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ED fellowship -- neurology (medicine) > CVA > Flashcards

CVA Flashcards

1
Q

Discuss the most common areas for HTN intracranial haemorrage

A

1) Basal ganglia (putamen especially) 44$
2) thalamic 13%
3) Cerebellum 9%
4) Pons 9%

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2
Q

Describe the penumbra

A

THe area of the brain surrounding the pirmary injury which is preserved by a tenuous supply of blood from collateral vessels.

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3
Q

Briefly describe the blood supply to the brain

A

Blood is supplied to the brain by the anterior and posterior circulation. The anterior ciruclation orginates from the carotid system and perfuses 80% of the brain including the optic nerve.

The ACA supplies the basal and medial aspects fo the cerebral hemispheres and extends to the anterior two thirds of the parietal lobel.

The MCA feeds the lenticulostriate branches that supply the putamen part of the anterior limb of the internal capsule the lentiform nucleus and the external capsule

Posterior syuplies the brainstem - dereived from the two vertebral arteries that ascend through the transvere processes of the cervical vertebrae.

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4
Q

Discuss ACA strokes

A

Mainly affects the frontal lobe function. The patient has altered mentation coupled with impaired judgment and insight as well as the presence of primitive grasp and suck reflexes

Bowel and bladder incontinence may be features of ACA

Paralysis and hypesthesia of the lower limb opposite the side of the lesion are characteristic. Leg weakness greater than arm weakness is classic of ACA

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5
Q

Describe MCA stroke

A

Motor and sensory disturbances are the hallmakrs of the occlusions of the MCA

Arm > leg
may involve only a distal portion or part of the face but almost always has both motor and sensory deficit

Hemianopsia or blindness in one half of the visal field occurs ipsilateral to the lesion. Agnosia and aphasia are common especially if the lesion occurs in the dominant hemishere.

Aphasia is common in dominant hemisphere strokes. Aphasia may be expressive receptive or bot.

Dysarthria is difficulty forming words due to muscle deficit they understand verbal communication and uses word choices appropriately

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6
Q

Define dominant cerebral hemisphere

A

the hemisphere that controls language usually left (95%)

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7
Q

Describe posterior stroke

A

Causes the widest variety of symptoms and as a result may be the most difficult to diagnose

The symptoms reflect CN deficits, cerebellar involvement and involvement of the neurosensory tracts.
The brainstem also contains the reticular activating system which is responsible for consciousness and emesis control

Unlike anterior strokes those with posterior may have ALOC and nausea and vomiting. Visual agnosia (inability to recognize objects seen)

3rd nerve palsy can occur as can homonymous hemianopsia. Visual neglect also seen

Vertigo syncope diplopia, visual field defects wekaness paralysis dysarthria dysphagia, spasticity ataixa or nystagmus may be present.

Posterior circulation strokes can also have crossed deficits with more deficits on one side and sensory loss on the other

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8
Q

Discuss components of the NIHSS score

A

1) LOC - GCS
2) Best gaze - horizontal EOM by voluntary or doll’s eye maneuver
3) visual field
4) facial palsy
5) motor arms
6) motor leg
7) limb ataxia
8) sensory
9) best language (describe a cookie jar picture or name objects)
10) dysarthria (read list of words)
11) extinction or neglect

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9
Q

Describe haemorrhagic stroke

A

Sudden onset of headache, vomiting severly elevated BP and focal neurologic deficits that progress over minutes.

Poor prognostic indicators for patients with ICH include a decreased level of consciouness on arrival, IVH and large volue ICH

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10
Q

Discuss the ICH score

A

Intracerebral haemorrahge score prediciting mortality after acute ICH

GCS
3-4 =2
5-12 =1
13-15 = 0

ICH volume
>30mls =1
<30mls =0

Intraventricular haemorrhage
Present =1
Abscent = 0

Age
>80 1
< 80 0

30 day mortality 
0=0
1=13%
2=26
3=72
4= 97
5= 100%
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11
Q

Define TIA

A

Time based – originally defined as a sudden onset of a focal neurolgoical symptoms and or sign lasting less than 24 hours brought on by a transiet decrease in blood flow which renders the brain ischemic in the area producing symptoms. LImited as infarction can occur in this time

Tissue based - TIA is a transient episode of neurological dysfunction caused by focal brain or spinal cord or retinal ischemia without acute infarction

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12
Q

Discuss ABCD2 score

A

Age >60 =1

BP >140/90 when first assessed post TIA = 1

Clinical features

  • Motor =2
  • sensation =1
  • other =0

Duration of symptoms
->60minutes =2
-10-60 =1
<10 =0

T2DM = 1

Score
6-7 high risk 7 day stroke
4-5 moderate risk 4 percent -
>4 low risk 1 percent –> aspirin and OPD

ABCD 31
-adds if recurrent in the last week or imaging suggestive of infarct or icnrease risk +ve carotid doppler or MRI

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13
Q

Discuss early signs of ischaemic stroke on CT

A

1) Visualisation of the clot - immediately
- Dense artery sign

2) Early parenchymal signs
- sulcal effacement
- loss of insular ribbon
- loss of grey-white interface
- mass effect
- acute hypodensity

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14
Q

What are the national institute of neurological disorders and stroke reccomended stroke evaluation targets for potential lytic candidates

A

Door to doctor –>10minutes
Door to CT completion –> 25 minutes
Door to CT reading –> 45 minutes
Door to treatment –> 60 minutes

Access to neurological expertise –> 15 minutes
access to neurosurigcal expertise –> 2 hours

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15
Q

Discuss management of ischemic stroke

A 
Neuroprotective measures
-30 degrees head
-normal bsl 
-normal sodium 
-maintain appropriate MAP >80 
-

A: as needed although most ischemic strokes have a normal GCS and do not require intubation
B: maintain o2 >94% nil need for hyperoxia
C: Unless eligible for thrombolytic therapy blood pressure lowering is not indicated in acute ischaemic stroke unless severe >220/120 or if the patient has active ischaemic coronary disease heart failure aortic dissection hypertensive encephalopathy or pre-eclampsia
If parenteral agents are used labetalol 10-20mg or a calcium channel blocker (nicardipine) can be used.

If eligible for lysis blood pressure most be below 185/110

  • labetablol 10-20 mg IV over 1-2 minutes
  • hydralazine can be consided
  • measure BP every 15 minutes during treatment and 2 hours post and than 30 minutly for 6 hours
  • may require infusion of labetalol or nicardipine to maintain BP >180
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16
Q

Discuss inclusions criteria for lysis

A

Inclusion criteria

  • clinical diagnosis of ischaemic stroke causing measurable neurological deficit
  • Onset of symptoms <4.5 hours before beginning treatemtn - if exact time not known taken as the last time the patient was seen well
  • Age> 18 years
  • No ICH on initial CT
17
Q

Discuss exclusion criteria for lysis

A

Patient history

  • ischaemic stroke or severe head trauma in the previous three months
  • previous intracranial haemorrhage
  • intra-axial intracranial neopalsm
  • GIT malignancy
  • GIT haemorrhage in the previous 21 days
  • intracranial or intraspinal surgery wihtin the prior three months

Clinical

  • Persistent Bp >185/110
  • symptoms suggestive of SAH
  • active internal bleeding
  • presentation consistent with IE
  • stroke known or suspected to be associted with dissection
  • acute bleeding diathesis
Haem 
-platelets <100
current anticoagulation INR >1.7
Therapeutic doses of clexane received wihtin the past 24 hours
-current use of DOAC

CT

  • evidence of haemorrahge
  • extensive regions of obvious hypodensity consistent with irreversible injury
18
Q

Discuss warning criteria (careful consideration and weighting of risk to benefit)

A

Only minor neuro signs or radpidly improving

  • serum glucose <2.8
  • serious trauma in the previous 14 days
  • major surgery in the previous 14 days
  • history of GIT or GUT bleeding
  • seizure at the onset of stroke
  • pregnancy
  • art punction at a noncompressible site in the previous 7 days
  • large untreated unruptured intracranial aneurysms

Additional for treatment at 3-4.5 hour (exclusion criteria for ECASS 3)
>80 years of age
oral anticoagulant use reguardless of INR
sever stroke (NIHSS >25)
Combination of both previous stroke and diabetes mellitus

19
Q

Discuss dose of alteplase

A

0.9mg/kg IV up to 90mg (10% of dose as bolus with the rest as an infusion over 60 minutes)

20
Q

Discuss option for mechanical thrombectomy

A

4.5 0 24 hours otherwise either lyse or standard care

If stroke is due to posterior circulation LAO consider MTA

Stroke is due to anterior circulation LAO and <6 hours MT indicated if

  • treatment can be started within 6 hours of stroke symptom
  • neuroimaging with small infarct core and no haemorrahge
  • there is persistent potentionally disabling neurological deficit

Stroke is due to anterior ciruclation LAO 6-24hours

  • treatment can be started within 6-24 hours of the time last known to be well and there is clinical core mismatch as defined by the DAWN trial
  • treatment can be started within 6 -16 hours of time last known ot be well and there is an imaging target mismatch as defined by the DEFUSE 3 trial
21
Q

Discuss DAWN trial eligibility

A
  • Treatment can start withi 6 -24 hours of time last known well
  • failed or contracindiated IV TPA
  • A deficit on the NIHSS of >10
  • No signfiaicnt prestroke disability
  • Baseline infarct involving <1/3 of MCA territory
  • A clinical core mismatch according to age
    1) >80 years - NIHSSS >10 and infarct volume <21,;
    2) <80 years - NIHSS 10-19 and infarct volume <31
    3) <80 NIHSS >20 and infarct volume <51ml
22
Q

Discuss DEFUSE 3 trial eligibility

A

Treatemtent can started within 6-16 hours

  • a defciti of the NIHSS of >6
  • Only slight prestroke disability: baseline mRS score <2
  • Occlusions of the cervical or intracranial ICA or the M1 segment of the MCA
  • age 18-90
  • A target mismatch profile on CT perfusion or mRI defeined as
    1) ischaemic core volume <70 ml
    2) a mismatch ratio (the volume of the perfusion lesion divided by the volume of the ischemic core) >1.8
    3) a mismatch volume (volume of perfusion lesion minus volume of the ishcaemic core) >15mls
23
Q

Discuss management of ICH

A

Supportive care
-Intubation often needed – consideration for short acting sedation for neurological evaluation

BP control is commonly performed after ICH. Controversial as dropping a normally hypertensive patient BP may reduced CPP
-consensus target is between 140-180 and a MAP <130 - INTERACT study, Atach 2- nil benifit in more strict BP control <140

Reverse anticoagulants
Nil evidence to suggest the use of platelets in ICH in those on antiplatelet therapy (PATCH trial) – still used if there is a new thrombocytopenia

For patients with clinical or radiographic evidence of raised ICP therapies aimed at lowering ICP should be considered
-discussion with neurosurgery in regards to the benefits of an extraventricular drain (EVD)

24
Q

Discuss stroke mimics

A 
Hypoglycaemia 
-Mass lession 
-Seizures (todds paresis) 
-Hemiplegic migraine 
-Functional factitious 
-Encpehalopathies/metabolic 
MS 
BElls
25
Q

Discuss the modified Rankin Scale

A

Measures the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability

26
Q

Describe lateral medullary infarction

A

Involves PICA

Vestibulocerebellar symptoms and signs

  • feeling dizzy or off balance
  • –turning rotating or whirling in relation to the environment
  • –being pulled or falling towards one side most often ipsalateral to the lesion
  • Difficulty sitting upright wihtout support
  • hypotonia of the ipsilateral arm
  • blurred vision or duplopia
  • nystagmus
  • ocular torsion
  • limb ataxia

Sensory symptoms and sings

  • Pain or unpleasant feeling in the face are sometimes the earliest and most prominent features of the lateral medullary syndrome,
  • Loss of pain and temperature sensation in the conrtralateral trunk and limbs and the ipsilateral face

Bulbar muscle weakness
-paralysis of the ipsilateral palate pharynx and larynx resulting in hoarsenss and dysphagia

Resp dysfunction
- Failure of automatic respiration

Autonomic dysfunction
-ipsilateral eye shows features of horners syndroe
-CVS - tachy orthostatic hypotension and cardiac rate acceleration and intermittent bradycardia.
-

27
Q

Discuss complications of stroke

A

CNS

  • Cerebral oedema and raised ICP - uncommon but may occur with large anterior circulation strokes.
  • haemorrhagic transformation of ischaemic stroke
  • Seizures

Non CNS

  • Aspiration
  • pneumonia
  • hypoventilation
  • DVT and PE
  • UTI
  • pressure ulcers
28
Q

Briefly discuss evidence surrounding lysis in the ED for CVA

A

12 RCTS

  • 2+ve
    1) NINDS
    2) ECASS

10-ve and 4 stopped for harm

The numbers needed to treat to achieve a good neurological outcome is approximately 10. Howevere NNT to achieve functionla independence mRS outcome of 0-2 is 13

Numbers needed to harm due to increased spon intracranial haemorrhage is 42

29
Q

Describe the ROSIER Score

A

Recognition of stroke in the emergency Room scale

  • asymmetric face weakness +1
  • asymmetric arm weakens +1
  • Asymmetric leg weakness +1
  • Speech disturbance +1
  • Visual field defect +1
  • Seizure activity -1
  • Loss of consciousness or syncope -1

If total score is +1 or more or stroke is suspected on other clinical grounds then triage of cat 2

30
Q

Discuss indications for endovascular clot retrieval

A

Ischaemic stroke with large vessel occlusions
Substantial neurological deficit, NIHSS >5
Time frame
-less than 6 hours broad clinical and imaging criteria
-6-24hours significant volume of salvageable tissues
-Good level of premorbid independence

31
Q

Discuss management of post lysis bleeding

A

1) stop infusions of thrombolytic drug
2) bloods and cross match
3) Reverse fibrinolysis
- FFP 2 units Q6houtly for 24 hours
- Cryoprecipitate 10units or fib con
- TXA 1G
4) Reverse antiplatelet effect
- platelets 1 unit
- DDAVP 0.3mic/kg
5) reverse anticoagulant effects
- protamine 1mg for every 100U of unfractionated heparin given in the preceding 4 hours
- protamine 1mg for every mg of enoxaparin given in the preceding 8 horus
6) if intracerebral prognosis poor control BP <160 and MAP <110
7) intubate and control ICP

ED fellowship -- neurology (medicine) (12 decks)

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