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Setha: Neuro > Handler: Stroke > Flashcards

Handler: Stroke Flashcards

1
Q

the sudden or rapid onset of a neurologic deficit in distribution of a vascular territory lasting > 24 hours

A

Stroke

“Brain attack”

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2
Q

the sudden or rapid onset of a neurologic deficit in the distributionof a vascular territory lasting < 24 houts.

Most last <30 mins

A

TIA

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3
Q

Reversible ischemicinsult to brain cells that recover but increases risk of subsequent stroke

A

TIA

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4
Q

Worsening signs or symtpoms over time

A

Stroke-in-evolution

(progressive stroke)

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5
Q

Ischemia/infart __%

hemorrhage __%

A

85%

15%

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6
Q

3rd leading cause of death in the US

>200,000 deaths/year

Perception of elderly

Men 1.3x > Women

Blacks 1.3x > whites

A

Stroke

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7
Q

Most common cause of death in patients with cerebrovascular disease is _________?

A

Myocardial infarction

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8
Q

What is the most powerful risk factor for a stroke?

A

HTN

goal <140/90

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9
Q

Smoking (2-4x)

Atherosclerosis eslewhere (CHD, PAD)

Diabetes Mellitus (3x)

A fib (cardaic emboli)

Male gender, OCP, ETOH in excess, hyperlipidemia

Risk factors for?

A

Stroke

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10
Q

Large vessels (atheroscleorsis) often involved in ___% of all ischemic strokes (infarcts)

A

50%

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11
Q

Atherosclerosis: ______ vessels often involved

A

Large

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12
Q

___% of strokes are in anterior circulation of brain

A

80%

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13
Q

Why has incidence of stroke declined?

A

Development and treatment of HTN

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14
Q

Pathological outcomes depend on:

Adequacy of collateral circulation

Development of Circle of Willis

Duration of insult/restoration of blood flow

A

Stroke

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15
Q

Carotid bifurcation, origin of internal carotid

Base of aorta, external carotid, vertebral/basilar arteries

Effected in _____ strokes?

A

Ischemic

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16
Q

Small vessel disease

deep penetrating arterioles occlude/thrombose

A

Lacunar infarcts

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17
Q

20% of ischemic strokes are ____?

A

Lacunar infarcts

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18
Q

Major risk factor for lacunar infarcts is ____

lipids, DM contribute

A

HTN

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19
Q

Fibrous cap can erode and lead to an ______ placque?

A

ulcerative

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20
Q

Very small strokes or TIA’s defect < ____ cm (most are 5mm) on CT or MRI

A

1.5

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21
Q

May be without sx

detected by CT scan as incidental finding (small, punched out lesion)

A

lacunar infarcts

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22
Q

Embolism from heart or artery to brain

Important role in pathology of strokes and TIA’s

A

Cerebral Emboli

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23
Q

Blood clot breaks off, occludes more distant/distal vessel

A

Cerebral emboli

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24
Q

Often lodge in medium sized vessels (MCA,ACA)

If identified one, likely there are others

A

Cardiac emboli

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25
Q

20% of ischemic strokes are ____?

A

Cardioembolism

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26
Q

What is a very common cause of cardioelmbolism?

A

A fib

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27
Q

Abrupt onset of non-convulsive focal defect in a vascular territory

A

Stroke

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28
Q

___% of patients have no warning sx of stroke

___% have warning (TIA)

A

80-90%

10-20%

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29
Q

Contralateral hemiparesis or hemisensory loss

Hemianopsia (visual field defect)

If dominant hemisphere (left side of brain)-aphasia

If non-dominant- Speech and comprehension preserved; may develop anosognosia (denial/neglect of deficit) or a confusional state.

A

MCA

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30
Q

less common

Sx more pronounced in leg, associated language, gait disturbance.

A

ACA

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31
Q

least common

Vertebral artery (Branch of subclavian artery)

Crossed contralateral dysfunction (motor/sensory) plus ipsilateral bulbar/cerebellar signs: vertigo, dizziness, gait disturbance, diplopia, facial palsy, dysarthria, etc.

A

Posterior circulation

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32
Q

Clinical syndrome depending on where infarct is, may also present as TIA

Ex: contralateral motor/sensory deficit

Prognosis usually good

A

Lacunar strokes/infarcts

33
Q

Carotid dx present

Transient monocular blindness

Embolism to opthalmic artery (off carotid)

A

Amaurosis fugax

34
Q

What do you need to do to r/o hemorrhage associted with stroke?

A

MRI best in 1st 48 hours after intracranial hemorrhage

35
Q

Detection of infarcts on CT is limited to what?

A

size and timing

36
Q

__% of infarcts visible on CT in 1st 12 hours

>__% visible at one week

A

5%

90%

37
Q

Changes of infarct may be seen as early as 1 hour

usually not available or needed emergently

Provides better detail than CT for small lesions and for imaging posterior fossa

A

MRI/MRA

38
Q

Non-invasive with excellent resolution of large vessels

replaces need for arteriogramin some patients

May be difficult to differentiate complete vs. near complete occlusion

A

MRA

39
Q

Screening tool for evaluating common carotid and origin of internal carotid artery

May be difficult to differeniate complete vs. near complete occlusions

Non-invasive but limited capacity

A

Carotid Doppler Ultrasound (Duplex)

40
Q

MOST accurate

Invasive- “gold standard” for extra and intracranial disease

A

Arteriography

41
Q

Complications: contrast reaction, kidney failiure, placque rupture, stroke

Use of non-ionic constrast has reduced complications

What type of imaging?

A

Arteriography

42
Q

Risk factor modification: agressive control of BP, lipids, diabetes, smoking cessation, exercise, diet

Atrial fibrillation and emolization: full anticoagulation (Warfarin therapy long term)

Prevention for what?

A

CHD and stroke

43
Q

Abrupt onset of sx with transient focal neuro deficit dependent on involved anatomy

Sx may vary during episodes

Exam between episodes normal

Warning for subsequent stroke

A

TIA’s

44
Q

Embolic from carotid stenosis/placque or

Embolic from cardiac source

Severe carotid stenosis with transient HoTN

Small vessel occlusion: lacunar infarcts may minic

Etiology for ___?

A

TIA’s

45
Q

Important to listen for ___ with stethoscope with TIA’s?

A

bruit

46
Q

Carotid Endarterectomy and carotid angioplasty/stenting are surgical rx for?

A

Carotid TIA/Incomplete Stroke

47
Q

Surgical rx to remove placque

Best results if symptomatic blockage and >70% stenosis

Significantly recuces risk of subsequent ipsilateral stroke

For selected patients with sx and 50-70% stenosis

Risks: stroke and complications of surgery

A

Carotid endarterectomy

48
Q

Promising alternative to carotid endarterectomy but long term data is lacking

option in POOR surgical candidates

A

Carotid angioplasty/stenting

49
Q

For patients with poor operative risk

<70% stenosis or asymptomatic carotid disease

Risk factor modification: HTN, smoking, lipids, DM

A

Medical rx for carotid TIA’s

50
Q

Indicated for ALL patients with <70% stenosis and TIA sx, diffuse cerebrovascular dx, poor operative candidates, and asx carotid dx

Prevent platelet aggregation and release of vasoactive substances like thromboxane A2

A

Anti-platelet agents

51
Q

Inhibits cyclooxygenase

Inhibits synthesis of thromboxane A2, decreasing both platelet aggregation and vasoconstriction

Decreases frequency of TIA’s and risk of subsequent stroke and decreased recurrence of stroke

325mg daily: GI side effects and bleeding

A

Aspirin

52
Q

Inhibits platelet aggregation and prevents activation of glycoprotein ||b/|||a (a fibrinogen binder)

Decreases atherosclerotic events

Alternative to ASA for patients with recurrent TIA’s or ASA intolerance/allergy

75 mg/day: Diarrhea, rash

A

Clopidogrel (Plavix)

53
Q

Supportive measures plus ASA or Clopidogrel

Aggressive long term tx of BP and lipids

Usually good prognosis for recovery over 4-6 weeks

A

Lacunar infarct tx

54
Q

Hospitalize all patients (most TIA-1st episode)

Supportive (IV fluids)

Consider thrombolytic therapy

Tx for what?

A

Stroke

55
Q

What do you want to avoid when treating a stroke?

A

Rapid BP reduction

decreases perfusion and brain will autoregular perfusion

Only tx if <200/100 –> wait 2 weeks for oral meds if possible

56
Q

Dependent on timing

1st obtain head CT to r/o hemorrhage

if onset of sx <4.5 hours –> thrombolytic therapy with t-PA (bolus/infusion up to 90 mgs) over 1 hour

Tx for?

A

Cerebral infarct

57
Q

Requires team approach- best done in large tx centers

neurologic outcome improved at 3 mon and 1 year with decrease in expected deficit and reduction of intial deficit

increases chances of favorable outcome by ~50%

What type of stroke therapy?

A

Thrombolytic therapy

58
Q

Risks: Cerebral hemorrhage (6-7% incidence adn half will die)

Contraindications: recent bleeding, prior stroke, BP >185/110, recent major surgery

For what type of stroke therapy?

A

thrombolytic therapy (t-PA)

59
Q

loose mesh stent placed in thrombus obstructing cerebral vessels

removes thrombus and restores blood flow

Not yet FDA approved for all stroke patients

A

Solitare FR Revascularization Device

60
Q

Indications:

Embolus from heart (stroke or TIA)

A fib > 72 hours

Risk is cerebral hemorrhage

What type if tx?

A

FULL anticoagulation

61
Q

What must you do before starting full anticoagulation?

A

CT to r/o hemmorrhage

62
Q

Used for immediate and short term anticoagulation

Inhibit action of clotting factors

A

Heparin

63
Q

Long term oral anticoagulation

Inhibits production of clotting factors in liver

Stroke or TIA from cardiac embolism (decrease subsequent stroke risk)

Chronic A fib (decrease stroke risk)

Monitored by INR and frequent follow up for dosing

A

Warfarin

64
Q

Physical therapy, occupation therapy, speech therapy

Avoid prolonged best rest (UTI’s, skin infection/ulcers, PE)

A

Post stroke management

65
Q

What are the two types of Hemorrhagic stroke?

A

Intracerebral (HTN, AVM, Trauma)

Subarachnoid space (Aneurysm, AVM)

66
Q

________ is diagnositic for hemorrhagic stroke

A

CT

67
Q

What should you do if CT is negative for to rule out SAH?

A

Spinal tap

68
Q

Rupture of small arteries or microaneurysms of perforating vessels

Risks: HTN, hematologic and bleeding disorders (leukemia, thrombocytopenia, hemophilia), trauma, anticoagulant therapy, liver dx

A

Intracerebral hemorrhage

69
Q

Rapid evolution of neuro deficit often progressing to hemiparesis, hemiplegia, or hemisensory loss

50% mortality

Loss of or impaired consciousness develops in 50%

Vomiting and HA are common

A

Intracerebral hemorrhage

70
Q

Cautious BP reduction where applicable

Conservative and supportive tx - some benefit from surgical evacuation of hematoma

Surgery: decompression (limited usefulness)–> best in cerebellar bleeds and bleeding in AVM

Tx for?

A

Hemorrhagic stroke

71
Q

Most due to bleeding from saccular aneurysms

In 3-4% of population, usually w/o sx

2-3% risk of bleed per year

Highest risk if >6mm

A

Subarachnoid bleeds

72
Q

Sudden onset of severe HA followed by N and V, impaired or loss of consciousness +/- neuro deficits

Meningeal signs often present

A

Subarachnoid bleeds

73
Q

What are the two meningeal signs?

A

Kernigs and Brudzinski signs

74
Q

What imaging is used to identify blood in subarachnoid space?

A

CT

75
Q

If subarachnoid hemorrhage is suspected and CT is negative do _______ to look for blood or xanthochromia

A

CSF tap

76
Q

If patient conscious: bed rest, sx and supportive care with cautious reduction of BP

Once patient stable: angiography

Surgery or coil placement to precent re-bleed when applicable

Tx for?

A

Subarachnoid hemorrhage

77
Q

most common vascular malformation of CNS often involving MCA and branches

A
78
Q
A

Setha: Neuro (9 decks)

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