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DM Neuro 1 > CVA: Intro and Patho > Flashcards

CVA: Intro and Patho Flashcards

1
Q

Define stroke

A

Sudden cessation of cerebral blood flow leading to oxygen-glucose deprivation through blockage or hemorrhage

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2
Q

T/F: Stroke is the leading cause of serious long-term neurological disability

A

TRUE

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3
Q

List Non-modifiable stroke risk factors

A
  1. Women > Men
  2. Age >55 years
  3. Race (Black > White)
  4. Prior stroke
    • TIA and/or MI
  5. Genetics
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4
Q

List modifiable stroke risk factors

A
  1. HTN
  2. Diabetes
  3. CV disease
  4. Obesity
  5. Obstructive sleep apena
  6. Physical inactivity
  7. Diet
  8. Blood disorders
  9. Arrythmias
  10. Hyperglycemia
  11. Smoking
  12. Alochol
  13. Recreational drug use
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5
Q

How are strokes classified?

A
  1. Mechanism
  2. Location
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6
Q

What are the two mechanistic categories for stroke?

A
  1. Ischemic = blockage
    • thrombotic
    • embolic
  2. Hemorrhaggic = bleeding due to a weakened arterial wall rupture
    • intracerebral hemorrhage
    • subarachnoid hemorrhage
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7
Q

what is the cause of an ischemic stroke?

A

caused by clots

gradual worsening of fatty deposits lining arterial walls (artherosclerosis)

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8
Q

what is the difference between a thrombotic and embolic stroke?

A

Both are types of ischemic strokes

  1. thrombotic → blockage caused by clot formed within involved artery
  2. embolic → blockage caused by clot that travels from elsewhere in circulatory system
    • heart, large arteries of upper check/neck
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9
Q

what causes of hemorrhagic stroke?

A

rupture of artery due to weakening of vessel wall

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10
Q

what is the difference between an intracerebral and subarachnoid hemorrhage?

A

both types of hemorrhagic strokes, they differ by location and primary cause

  1. intracerebral hemorrhage (ICH) → primary cause is HTN
  2. subarachnoid hemorrhage (SAH) → primary cause is aneurysm and arteriovenous malformation (AVM)
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11
Q

What is an aneursym?

A

enlargement/ballooning of weakened vessel wall

typically asymptomatic until rupture

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12
Q

what is an AVM?

A
  • arteriovenous malformation
  • tanlge of abnormal blood vessels connecting arteries and veins found commonly in brain and spinal cord
  • symptoms vary depending on location
    • seizures, HA, weakness, speech and vision, can also be asymptomatic
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13
Q

What is a TIA?

A

transient ischemic attack

a mini stroke or “warning stroke”

normally these are evidence of underlying thrombotic disease somewhere in our cerebral vascular system

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14
Q

what is the cause of a TIA?

A
  1. not entirely understood
  2. leading hypothesis → temporary blockage that dissolves on its own or gets dislodged naturally
  3. potentially cerebral vasospasm and transient systemic arterial hypotension
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15
Q

T/F: TIA does not increase your risk for a full blown stroke

A

FALSE

10x increased chance for a full blown CVA w/history of TIA

highest risk for stroke in first 90 days post TIA

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16
Q

describe the ischemic cascade

A

after a stroke there is a cascade of damaging cellular events triggered by ischemia that begins to spread across brain tissue

  1. neuronal death via necrosis
    • loss of ATP production
    • stoppage of Na/K pump
    • cytotoxic edema
    • excess intracellular Ca2+ buildup
  2. neuronal death via apoptosis
    • breakdown of mitochondria in response to toxins and unstable cell membrane
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17
Q

describe the 2 regions of the ischemic cascade

A

infarct core → region of necrosis

penumbra → distal region of apoptosis, the peripheral area surrounding the infarct core

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18
Q

describe the timeframe of the ischemic cascade and why it is signficant

A
  • within minutes → neuronal death in infarct core
  • within hours → surrounding tissue (penumbra) death
  • every minute in which a large vessel ischemic stroke goes untreated = 1.9 million neurons lost, 1.38 billion synapses lost, 7 miles of myelinated axons lost
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19
Q

what are the 3 diagnostic steps involved in identifying a stroke?

A
  1. History of Present Illness (HPI)
    • PMH
    • Description of symptoms
      • onset and type of symptoms
  2. Clinical Examination
  3. Medical workup
    • diagnostic imaging
    • EKG
    • chest radiography
    • CBC
    • 24-hour cardiac monitoring
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20
Q

describe the onset of symptoms for the subtypes of strokes

A
  1. thrombotic → gradual onset, days to weeks
    • most common in late PM or first thing in AM (may see “wake up strokes”)
  2. Embolic → more abrupt than thrombotic, minutes to hours
  3. Hemorrhagic → immediate, severe
    • aneurysm: asymptomatic until rupture
    • AVM: may have preceding symptoms (seizures, etc)
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21
Q

describe the types of symptoms that may be present in stroke victims

A

largely dependent on location of insult

common complaints include:

  1. imbalance
  2. paresthesias
  3. weakness
  4. blurry or double vision
  5. “worse HA of my life” → common w/hemorrhages, particularly aneurysms
22
Q

T/F: you must perform a full clinical exam if you suspect a stroke

A

eventually yes, but intitially FALSE

acute only perform a neurologic screen to determine if there is need for further workup. Must be fast to get them to imaging since time is key with strokes

23
Q

T/F: most people recognize the symptoms of stroke and seek medical attention quickly

A

FALSE

40% of people wait 24 hours after having a stroke before contacting/going to ED

teach pt’s B.E.F.A.S.T

(balance, eyes, face, arms, speech, time)

24
Q

the NIHSS has 15 items that cover what categories?

A
  1. Consciousness
  2. Vision
  3. Motor and coordination
  4. Sensory and perception
  5. Language and fluency
  6. Behavior
25
Q

List the cut-off scores for the NIHSS

A
  • >25 very severe → frequently require long-term skilled care
  • 15-24 severe → frequently require long-term skilled care
  • 5-14 mild-moderate severe → typically require acute patient rehab
  • 1-5 mild → 80% will be D/C home from acute hospital
26
Q

what is the predictive validity of the NIHSS?

A
  1. NIHSS scores at baseline predict outcome at 7 and 90 days
    • <3 on NIHSS at 7 days correlated w/excellent recovery outcome in nearly 2/3 of pts
    • small # of pts who scored >15 at baseline achieve excellent outcomes after 90 days
    • NIHSS combined w/volumic of ischemic brain dissue found on MRDWI significantly predicts stroke recovery
27
Q

which form of diagnostic imaging is fastest and best tolerated by pts?

A

CT scan

28
Q

when is a CT scan preferred?

A
  1. head trauama
  2. financial concerns
  3. acute hemorrhage
  4. speed needed
  5. skull fracture
  6. calcified lesion
  7. claustrophobic pt
  8. pacemaker or other metallic implant
29
Q

when is an MRI preferred?

A
  1. subtle areas of tumor, infarct, demyelination, etc
  2. brainstem lesion
  3. ischemia
  4. subacute or chronic hemorrhage
  5. anatomy detail needed
30
Q

List some acute CVA complications

A
  1. Cerebral edema
    • increasing ICP
    • midline shift
    • brain herniation
  2. Vasospasm
  3. Seizures
  4. HTN
  5. infection
  6. fever
  7. pneumonia
  8. pressure ulcers
  9. hyperglycemia
31
Q

what is ICP and what are some PT considerations for it?

A
  1. ICP → pressure exerted by fluids in brain (CSF, ISF)
  2. PT considerations
    • monitor for S/S of increased ICP
    • avoid activity that may exacerbate
    • mobility usually contraindicated if >20 mmHg
32
Q

what is a midline shift and what are some PT considerations for it?

A
  1. Midline shift → shifting of structures into contralateral hemispheric space due to fluid buildup
  2. PT considerations
    • evaluate for bilateral symptoms
    • monitor closely for neuro decline
    • nothing can be done for midline shifts beyond surgical approaches
33
Q

what is a brain herniation and what are some PT considerations for it?

A
  1. brain herniation → protrusion of brain tissue through rigid intracranial barrier (ex. foramen magnum)
  2. Very poor prognositic indicator, typcially leads to mortality
  3. PT considerations:
    • PT usually not indicated
34
Q

What are vasospams?

How are they monitored/treated?

List some PT considerations for them

A
  1. Vasospam → persistent vasoconstriction and dilation of the blood vessels (typically asymptomatic but can be dangerous)
    • most commonly seen post SAH
  2. Monitoring → Transcranial Doppler (TCD)
  3. Treatment → permissive HTN
  4. PT considerations
    • mobility contraindicated w/moderate to severe vasospasms
    • consult MD prior to mobility
35
Q

When are seizures most commonly seen?

How are they monitored and treated?

List some PT considerations for them

A
  1. most commonly seen post ICH
    • greatest risk → first 48 hrs post ICH
  2. Monitoring → EEG
  3. Treatment → anti-seizure meds, surgery is rare
  4. PT considerations:
    • mobility usually deferred until >24 hrs after quiet EEG
    • Monitor closely for seizure activity
36
Q

How is an ischemic stroke managed?

A
  1. Major goal = revascularization
  2. Tissue plasminogen activator (tPA) → must be given in a 3-8 hr window
  3. Permissive HTN
    • <220/110
  4. Antiplatelets for first 24-48 hrs
37
Q

How is a hemorrhagic stroke managed?

A
  1. Major goal → reduce ICP
    • sedation, hyperosmolar agents, hyperventilation
  2. Anti-hypertensives for BP control
    • strict BP parameters (<130/80)
  3. Vasospasm prevention and management (SAH)
  4. Antiseizure prophylaxis (ICH)
38
Q

List some surgical approaches for acute management of ischemic strokes

A
  1. mechanical embolectomy
  2. mechanical thrombectomy
  3. carotid endarterectomy
39
Q

List and describe some surgical approaches for acute management of hemorrhagic strokes

A
  1. endovascular coiling (for aneurysms)
    • place coils endoscopically where aneurysm is and mesh up into a ball causing clot to form around it and stop blood flow
  2. surgical clipping (aneurysm)
    • physically/mechanically clip to stop blood flow
  3. resection (AVM)
    • remove AVM
  4. embolization (AVM, hemorrhage)
    • put surgical glue at area of rupture
  5. endoscopic evacuation
    • going in and sucking out the blood
  6. craniotomy → removing a skull flap to get access to the brain
  7. craniectomy → large piece of bone removed and kept off for a period of time, used for more severe swelling
40
Q

what type of info should be considered when determining the predicting outcomes?

A
  1. Type, stage, and location of diagnosis
  2. severity of impairments
  3. age
  4. comorbidities
  5. medical course
  6. prior level of function
  7. current level of function
41
Q

what should be considered from the PT’s perspective when predicting outcomes?

A
  1. is the pt a good rehab candidate?
  2. will the pt be able to return home? Family support?
  3. What type of locomotion will this pt likely rely on long-term?
  4. Prognosis for UE? ADL prognosis?
  5. What can we expect from this pt in 6 months? 12 months?
42
Q

List some major prognostic indicators for CVA

A
  1. time to medical intervention
  2. type of medical intervention
  3. Initial NIHSS score
  4. Age
  5. Education level
  6. Family support
  7. PLOF
  8. Ambulatory on evaluation (IP rehab)
43
Q

What is the difference in prognosis for hemorrhagic vs ischemic strokes?

A
  1. Hemorrhagic → higher mortality rate acutely, but better prognosis for neuro-recovery long-term
  2. Ischemic → lower mortality rate, but tend to demonstrate slower and less recovery
44
Q

Describe the general stroke recovery timeline

A
  1. first 3 months are crucial for rehab and neuro recovery
  2. evidence supports possibility of sig neuro recovery up to 18 months post injury
45
Q

describe the functional outcomes from most to least disabling by vascular territory

A
  1. multiple vascular territories
  2. MCA
  3. ACA
  4. PCA
  5. Brainstem
  6. Small vessel stroke
  7. Cerebellar
46
Q

describe some prognostic considerations for UE recovery following a stroke

A
  1. common impairments:
    • paresis
    • loss of isolated movement
    • abnormal muscle tone
    • sensory changes
  2. impairments are typically seen more in UE than LE and are directly correlated with ADL and IADL independence
  3. 80% of pts experiencing acute paresis of the UE
    • onlye 33% have been reported to achieve full functional recovery
47
Q

What are some positive prognostic indicators for UE recovery at 4 weeks post injury?

A
  1. early active finger extension, grasp release, shoulder shrug, and shoulder abduction observed
  2. absence of additional nonmotor impairments, such as somatosensory loss, visual field loss and/or neglect
  3. Presence of a measurable grip strength or active shoulder flexion
48
Q

what are some positive prognostic indicators for return to ambulation?

A
  1. ambulation on evaluation (IRF)
  2. Balance scores on evaluation (BBS, Romberg, DGI)
  3. Minimal loss of LE strength and somatosensory function
  4. No evidence of perceptual, vision, or cognitive deficits
  5. Healthy BMI
  6. Younger age (<65)
49
Q

how is gait speed a prognostic factor for stroke recovery?

A

higher the gait speed = better progosis

  • <0.4 m/s → household ambulation
  • 0.4-0.8 m/s → limited community ambulation
  • 0.8-1.2 m/s → unlimited community ambulation
50
Q

list some additional prognositic considerations for strokes

A
  1. lingering cognitive deficits are common
  2. activity intolerance is common among stroke survivors, especially elderly
  3. cardiac disease has been reported in up to 75% of stroke survivors
  4. Depression has been reported commonly in stroke (18-68% of patients)
  5. Lingering fatigue is common
    • may predict mortality
    • relatively understudied, reported in 16-70% of pts

DM Neuro 1 (16 decks)

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