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Emergency Med > CVA/ TIA > Flashcards

CVA/ TIA Flashcards

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1
Q

What is an Ischemic Stroke?

A

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

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2
Q

What causes an ischemic stroke?

A

Caused by thrombotic or embolic occlusion of a cerebral artery

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3
Q

Common signs & symptoms of an ischemic stroke?

A 
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
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4
Q

Epidemiology of strokes?

A

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%

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5
Q

Which symptoms are MC in hemorrhagic stroke?

A

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

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6
Q

What is hemiparesis is more likely a?

A

CVA/ TIA

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7
Q

Isolated extremity weakness is more likely

A

compressive radicular or peripheral neuropathy or peripheral vascular occlusion

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8
Q

Bilateral ascending paralysis of extremities is more likely

A

Gullian Barre Syndrome

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9
Q

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

A

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

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10
Q

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

A

spinal cord involvement

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11
Q

Bilateral weakness that effects proximal more than distal motor strength suggests

A

myopathy

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12
Q

Sudden onset of signs and symptoms implies

A

vaso-occlusive etiology such as stroke or TIA

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13
Q

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

A

vascular occlusion of the extremity

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14
Q

H/A associated with Ischemic Stroke

A

Not usually associated with ischemic stroke

Can be associated with hemorrhagic stroke

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15
Q

Visual Changes with Ischemic Stroke?

A

Diplopia may be associated with a posterior circulation ischemic event

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16
Q

N/V with Ischemic Stroke?

A

IOP usually increased with ischemic stroke**

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

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17
Q

4 goals of the neuro exam?

A

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

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18
Q

NIH Stroke Scale involves what? (12)

A
  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
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19
Q

NIH Scores (2)

A

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

20
Q

Middle Cerebral Artery (MCA) supplies what?

A

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

21
Q

Middle Cerebral Artery Stroke

A

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

22
Q

Anterior Cerebral Artery Stroke

A

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

23
Q

ACA occlusions primarily affect what lobe?

A

frontal lobe function

24
Q

Posterior Cerebral Artery Stroke

A 
Hallmark is the presence of crossed findings
Contralateral homonymous hemianopsia
Cortical blindness
Visual agnosia
Altered mental status
Impaired memory
25
Q

Posterior Cerebral Artery Stroke primarily affects what?

A

vision and thought

26
Q

Vertebrobasilar Artery Stroke

A 
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
27
Q

Lacunar Strokes

A 
Do not lead to impairments in cognition, memory, speech, or level of consciousness
Most common include: 
Pure motor
Pure sensory
Ataxic hemiparetic strokes
28
Q

Lacunar Strokes result from?

A

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

29
Q

Transient Ischemic Attack (TIA)

A

“mini stroke”

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

30
Q

symptoms of a TIA include? (5)

A

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

31
Q

Diagnosis of a stroke includes?

A 
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
32
Q

When should a head CT be done for strokes?

A

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

33
Q

When should an LP be done for strokes?

A

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

34
Q

Why do we see ischemia on a CT

A

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.

35
Q

What is Obscuration of the lentiform nucleus

A

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.

36
Q

What is the insular ribbon sign on the head CT?

A

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.

37
Q

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

A 
CBC
BMP
Coag study
cardiac markers
pregnancy test
ABG
toxicology
38
Q

ABG is ordered because?

A

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

39
Q

Why are cardiac markers ordered?

A

important because of the association of cerebral vascular disease & CAD

40
Q

Why is a CBC ordered for a stroke?

A

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

41
Q

Why is BMP ordered for a stroke?

A

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

42
Q

Why is a coag study ordered for a stroke?

A

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

43
Q

What are the 3 goals of an emergent stroke management?

A

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

44
Q

2 indications for thrombolytics

A

Acute ischemic stroke within 3-4.5 hours from symptom onset

Age > 18 y/o

45
Q

Endovascular Mechanical Interventional Therapies

A

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

46
Q

3 post treatment managements

A

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

47
Q

What is the management of TIA

A

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

Emergency Med (5 decks)

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