CT perfusion or MRI perfusion study
- Assesses extent of infarct versus surrounding penumbra – helps w/ risks/benefit analysis

128
Q

What are the secondary prevention methods in ischemic strokes?

A

Statins
- Goal - LDL < 70
- High dose statin if tolerated
Blood glucose control
- A1C <7.0
BP control
- Goal - < 120/70 mmHg

  • Lifestyle modifications – smoking, drinking, diet, exercise
  • Anti-thrombotic meds
129
Q

ABCD

A
  • > /= 60yo (1 point)
  • uncontrolled BP (>/= 140 or >/=90)
  • clinical
130
Q

Most patients will get which type of Antithrombotic meds?

A

antiplatelet tx

131
Q

What causes of stroke call for antiplatelet tx for stroke?

A

large or small vessel occlusion, unknown etiology; TIA

132
Q

Antiplatelet

137
Q

Prevention Strategies for ischemic stroke/TIA & give options

A

Tx of carotid artery stenosis
- carotid enterectomy
- carotid artery stenting

138
Q

Describe when a carotid endarterectomy should be done.

A
  • If stenosis 70-99% & likely cause of embolic stroke
  • No tx if 100% occlusion
  • Risk of embolism & stroke from plaque during removal
139
Q

How is carotid artery stenting done?

A

percutaneous stent placed

140
Q

Stroke/TIA in children presentation

A

seizures more common than in adults

141
Q

Causes of stroke/TIA in children

A
  • Genetic disorders – Sickle cell dz, hypercoagulable disorders
  • Trauma w/ arterial dissection
  • Congenital heart dz
142
Q

Workup & tx for stoke/TIA in children

A

similar to adults

143
Q

Prognosis of an ischemic stroke/TIA?

A
  • Recovery of function greatest during 1st 3 months & usually close to max recovery at 6mos
  • Depressive symptoms that can limit recovery
  • Higher NIHSS scores at discharge assoc. w/ worse outcomes
  • Higher risk of death compared to general population
    –> Hemorrhagic stroke higher risk than ischemic stroke

Block 3: Neuro (10 decks)

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