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NMSP Exam 2 > Clin: Stroke - Hon > Flashcards

Clin: Stroke - Hon Flashcards

1
Q

what is the leading cause of long-term disability in the U.S?

A

stroke

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2
Q

what is the greatest risk factor for stroke?

A

previous stroke

  • 25% of survivors will have another one
  • also increasing age, and anything that causes atherosclerosis
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3
Q

what kid of stroke:

  • intracerebral (cortical vs. subcortical)
  • subarachnoid
A

hemorrhagic (20% of cases)

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4
Q

what kind of stroke:

  • large artery atherosclerosis with thromboembolism
  • small vessel (lacunar disease)
  • cardioembolism
  • nonatherosclerotic vasculopathies
  • hypercoagulable state
A

ischemic (80% of cases)

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5
Q

what cardiac disorders are risk factors for stroke?

A
  • valvular heart disease
  • cardiac dysrhythmia
  • mural thrombus
  • endocarditis
  • atrial myxoma
  • inter-atrial septal abnormalities
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6
Q

what hypercoagulable states are risk factors for stroke?

A
  • thrombocytosis
  • polycythemia
  • sickle cell disease
  • leukocytosis
  • protein C, protein S deficiencies
  • homocysteine
  • anticardiolipin/antiphospholipid Ab’s
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7
Q

what two STI’s did Hon say can do anything, anytime, anywhere in the nervous system (central or peripheral)?

A

HIV and syphillis

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8
Q

what inflammatory disorders are risk factors for stroke?

A
  • giant cell arteritis
  • SLE
  • polyarteritis nodosa
  • granulomatous angiitis
  • AIDS
  • syphilitic arteritis
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9
Q

where is the stroke?

  • aphasia
  • right sided sensory symptoms
  • right sided motor symptoms
  • right visual field cut
A

LEFT hemisphere

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10
Q

where is the stroke?

  • left hemineglect (can’t recognize own body parts)
  • left sided sensory symptoms
  • left sided motor symptoms
  • left visual field cut
A

RIGHT hemisphere

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11
Q

where is the stroke?

- ipsilateral ataxia, vertigo, nystagmus

A

cerebellum

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12
Q

where is the stroke?

  • cranial nerve findings with contralateral hemisensory or hemimotor symptoms
  • vertigo
A

brainstem

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13
Q

where is one of the most classic sites for hemorrhage?

A

basal ganglia

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14
Q

what accounts for 50% of deaths attributable to stroke?

A

medical complications

- pneumonia, DVT, PE, UTI, decubitus ulcers

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15
Q

what is common in acute ischemic stroke, and should NOT be treated?

A

acute HTN
- the area of infarction may have lost autoregulatory function, so that “normal” BP may be relatively hypotensive in the brain -> might even need to raise BP if too low!

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16
Q

ALL stroke patients need to have IV access

- what should NOT be included in the fluid?

A
  • *NO glucose**
  • hyperglycemia is associated with worse neurologic outcomes

NOTE: if TPA is a consideration, two IV access sites will

17
Q

what labs should be run for stroke pt?

A
  • CBC w/diff
  • PT, PTT
  • full chemistry panel and finger stick glucose
  • UA
  • CXR
18
Q

what is important if tPA or intra-arterial intervention is a consideration?

A

NIH stroke scale

  • score ranges from 0 (normal) - 42 (coma)
  • can be used to predict hemorrhagic conversion as well as indication for potential intra-arterial intervention
19
Q

what are some other important protocols for stroke pt?

A
  • elevate head of bed to 30 degrees
  • O2 @ 2L per NC
  • obtain pt weight
  • try to identify cause and treat fever if present
20
Q

what questions are important to ask in the history?

A
  • when was last time pt known to be w/out sx?
  • did head trauma or seizure occur at onset of sx?
  • is patient on warfarin/heparin or NOAC (thrombin inhibitor)?
  • does pt have sx suggestive of M.I?
  • does pt have sx suggestive of intracranial hemorrhage?
21
Q

what should be done if CT findings show cerebral infarction?

A

if pt meets all tPA criteria, consider administering tPA if absolutely sure of time of deficits

22
Q

what should be done if CT findings are normal?

A
  • consider another cause: seizure, migraine, hypoglycemia

- if history most consistent with ischemia, consider tPA or other therapies (ASA, Aggrenox, Ticlid, Plavix)

23
Q

the results of parts 1 and 2 of NINDS rt-tPA stroke study support the use of tPA for the treatment of acute ischemic stroke in patients who met the eligibility requirements, if treatment is initiated within how many hours of onset?

A

3, but better within 1.5 hrs

24
Q

what is the eligibility criteria for IV tPA?

A
  • age > 18
  • diagnosis of ischemic stroke with clinically apparent neurological deficits
  • no stroke or head trauma in preceding 3 months
  • no major surgery in preceding 14 days
  • no hx of intracranial hemorrhage
  • no rapidly resolving sx or only minor sx of stroke
  • no sx of SAH
  • no GI or GU hemorrhage in preceding 21 days
  • no seizure at onset of sx
25
Q

what lab values fit the eligibility criteria for IV tPA?

  • PT, PTT
  • platelet count
  • blood glucose
  • BP
A
  • PT <15 sec, INR <1.7, without use of warfarin
  • PTT WNL if heparin was given in preceding 48 hr
  • platelet count > 100,000
  • blod glucose >50mg/dL
  • systolic BP <185
  • diastolic BP <110
26
Q

what is the tx of acute ischemic stroke with IV tPA?

A
  • infuse tPA at dose of .9mg/kg over 60 min period, with the first 10% of the dose given as bolus over 1 min
  • perform neuro assessments and check BP q15 min during infusion, q6 hr after, and then q60 min for the next 16hrs
  • if BP >180/105, check BP more frequently and give anti-HTN drugs as needed
27
Q

what should be done if stroke pt has severe HA, acute HTN, or N/V?

A

stop infusion and obtain emergent head CT

28
Q

what did Hon want us to know about anti-coagulation medication?

A

early studies have been found to have serious methodological flaws
- in general ,there is little role for acute anticoagulation in stroke patients

29
Q

what are the only 2 clinical situations in which warfarin is absolutely indicated?

A
  • Afib
  • prosthetic valve

other possibilities: MI, ASD, hypercoagulable state, large vessel disease, aortic arch disease

30
Q

in addition to emergent CT scan, what other studies may be helpful in stroke pt?

A
  • CT perfusion studies
  • MRI, MRA, diffusion weighted and perfusion weighted MRI
  • transcranial doppler US
  • CT angiography
  • xenon-enhanced CT, single photon-emission CT
  • cerebral angiography
31
Q

what is a promising new therapy for stroke pts?

A

endovascular therapy
- several new studied have shown improvement in patients treated with endovascular/intra-arterial intervention in addition to tPA when compared to tPA use alone

NMSP Exam 2 (13 decks)

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