Exam 2: Stroke - Dr. Shappy Flashcards
What are two types of strokes?
which is most common and by how much?
- Thromboembolic strokes: 80% of strokes (most common)
- Hemorrhagic (pts call it an aneurism): 20% of strokes
what kinds of deficits do strokes cause?
(name two that we shouldn’t forget about)
All kinds of stuff (she had us come up with several, but I couldn’t write fast enough)
Don’t forget autonomic functions
Proprioception
how severe are strokes?
Severity can range from minute losses to zero function
What is a TIA
(Transient Ischemic Attack)
Symptoms Last less than 24 hours
- pt may not even know it happened
- pt may never seek medical attention for these symptoms
What is the difference between hemiplegia vs hemiparesis?
Hemiplegia vs Hemiparesis
Hemiparesis is weakness of the entire left or right side of the body.
Hemiplegia is its most severe form, complete paralysis of half of the body.
(http://en.wikipedia.org/wiki/Hemiparesis)
Dr. Shappy’s lecture:
- Plegia = complete loss
- paresis = half loss
what is significant about the 3-week mark after a stroke?
Return of Function in the First three weeks gives us a pretty good prediction of recovery
(anything)
- sensory
- motor
- autonomic
Where do strokes fall in leading causes of death in the USA? (are they common or not?)
what is a demographic who is at greater risk?
Strokes are Third leading cause of death in the United States (not a test number)
- strokes are in abundance
- millions of people who have had a stroke at some level
- minorities are at greater risks (2x higher)
- probably because of preventative care
what are some risk factors for stroke?
(three main ideas)
Risks (similar to Heart Disease)
- minorities
- age 65 or older
Mortalitiy numbers:
What percentage of people with a stroke will die within a year?
what percene will die in 8 years?
(these should not be on the exam)
Mortality
- About 25% of those with a stroke will die within a year
- About 50% will die in 8 years
what are IADLs?
(It stands for Instrumental Activities of Daily Living)
More advanced ADLs
Example: writing checks or grocery shopping (more than just basic self-care in the home. They require more complex reasoning)
how many pts with strokes oare found in Inpatient Rehab Units (IRUs)?
Stroke pts are the largest percent of people admitted into IRUs
What is the actronym taught for stroke detection to the general public?
What does it mean?
FAST acronym
- face
- look for drooping on one side
- arms
- look for one lagging when held out
- speech
- slurred
- time
- can use clot-buster if caught in time (I think 1 hour window)
what is done for aneurisms (hemmorhagic strokes)?
What do they do with aneurysms?
- surgery - clip it
- metal clips that stay in there
what percentage of stroke pts will end up in a nursing home in the first year?
25% stroke pts will end up in nursing home
- if you have a stroke and you are older, not as many people want to take you home, or they may not be able to take you home
- number is probably a lot higher after a year
what is the etiology of stroke? (6-ish)
Similar to Cardiac
- Atherosclerotic narrowing of arteries
- Ischemic issues, clot growing or staying stationary
- Thromboembolic formation
- breaking free and flowing downstream
- blocking anything distal to where clot is
- Ischemia etc.
What are some different areas of stroke? (4)
Different areas of stroke
- Anterior Cerebral Artery
- Posterior Cerebral Artery
- Middle Cerebral Artery
- Homunculus
What is a lacunar stroke?
Dr. Shappy said: “A stroke caused by clots in the more distal vessels”
So I think she meant the penetrating arteries, but also closer to the surface
Wikipedia says:
Lacunar stroke or lacunar infarct (LACI) is a type of stroke that results from occlusion of one of the penetrating arteries that provides blood to the brain’s deep structures. Patients who present with symptoms of a lacunar stroke, but who have not yet had diagnostic imaging performed, may be described as suffering from lacunar stroke syndrome (LACS).
http://en.wikipedia.org/wiki/Lacunar_stroke
If a stroke is called an “ischemic stroke” what does that mean?
A trhomboembolic stroke is referred to as an ischemic stroke
A hemorrhatic stroke ist not called an ischemic stroke (even though it is technically ischemic too)
Hemorrhagic stroke: large or small?
could be either
blood can clot and brain can heal, resulting in a small attack
- cell injury (not death)
- cell death - no regeneration
Hemorrhagic stroke: typical attributes of pt (risk factors) (3)
- pts tend to be younger
- HTN
- anatomical malformations
- arteriovenous malformations
- can cause lack of blood flow??
- arteriovenous malformations
what is a uniqe problem of hemorrhatic strokes?
Blood getting into the brain can also cause its own problems
Risk factors for stroke (10)
Risk Factors (about the same as cardiac disease)
- 75%? of those who have stroke have HTN
- CHF
- PAD
- CAD
- Diabetes
- Hyperlipidemia
- Valve disorders in the heart
- Coronary artery bypass surgery
- during surgery and after
- after because if vessels in the heart have atherosclerosis, then vessels in other places have it too.
- A-fib (5x more likely to have stroke)
- because blood coagulates in the atria
- Aorta is the first one out
- first sets of arteries go to heart and brain
- Endocarditis
*
Is a stroke preventable?
yes the same old lifestyle stuff
What is a TIA a warning sign for?
TIA is warning sign for impending stroke (not as good as angina in the heart)
- 10% of people with TIAs will have a full stroke within 90 days?
- 5% will have strokes within 2 days
In heart we get angina that warns us about impending MI
What are early warning signs of stroke? (10)
Early warning signs
- FAST, etc.
- doesn’t have to have all FAST symptoms
- FAST is more for middle cerebral artery stroke
- numbness
- weakness
- facial droop
- trouble speaking
- gait/balance disturbances
- sudden severe headache (hemorrhagic)
- nausea/vomiting
- anxiety
- Faint/syncope/coma
Ischemic Cascade happens in what time frame?
3-4 hours
Eschemic Cascade process (5)
- •Excess neurotransmitter substances
- •Limits energy production
- •Influx of calcium ions with neuronal membrane pump failure
- •Free radical formation
- •Inflammatory factors
what happens after ischemic cascade?
Cerebral Edema
Describe what happens during Cerebral Edema/ Due to Cerebral edema: (5)
- •Fluid accumulation
- •Inflammatory mediators and blood factors
- •Increased ICP
- •Brainstem herniation
- •Cell death
how long does it take to reach maximum cerebral edema?
Max accumulation in 3-4 days
how long can you continue to have cerebral edema
2-3 weeks
what is a brainstem stroke called?
Uncus herniation
What is a TIA
A vascular syndrome with no neurological eficits
Any effects last less than 24 hours
what is a Carotid Endarterectomy?
rotor-rooter procedure for corotid artery
is the carotid artery easy or hard to fix?
easier to fix
the vessels in the brain are much harder
what is the severity of the stroke/CVA dependant upon? (4)
- –Location of ischemia
- –Size
- –Structures injured
- –Availability of collateral circulation
what can be done to fix a hemorrhagic stroke?
put metal clips on the vessel
if outpoutches are found in the brain do they ever prophylactically clip them?
yes
do MDs check for anurisms or outpoutches before putting pt on blood thinners for heart problems?
usually not
How would the decision be made about prophylactically clipping anurisms?
weigh the risks and benefits
how distal is the aneurism?
how hard is it to reach?
what does the pt want to do?
can angiogenesis happen in the brain?
yes
collateral arteries can grow more blood supply to an underperfused area
usually only is stimulated by ischemia as a result of pathology
how is the cerebral blood flow regulated?
it is autoregulated
What forms the extracranial blood supply? (2 pairs)
Internal carotid arteries
Vertebral arteries
What are three branches/related arteries of the internal cartotid artery in the brain?
- •Middle cerebral and
- anterior cerebral arteries
- •Anterior communicating
What are three cerebral arteries that are supplied by the Vertebral Artries
- •Basilar
- •Posterior cerebral
- •Posterior communicating
describe/draw the circle of willis
Imagine the parts of the cerebrum that are supplied by the anterior, middle, and posterior cerebral arteries
Anterior Cerebral Artery Syndrome
- •First terminal branch of internal carotid
- •Medial aspect of hemisphere
- •Contralateral symptoms
- •LE greater than UE
- –Sensory and motor
Describe 4 different spots where the Anterior Cerebral Artery may be blocked and what the difference in effect might be.
limbic versus _______ (look it up and fix this card)
(( tried to look it up and can’t find anything besides that “Profound albulia, a delay in verbal and motor response, is common. Akinetic mutism also can result in significant disability” - our patho textbook)
Middle Cerebral Artery Syndrome (7)
- •Frontal, Parietal and Temporal Lobes
- •Second main branch off internal carotid
- •Lateral aspect of cerebral hemisphere and subcortical
- •Contralateral symptoms
- •Sensory and motor
- –Face, UE greater than LE
- •Left hemisphere
- –Broca’s area- speech production, expressive aphasia
- –Wernicke’s area- speech comprehension, receptive aphasia
- •Right hemisphere
- left neglect
MCA stands for
Middle Cerebral Artery Sndrome
Frontal strokes do what to personality
may change it
not neccessarily better or worse
hard to deal with the fact they are different
Internal Carotid Artery Syndrome (2)
Massive symptoms
MCA & ACA involved
What type of stroke is FAST made for?
Middle Cerebral Artery Syndrome
(specifically on the left - speech)
A stroke effecting what side of the body will clue you in to probable speech problems?
A stroke that effects the right side of the body
(because Broca’s and Wernickie’s areas are on the left side of the brain)
what might you get with a stroke effecting the left side of the body
left neglect
what is left negelct?
a neuropsychological condition in which, after damage to one hemisphere of the brain is sustained, a deficit in attention to and awareness of one side of space is observed.
http://en.wikipedia.org/wiki/Hemispatial_neglect
Posteiro Cerebral Artery Syndrome (8)
- •Branch off Basilar Artery
- •Occipital lobe, temporal lobe, upper brainstem
- •Hemi anesthesia
- Homonymous Hemianopsia
- •Visual Agnosia
- •Prosopagnosia
- •Dyslexia
- •Memory deficits
Prosopragnosia definition
Prosopragnosia = difficulty identifying people
Homonymous hemianopsia definition
Homonymous hemianopsia, or homonymous hemianopia, is hemianopic visual field loss on the same side of both eyes.
Lacunar Syndrome (8)
- •Penetrating artery disease
- •Small and specific regions affected
- •Pure motor lacunar stroke
- •Pure sensory lacunar stroke
- •Dysarthria/clumsy hand syndrome
- •Ataxic hemiparesis
- •Sensory/motor
- •Dystonial/involuntary movements
are you likely to see Lacunar Syndrome patients in rehab?
not unless they have had lots of them
my be more likely to see in outpatient
(because their impairments are usually not as severe)
explain testing for Lacunar Syndrome
There are different diagnostic techniques for Lacunar Syndrome diagnosis
Sometimes it fails and we can’t find it but we treat the symptoms anyway
expain the difference in hemorrhagic stroke vs Ischemic stroke
Clotting stroke is called Ischemic even though both could technically have ischemia
What could be a risk from cervical manipulations?
a hemorrhagic stroke
but it is not well documented because it doesn’t happen immediately
Vetebrobasilar Artery Srroke potentially involves which three structures
- Vertebral Artery
- Basialr ARtery
- Circle of Willis
- supplies blood to the Posterior Cerebral ARtery if possible
what can a Vertebrobasilar ARtery Stoke in the Vertebral artery effect?
cerebelum
medulla
Vertebrobasilar artery stroke in basilar artery effects?
causes?
effects
- –Pons,
- Internal ear and
- cerebellum
couases –Locked-in syndrome
Locked in Syndrome
Damage to Basilar Artery (Vertebrobasilar Artery STroke)
- •Bilateral ventral Pons damage
- •Tetraplegia
- •CN V-XII involved
- •Vertical eye movements and blinking remain
- •Consciousness and sensation intact only
How To diagnose a Stroke (4 things - practice thinking of details if you want)
- •History
- •Physical Exam
- •Tests
- blood tests
- clotting time
- CBC
- Urinalysis
- Lumbar puncture
- EKG
- blood tests
- •Imaging
- CT
- MRI
- Ultrasound (dopplar)
- echocardiogram
Medical Management of stroke (Treatment)
considerations besides pharma or surgery (10)
Doctor will assess and treat the following
- •Blood flow
- •Blood pressure
- •Cardiac output
- •Fluid/electrolyte balance
- •Blood glucose
- •Seizures (seizures not too common)
- infections
- •ICP - pressure monitor
- we need to know how low to stay and monitori it. Highest is 20
- •Bladder and Bowel
- constipation and incontinance etc
- •Skin
Medical Management of stroke (Treatment)
Three Pharmacology options
•Pharmacology options
- –Anticoagulant
- –Antiplatelet
- –Antihypertensives
Medical Management of stroke (Treatment)
surgery options (2)
•Surgery options
- –Endarterectomy
- –Hemorrhagic
FIM stands for
FAM stands for
what is it?
who uses it?
FIM = Functional Independence Measure
FAM = Fucntional Assessment Measure
(it is a functional outcome tool)
everyone involved has a treatment has a say
describe FIM & FAM scale
- Complete Independence (timely, safely)
6 Modified Independence (extra time, devices)
5 Supervision (cuing, coaxing, prompting)
4 Minimal Assist (performs 75% or more of task)
3 Moderate Assist (performs 50%-74% of task)
2 Maximal Assist (performs 25%-49% of task)
1 Total Assist (performs less than 25% of task)
what does IADLs stand for?
Instrumental Activities of Daily Living
