CVA: Continuum Deck Flashcards
% of strokes that are cardioembolic
20-30%
Sources of embolic
any where proximal to the ischemic territory ( atria, ventricles, valves, aorta, extracranial cervical arteries
Embolic strokes are more likely to cause what two things ?
seizures and hemorrhagic transformations
Lab work up for cardioembolic stroke
CBC, BC, ESR, CRP, PT/INR, TSH, Lipids, Hypercoag (APC resistant)
risk of stroke in a-fib w/o AC
5%
Important scores in CE stroke
hasbled, chadsvasc
Four main ACs
warfarin, dabigatrin (pradaxa), apixaban (eliquis), rivaroxaban (xarelto)
AC with shortest half-life and once daily dosing
Xarelto (rivaroxaban) (5-9 hours)
Renal dosing for ACs
Crcl <30 Dabigatran 75mg/d Crcl <50 Xarelto 15mg/d Creatine >1.5, age >80, <132 lbs Eliquis 2.5mg
how many times would someone have to fall for the risk to outweigh the benefit for AC and subdural hematomas
295 times
When to resume AC after stroke
14 days but bigger strokes may need 4 weeds but asa should be administered in the meantime
atheroma definitions
>4mm, noncalcified, mobile components
LKW (time not hours) +/- AC (take last dose ?)
First two critical questions
Alert, commands, eyes, head/gaze deviation, limb position and presence of purposeful movements
Things to observe initially on the way to the CT
LKW/AC ? , Vitals CAB and <185/110, glucose, Observe then NIH
Stroke alert first 5 steps
PT/PTT/INR, Plt, CBC, CMP, troponins
You only need a glucose but order these 5 additional labs.
BP, Glucose, and 2 IVs
Three things you need from the nurse first
does the presentation make neuroanatomic sense ?
Key to stroke syndromes
Acute focal infarction of the cerebral, spinal or retinal tissue.
What is stroke ?
ACA/MCA syndrome, amoaurosis fugax/altitudinal field cuts
ICA syndrome S/Sx
Right leg weak/numb, transcortical motor aphasia, ideomotor apraxia (i/l or c/l)
L ACA stroke S/Sxs
Left leg weak/numb, motor neglect, ideomotor apraxia (i/l or c/l)
R ACA stroke S/Sxs
Right face/arm >leg numb/weak, aphasia and left gaze preference
L MCA stroke S/Sxs
Left Face/arm >leg numb/weak, left hemineglect, right gaze preference, agraph/astereo
R MCA stroke S/Sxs
Right hemianopsia, alexia w/o agraphia, MIDBRAIN (WEBER) CN 3 I/L with mydriasis and hemiparesis
L PCA stroke S/Sxs
left hemianopsia and/or Weber syndrome CN 3, mydriasis and hemiparesis
R PCA stroke S/Sxs
I/L limb and gait ataxia
SCA stroke S/Sxs
Vertigo, I/L deafness, and/or i/l facial weakness/ataxia
AICA stroke S/Sxs
I/L limb and gait ataxia and/or Wallenberg syndrome (lateral medulla)
Vert/PICA
Pontine with impaired lateral gaze, horizontal diplopia and dysconjugate gaze, dysarthria, locked in
Basilar
dietary modification, exercise, ASA, statin, antihypertensive agent
5 proven stroke prevention strategies
olive oil, fruits, vegetables, nuts and whole grains with moderate fish and poultry.
Mediterranean diet
if CK >4x NL then stop and recheck in 6 weeks then try a low dose high potency statin (rosuva>lipitor with regards to SE profile)
Statin induced ck elevation approach
<140/90 (if lacunar then 130/90)
BP goals
no
Is there a difference in outcomes base on minor ischemic str
speech and motor
Stroke mimics are more likely if what two symptoms are absen
10% highest in the first 24 hours)
What percent of people who present with TIAs will ahve recur
50%
What amount of stenosis in a vessel places a patient at risk
CHANCE and FASTER (ended d/t slow recruitment )
Two trials that used DAPT for 21 days after TIA/small stroke
Aggressive medical therpy (DAPT 90 days) along > stenting both groups took ASA however (reason for point trial)
SAMMPRIS
1-8% and fronto/insular stroke and patient taking ace-i
Orolingual angioedema % and increased risk by 2 things
within 2 hours give 50/50/10 (benadryl,ranitidine,dexamethasone) for severe cases ad 0.3 mg epinephrine IM`
When does angioedema occurr and what do you do ?
within 36 hours of tPA/stroke (6.4%)
Definition of symptomatic ICH
HT1 scattered petechiaeHT2 more confluent but heterogenousPH 1 vs 2 is 30% of infarct volume
Four types of HT per ECASSII
10g cryopercipitate (if fibrinogen <150 can repeat,alternatives are tranexamic acid 10mg/kg over 20 min or e-aminocaproic acid 5g)
Tx for concerning hemorrhagic conversion
HERMES said no
Is there a difference in HT between thrombectomy vs tpa ?
Dominant hemisphere NIH >20 Nondominant NIH <15>80ml at 6 hours on dwi
NIH for malignant infarction ? DWI ml for fulminant edema ?
Mannitol 0.5 to 1 g/kg every 4-6 hours with goal osml of 310-3203% Hypertonic Saline for goal sodium of 150-155
Rx for malignant infarcrtion ?
<60 y/o who deteriorate within 48 hours (mrs <4
Indications for decompressive hemicraniectomy
13-25% in weeks 2-4
Early deaths d/t stroke % for PE
2-7
DVT risk on days
ON PRESENTATION unless they get Tpa the 24 hours if ICH 1 to 4 days
When shoud DVT Ppx begin
IV fluids and early NG tube
If patient fails swallow screen beyon dvt ppx what else shou
70%
What percent of patients will have a fall in 6 months post s
10% most in the first 24 hours
What percent of patients develop seizures ?
>5
Significant AHI for stroke risk ?
55% and fluoxetine per FLAME trial improves motor recovery
Depression % and what can be done ?
