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Neurology 2 > Clin Med - Stroke > Flashcards

Clin Med - Stroke Flashcards

1
Q

Impact of stroke

A
  • stroke is the second leading cause of death worldwide
  • 5th leading cause of death in the U.S.
  • # 1 cause of adult disability
  • nearly 800,000 new stroke cases/year in U.S.
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2
Q

Oklahoma stroke rate

A

4th highest in US

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3
Q

Define stroke

- 2 types

A

a sudden brain dysfunction related to a blood vessel abnormality

  1. ischemic
  2. hemorrhagic
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4
Q

Define ischemic stroke

A

diminished blood flow to a FOCAL area of brain; primarily thromboembolic
-85% of strokes are ischemic

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5
Q

Define hemorrhagic stroke

A
  • rupture of intracranial vessel that is NOT due to trauma
  • intracerebral (10%): usually hypertensive
  • subarachnoid (5%): usually ruptured aneurysm
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6
Q

Define transient ischemic attack (TIA)

A
  • transient episode of neurological dysfunction caused by focal cerebral ischemia without infarction
  • time duration is no longer part of definition (but typically lasts 5 to 20 minutes)
  • increased risk of stroke
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7
Q

TOAST criteria

A

-large artery atherosclerosis (extra/intracranial)
-cardioembolism (afib, LV thrombus)
-small vessel occlusion (lacunar strokes)
-stroke of other determined etiology (i.e.
venous thrombus)
-stroke of undetermined etiology (after extensive workup) 20-30% have paroxysmal afib

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8
Q

What are the 2 kinds of hemorrhagic stroke?

A
  1. Intracerebral Hemorrhage (ICH)

2. Subarachnoid Hemorrhage (SAH)

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9
Q

Causes of intracerebral hemorrhage (ICH)

A
  • chronic Hypertension - #1 cause
  • amyloid angiopathy
  • ischemic stroke with hemorrhagic transformation
  • venous infarct with 2* hemorrhage (sagittal sinus)
  • coagulopathies
  • arteriovenous malformation (AVM)
  • illicit drug use (cocaine is MC, meth in Oklahoma)
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10
Q

ICH presentation

A
  • often HA, vomiting, altered level of consciousness, and a focal deficit.
  • sx vary depending on the area of the brain affected and the extent of the bleeding
  • may present as new onset of seizure
  • HTN is usually a prominent finding
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11
Q

Define patient presentation in subarachnoid hemorrhage (SAH)

A

The patient experiences a characteristic, intense, unrelenting headache of sudden onset often described as “the worst headache of my life!”
-may have transient loss of or altered consciousness

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12
Q

What is MCC of SAH?

A

Ruptured aneurysm is the most common cause of spontaneous SAH.

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13
Q

Targeted history in stroke recognition

-presentation

A

In general, tends to present with the sudden and immediate onset of symptoms, usually reaching maximal intensity at once

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14
Q

Targeted history in stroke recognition

-risk factors

A

DM, HTN, CAD, Hyperlipidemia, Afib, Smoking

-exact time of onset or if it was not a witnessed event, time they were last known to be normal

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15
Q

Stroke clinical pearl

-abrupt onset

A

Abrupt onset = strong predictor of stroke diagnosis

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16
Q

Cursory Neuro Exam

A
  • Mental Status
  • Language/Speech
  • Gross Motor Function
  • Visual fields/gaze
  • Sensation
  • Coordination
  • Are there any focal or lateralizing deficits?
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17
Q

Level of consciousness

-alert and oriented

A

Alert, attentive, following commands.

If asleep, awakens and remains attentive.

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18
Q

Level of consciousness

-lethargic

A

Drowsy but will awaken to stimulation.
Slow to
answer questions or inattentive.

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19
Q

Level of consciousness

-obtunded

A

Difficult to arouse, needs constant stimulation to follow commands.
Will fall back to sleep without stimulation

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20
Q

Level of consciousness

-stupor

A
  • patient needs vigorous and continuous stimulation
  • often requires painful stimuli
  • will NOT follow commands
  • may moan and withdrawal from pain
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21
Q

Level of consciousness

-coma

A

No response to painful stimuli, no verbal sound, reflexive movement only.

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22
Q

Which stroke involves loss of consciousness?

A

Loss of consciousness not normally seen with acute ischemic stroke - must have bilateral hemispheric or brainstem involvement

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23
Q

What 2 types of language/speech are you evaluating for?

A

Aphasia and dysarthria.

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24
Q

Define aphasia

A

“Can they repeat,
understand, name, and can they speak?”

A language problem, very localizing.

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25
Q

Define dysarthria

A

“Slurred speech”

It is an articulation problem, not localizing.

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26
Q

Gross motor function

-assess face and extremities

A

-ask pt to smile: easy way to detect unilateral facial weakness

  • have pt hold both arms straight out with palms up, If you observe pronation or a turning inward of the arm, that is a pronator drift
  • Ask them to raise their leg (if seated-raise knee)

-use noxious stimuli (i.e. pinch the arm) in the obtunded or unresponsive patient to look for asymmetrical grimace or withdrawal

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27
Q

Clinical pearl

-gross motor function

A

Pronator drift/asymmetrical weakness strong predictors of stroke diagnosis

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28
Q

Visual fields/gaze assessment

A
  • finger counting or by threat
  • can also check for visual neglect at the same time
  • are the eyes deviated?
  • is the gaze conjugate, do the eyes move together?
  • look for nystagmus – vertical or bidirectional = central cause
29
Q

Clinical pearl

-visual fields/gaze

A

Abnormal Visual Fields and Gaze Deviation

– strong predictors of stroke diagnosis

30
Q

Sensory function

-light touch

A
  • can they feel light touch equally on both sides of the body?
  • ask pt to close eyes and then touch both arms at the same time
  • ask patient where they felt it.
  • not only is this a brief sensory test, you are also testing for neglect
31
Q

Sensory function

-sharp/dull

A

can they distinguish between a sharp or dull object on both sides of the body?

32
Q

Coordination assessment

A

Test finger to nose (looking for dysmetria- ataxia) and heel to shin.

If cerebellar stroke is suspected (i.e. patient presents vertigo, you must test their ability to walk)

33
Q

Clinical pearl

-coordination

A

bidirectional nystagmus and sudden inability to walk are strong predictors of a cerebellar stroke

34
Q

Decreased LOC

-gaze

A

Gaze: eyes look towards the cerebral lesion // eyes look away from a brainstem lesion.

Check for dolls eyes, useful to assess brain stem.

Pupils - will see changes in metabolic/toxic conditions, will be symmetrical.

35
Q

Decreased LOC
-response to pain
+/- Babinski

A

Check response to pain - asymmetric grimace, withdraw of extremities

Check for presence of a Babinski- usually a late finding

36
Q 
The National Institute of Health
Stroke Scale (NIHSS)
A
  • Level of consciousness
  • Gaze
  • Visual fields
  • Facial strength
  • Arm strength
  • Leg strength
  • Limb ataxia
  • Sensation
  • Language
  • Dysarthria
  • Extinction/inattention

Maximum Score = 42

37
Q 
Clinical features (3)
-acute ischemic stroke
A
  1. Sudden onset of focal neurological symptoms: usually maximal at onset
  2. Signs should fit within defined vascular territory:
    - Hemisphere: cortex or subcortical
    - Brainstem and/or cerebellum
  3. Rarely associated with loss of consciousness
38
Q

5 major stroke syndromes

A
  1. left hemisphere
  2. right hemisphere
  3. ICH
  4. cerebellar
  5. brainstem
39
Q

Stroke Syndromes Simplified

-hemispheric

A

Contralateral deficits of face and body

Aphasia – Left
Neglect – Right

40
Q

Stroke Syndromes Simplified

-brainstem

A

Contralateral hemiplegia with ipsilateral cranial nerve deficits, diplopia, dysarthria

41
Q

Stroke Syndromes Simplified

-cerebellar

A

Balance (trouble walking) and unilateral coordination difficulties

42
Q

Stroke Syndromes Simplified

-hemorrhage

A

Headache, N/V, decreased LOC

ICH – Focal neuro deficits
SAH – neck stiffness/pain, light intolerance

43
Q

Stroke treatment

- 3 strategies

A
  1. IV tPA
  2. Endovascular therapy
  3. Medical management
44
Q

Stroke tx

- IV tPA

A

Gold standard in ischemic stroke care - give within 4.5 hrs

45
Q

Stroke tx

- endovascular therapy

A

Mechanical disruption or removal of clot using endovascular approaches

46
Q

Stroke tx

- medical management

A

Monitor and provide secondary stroke prevention

47
Q

What are of the brain are we trying to save in stroke?

A

The penumbra

48
Q

Define penumbra

A
  • zone of reversible ischemia around core of irreversible infarction
  • salvageable in first few hours after ischemic stroke onset if blood flow is restored
  • damaged by hypoperfusion, hyperglycemia (100-180), fever and seizures
49
Q

General emergency management

-ABC’s

A
  • intubation - ensure adequate ventilation and protect airway in comatose patients
  • monitor vital signs, cardiac rhythm, O2 sat% (keep > 94%)
  • IV fluids: normal saline
  • Improve perfusion
  • Cursory Neuro exam
  • Diagnostic studies
50
Q

Emergency Diagnostic Studies

A
  1. FSBS
  2. Blood chemistries
  3. Brain imaging – Noncontrast CT or MRI
  4. Electrocardiogram
  5. Complete blood count and platelet count*
  6. INR and aPTT*

*only wait for labs to come back if you suspect pt is bleeding or on warfarin - otherwise start tPA immediately

51
Q

CT’s role in stroke

A
  • necessary to differentiate ischemic versus hemorrhagic stroke (clinical exam alone cannot distinguish between the two)
  • necessary to rule out other possible cause of symptoms

*Always start with non-contrast scan!

52
Q

CT Advantages

A

-fastest mode of any imaging
-almost universally
available in all hospitals
-no absolute contraindications
-excellent display of bone
-very high sensitivity for
hemorrhage (100% for ICH and 90% for SAH)

53
Q

CT disadvantages

A
  • poor for evaluating the posterior fossa
  • poor sensitivity in the identifying early ischemic changes

NOTE: A normal CT does not rule out an ischemic stroke

54
Q

General Management of SAH

A
  1. Surgical clipping or endovascular coiling of the ruptured aneurysm to stabilize it.
  2. BP control – target BP changes after aneurysm is secured
  3. Maintain euvolemia - avoid hypervolemia
  4. Meds: Nimodipine – x 21 days
55
Q

MRI lesion descriptions

A
  • the MRI lesions are described in terms of their signal intensity:
    1. low signal intensity lesions are dark
    2. high signal intensity lesions are bright
56
Q

Advantages of MRI

A
  • no radiation
  • extremely sensitive to early (within 5 min.) or old ischemic changes and infarction
  • much better visualization of the entire brain (especially the posterior fossa)
57
Q

Disadvantages of MRI

A
  • contraindications in some patients (metallic implants, pacemakers, claustrophobia, etc.)
  • prone to artifact
  • longer acquisition time
58
Q

Acute Findings for Ischemic Stroke on MRI

A
  • DWI and ADC changes persist for 10-14 days

- flair signal changes last indefinitely

59
Q

Medical Management of ICH

-ABC’s

A
  • Maintain oxygen saturation ≥ 94%

- Intubation for decreased LOC/inability to protect airway

60
Q

Medical management of ICH

A
  • BP reduction (target SBP < 140)
  • treat any hyperthermia (<37.5oC) with Tylenol, cooling blankets
  • glycemic control
  • coagulopathy correction (for INR > 1.4)
  • no corticosteroids
  • secondary complication prevention
61
Q

Acute Ischemic Stroke Intervention

-optimize cerebral perfusion

A

Support normal physiology to enhance collateral blood flow.

-Oxygen, temperature, glucose, permissive HTN

62
Q

Acute Ischemic Stroke Intervention

-restore blood flow

A
  • IV tPA up to 4.5 hrs

- Endovascular Therapy (EVT): up to 24 hrs depending on certain imaging

63
Q

Optimize Cerebral Perfusion (Save the Penumbra)

-do’s and don’ts

A
  • DO NOT treat elevated BP (unless exceeds goals)
  • AVOID hyperglycemia (>180); use NS in IV (No glucose in IV - unless hypoglycemic)
  • DO keep the head of the bed at 0 -15 degrees
  • DO use supplemental oxygen to keep O2 sat. > 94%
  • DO treat any temp elevation
64
Q

What trial established tPA as the gold standard?

A

NINDS tPA trial in 1995

65
Q

Limitations of IV tPA

A
  • multiple exclusion criteria
  • narrow therapeutic window
  • risk of cerebral and systemic hemorrhage
  • often ineffective for large vessel occlusions
  • treatment rate only 7% (in 2011)
66
Q

Acute Stroke Intervention

-when to use endovascular therapy (EVT)

A
  • for use in certain patients up to 6 hours from stroke onset
  • tx guidelines based on 5 recent clinical trials that showed significant benefit of EVT in treating large vessel occlusions
67
Q

Stent retrievers

  • generation
  • definition
A
  • 3rd generation endovascular stroke treatment
  • they immediately restore flow
  • trap thrombus within stent and retrieved
  • they are a removable device (no anti-platelets needed)
68
Q

AHA/ASA Recommendations for EVT

A
  • age > 18
  • NIHSS score > 6
  • Documented large vessel occlusion (LVO) in the anterior circulation: distal ICA or proximal MCA
  • onset to groin puncture within 6 hours
69
Q

When the moon hits your eye like a big pizza pie,

that’s amore…..

A

When you swim in a creek and an eel bites your cheek,
that’s a moray

:) :)

Neurology 2 (21 decks)

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