Clinical Care: Stokes

Question 1

Two major branches Internal Carotid Arteries

Answer 1

1) Anterior cerebral artery (ACA)
2) Middle cerebral artery (MCA)

Question 2

(a) Two arteries fuse to become the basilar artery
(b) Supplies the Cerebellum and Brainstem

Answer 2

Vertebral - Basilar Arteries

Question 3

1) The PCA connects internal carotid artery and vertebral basilar arteries
2) The ACA connects the anterior cerebral arteries
3) The MCA is a direct branch off of the internal carotid artery

Answer 3

Circle of Willis

Question 4

Rupture of a blood vessel causing bleeding into the brain and lack of cerebral blood flow leading to ischemia

Answer 4

Hemorrhagic stroke

Question 5

Blockage of a blood vessel causing lack of cerebral blood flow leading to ischemia

Answer 5

Ischemic stroke

Question 6

is the acute neurologic injury that occurs as the result of the interrupted blood flow to the brain

Answer 6

“stroke”

Question 7

80% of strokes are

Answer 7

ischemic

Question 8

Can Ischemic and hemorrhagic be distinguished without exam?

Answer 8

Cannot distinguish between the two based on clinical criteria

Question 9

-3rd leading medical cause of death
-2nd most frequent cause of neurologic morbidity
-Risk factors are HTN, atherosclerosis and age

Answer 9

stroke

Question 10

• obstruction of an artery due to a blockage that forms in the vessel

Answer 10

Ischemic Stroke: Thrombotic

Question 11

• obstruction of an artery due to a blockage from debris that has broken off from a distal area

Answer 11

Ischemic Stroke: Embolic

Question 12

• lack of brain blood flow to decreased systemic
  blood flow

Answer 12

Ischemic Stroke: Systemic hypo perfusion

Question 13

a transient episode of neurologic
dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction (previously was reversible neurologic dysfunction that resolved within 24 hours, however that criteria has been replaced with the above).

Answer 13

Transient ischemic attack TIA

Question 14

is a stroke is defined as neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia with infarction
(tissue death) of central nervous system tissue.

Answer 14

Cerebral Vascular Accident (CVA)

Question 15

The only way to determine the difference is by

Answer 15

MRI

Question 16

“FASTER” Mneumonic

Answer 16

1) Face – drooping or numbness on one side of the face
2) Arms – one limb being weaker or more numb than the other
3) Stability – steadiness on feet
4) Talking – slurring, garbled, nonsensical words, inability to respond normally
5) Eyes – visual changes
6) React – MEDEVAC immediately and note time of symptom onset

Question 17

What hemorrhage bleeds directly into the brain tissue

Answer 17

Intracerebral hemorrhage

Question 18

What hemorrhage bleeds into the subarachnoid space

Answer 18

Subarachnoid hemorrhage

Question 19

(a) Depends on the site of bleed
(b) Intracerebral hemorrhage usually has gradual onset as blood builds
(c) SAH has maximal impact right away usually with intense “worse headache of my life” headache
(d) Headache, vomiting, decreased level of consciousness occurs in about half the
patients with ICH
(e) Symptoms tend to worsen gradually overtime

Answer 19

Hemorrhagic Strokes or Intracranial Hemorrhage (ICH):
Clinical Manifestations

Question 20

1) Maintain oxygenation > 94%
a) Do not give oxygenation to non-hypoxic patients

2) Elevate head of bed to ~30 degree

3) Labs:
a) EKG
b) CBC
c) FBG Finherstick blood glucose
d) O2 sat

4) Imaging
a) Helps to differentiate between ischemic and hemorrhagic stroke
b) Non-contrast CT
c) MRI

5) Blood pressure
a) May be cause of stroke or spike in response to blockage/stress
b) Do not lower it acutely as it may be the only thing maintaining adequate perfusion
c) UNLESS pressure is above systolic of 220 and/or diastolic of 120 in which case you should lower the pressure by 15%

d) Labetalol (Trandate) - non-selective beta blocker
(1 Dosing: 10-20 mg IV, may give same or double dose every 10-20 minutes to max of 150mg

e) Monitor BP every 15 minutes

7) Medication
a) Aspirin 325mg

8) MEDEVAC!

Answer 20

Initial interventions for ischemic stroke

Question 21

“Cerebrovascular disease including stroke, transient ischemic attack, and vascular malformation is disqualifying.”

Answer 21

Overall Disposition: MANMED 15-106

Question 22

for papilledema which may indicate increased
intracranial pressure

Answer 22

Fundoscopic examination

Question 23

Suspect stroke

Answer 23

Differential blood pressure readings between upper extremities may indicate an aortic dissection