CVA/ TIA

Question 1

What is an Ischemic Stroke?

Answer 1

Characterized by the sudden loss of blood circulation to an area of the brain resulting in a corresponding loss of neurologic function

Question 2

What causes an ischemic stroke?

Answer 2

Caused by thrombotic or embolic occlusion of a cerebral artery

Question 3

Common signs & symptoms of an ischemic stroke?

Answer 3

Abrupt onset of hemiparesis, monoparesis, or
    quadriparesis (rare)
 - Hemisensory deficits
 - Monocular or binocular vision loss
 - Visual field deficits
 - Diplopia
 - Dysarthria
 - Facial Droop
 - Ataxia
 - Vertigo (rarely in isolation)
 - Nystagmus
 - Aphasia
 - Sudden decrease in level of consciousness

Question 4

Epidemiology of strokes?

Answer 4

Ischemic is MC
Stroke is the leading cause of disability & 4th leading cause of death in the US
Approximately 795,000 people in the US experience new or recurrent stroke each year
82-92% of strokes in the US are ischemic
Overall mortality rate at 30 days after stroke was 28% & 19% after ischemic stroke in the
1 year survival rate for ischemic stroke was 77%

Question 5

Which symptoms are MC in hemorrhagic stroke?

Answer 5

Nausea, vomiting, headache, & sudden change in level of consciousness
no feature distinguishes hemorrhage from ischemic

Question 6

What is hemiparesis is more likely a?

Answer 6

CVA/ TIA

Question 7

Isolated extremity weakness is more likely

Answer 7

compressive radicular or peripheral neuropathy or peripheral vascular occlusion

Question 8

Bilateral ascending paralysis of extremities is more likely

Answer 8

Gullian Barre Syndrome

Question 9

Bilateral motor weakness of both cranial & peripheral nerve distribution is more likely

Answer 9

inflammatory (MS), toxic/metabolic (botulism), or autoimmune (Myasthenia Gravis)

Question 10

Bilateral weakness & distinct sensory level loss, and/or bladder dysfunction is more likely

Answer 10

spinal cord involvement

Question 11

Bilateral weakness that effects proximal more than distal motor strength suggests

Answer 11

myopathy

Question 12

Sudden onset of signs and symptoms implies

Answer 12

vaso-occlusive etiology such as stroke or TIA

Question 13

Sudden extremity weakness with pain, pallor, paresthesias, & pulselessness is more likely

Answer 13

vascular occlusion of the extremity

Question 14

H/A associated with Ischemic Stroke

Answer 14

Not usually associated with ischemic stroke

Can be associated with hemorrhagic stroke

Question 15

Visual Changes with Ischemic Stroke?

Answer 15

Diplopia may be associated with a posterior circulation ischemic event

Question 16

N/V with Ischemic Stroke?

Answer 16

IOP usually increased with ischemic stroke**

May be a warning sign of increased intracranial pressure or posterior circulation ischemic event

Question 17

4 goals of the neuro exam?

Answer 17

Confirm the presence of a stroke syndrome
Distinguish stroke from stroke mimics
Establish a neurologic baseline, should the patient’s symptoms improve or deteriorate
Establish stroke severity with NIH Stroke Scale

Question 18

NIH Stroke Scale involves what? (12)

Answer 18

1. level of consciousness
2. opens & closes eyes on command
3. pt knows month & their age
4. Best gaze
5. VF test
6. facial paresis (show teeth etc)
7. Motor function of the extremeities
8. sensory
9. limb ataxia
10. language
11. dysarthria
12. extinction and inattention

Question 19

NIH Scores (2)

Answer 19

NIH Stroke scores > 22 are considered very significant and may predict increased complication risk.
The score is commonly used to track outcomes, improvement or deterioration of a stroke

Question 20

Middle Cerebral Artery (MCA) supplies what?

Answer 20

the upper extremity motor strip so that weakness of the arm & face is usually worse than that of the lower extremity

Question 21

Middle Cerebral Artery Stroke

Answer 21

Contralateral hemiparesis
Contralateral hypesthesia
Ipsilateral hemianopsia
Gaze preference towards the side of the lesion
Agnosia (lose the ability to recognize objects)
Receptive or expressive aphasia, if the lesion occurs in the dominant hemisphere
Neglect, inattention, & extinction of double simultaneous stimulation with some non-dominant hemisphere lesions

Question 22

Anterior Cerebral Artery Stroke

Answer 22

Disinhibition & speech preservation
Primitive reflexes (grasping, sucking reflexes)
Altered mental status
Impaired judgment
Contralateral weakness (greater in legs than arms)
Contralateral cortical sensory deficits (stereognosis, graphesthesia, position sense)
Gait apraxia
Urinary incontinence

Question 23

ACA occlusions primarily affect what lobe?

Answer 23

frontal lobe function

Question 24

Posterior Cerebral Artery Stroke

Answer 24

Hallmark is the presence of crossed findings
Contralateral homonymous hemianopsia
Cortical blindness
Visual agnosia
Altered mental status
Impaired memory

Question 25

Posterior Cerebral Artery Stroke primarily affects what?

Answer 25

vision and thought

Question 26

Vertebrobasilar Artery Stroke

Answer 26

``` Difficult to localize because they can cause a wide variety of CN, cerebellar, & brainstem deficits Vertigo Nystagmus Diplopia Visual field deficits Dysphagia Dysarthria Facial hypesthesia Syncope Ataxia ```

Question 27

Lacunar Strokes

Answer 27

``` Do not lead to impairments in cognition, memory, speech, or level of consciousness Most common include: Pure motor Pure sensory Ataxic hemiparetic strokes ```

Question 28

Lacunar Strokes result from?

Answer 28

Result from occlusion of the small perforating arteries of the deep subcortical areas of the brain Generally 2 – 20 mm in diameter

Question 29

Transient Ischemic Attack (TIA)

Answer 29

"mini stroke" | symptoms are similar to stroke BUT resolve sponatenously (usually less than 24 hours)

Question 30

symptoms of a TIA include? (5)

Answer 30

Sudden numbness, tingling, weakness, or paralysis in your face, arm, or leg unilaterally Sudden vision changes (amaurosis fugax) Sudden trouble speaking Sudden trouble or confusion understanding simple statements Sudden walking or problems with balance

Question 31

Diagnosis of a stroke includes?

Answer 31

``` Initial diagnosis will always come from history & physical Diagnostic imaging (head CT or MRI of the brain & neck) confirms & localizes the diagnosis Labs & EKG are done to assess for other causes ```

Question 32

When should a head CT be done for strokes?

Answer 32

Should be done emergently Non-contrast head CT is the most commonly used Essential for confirming the diagnosis the diagnosis of ischemic stroke

Question 33

When should an LP be done for strokes?

Answer 33

Required to rule out meningitis or subarachnoid hemorrhage when CT is negative but clinical suspicion is high

Question 34

Why do we see ischemia on a CT

Answer 34

The reason we see ischemia on CT is that in ischemia cytotoxic edema develops as a result of failure of the ion-pumps.These fail due to an inadequate supply of ATP.An increase of brain water content by 1% will result in a CT attenuation decrease of 2.5 HU.

Question 35

What is Obscuration of the lentiform nucleus

Answer 35

Obscuration of the lentiform nucleus, also called blurred basal ganglia, is an important sign of infarction.It is seen in middle cerebral artery infarction and is one of the earliest and most frequently seen signs (2).The basal ganglia are almost always involved in MCA-infarction.

Question 36

What is the insular ribbon sign on the head CT?

Answer 36

This refers to hypodensity and swelling of the insular cortex. It is a very indicative and subtle early CT-sign of infarction in the territory of the middle cerebral artery. This region is very sensitive to ischemia because it is the furthest removed from collateral flow. It has to be differentiated from herpes encephalitis.

Question 37

What are some labs that should be ordered for a stroke?

Answer 37

``` CBC BMP Coag study cardiac markers pregnancy test ABG toxicology ```

Question 38

ABG is ordered because?

Answer 38

is used in select patients with suspected hypoxemia & to detect acid – base distubances

Question 39

Why are cardiac markers ordered?

Answer 39

important because of the association of cerebral vascular disease & CAD

Question 40

Why is a CBC ordered for a stroke?

Answer 40

reveal a cause (polycythemia, thrombocytosis, thrombocytopenia, leukemia) or evidence of concurrent illness (anemia)

Question 41

Why is BMP ordered for a stroke?

Answer 41

baseline study that may reveal a stroke mimic (hypoglycemia, hyponatremia) or provide evidence of a concurrent illness (DM, renal insufficiency)

Question 42

Why is a coag study ordered for a stroke?

Answer 42

may reveal a coagulopathy & is useful when fibrinolytics or anticoagulants are to be used

Question 43

What are the 3 goals of an emergent stroke management?

Answer 43

Goal of emergent management of stroke is to complete the following within 60 minutes of arrival 1. Assess ABC’s & stabilize the patient as necessary 2. Complete the initial evaluation & assessment including imaging & labs 3. Initiate reperfusion therapy if appropriate

Question 44

2 indications for thrombolytics

Answer 44

Acute ischemic stroke within 3-4.5 hours from symptom onset Age > 18 y/o

Question 45

Endovascular Mechanical Interventional Therapies

Answer 45

Mechanical Embolus Removal in Cerebral Ischemia (MERCI) Retrieval System removes the clot May be used regardless of whether thrombolytics have been given or not Time window is 8 hours EKOS MicroLysUS catheter system utilizes high frequency ultrasound to destabilize clots & facilitate thrombolysis Also used at highly specialized stroke centers

Question 46

3 post treatment managements

Answer 46

Admission to neuro ICU immediately following thrombolytic therapy or mechanical intervention Neuro exam & BP monitoring at regular intervals to observe the patient for improvement or decompensation If no availability transfer the patient to a facility that is capable of providing this service

Question 47

What is the management of TIA

Answer 47

No specific emergency treatment for acute TIA TIA is a significant risk for further acute ischemic stroke (AIS) Risk of AIS is about 10.5% within 3 months & ½ occur within the first 48 hours following TIA Neuro consult & antiplatelet therapy are recommended If already on max dose of antiplatelet therapy addition of warfarin should be considered