Intro & Pathophysiology of CVA

Question 1

stroke

Answer 1

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

Question 2

what is the leading cause of serious long-term neurological disability

Answer 2

stroke

Question 3

modifiable risks

Answer 3

• things we can change
• HTN, diabetes, CV disease, obestiy, obstructive sleep apnea, physical inactivity, diet, blood disorders, arrhythmias, hyperglycemia, smoking, alcohol, drugs

Question 4

non-modifiable risk

Answer 4

• things we cant change
• women > men
• 55 years old
• black/hispanic, american indian, alaskan natives
• prior stroke, TIA and/or MI
• genetics

Question 5

women > men

Answer 5

• 55,000 more females have a stroke than males

- higher lifetime risk

Question 6

when you’re older..

Answer 6

incidence doubles >55 years old

Question 7

race risk factors

Answer 7

• black/hispanic:white - 2:1 ratio –> increases to 4:1 btw ages 45-54
• american indian and alaskan natives are at high risk too

Question 8

prior stroke, TIA, and/or MI

Answer 8

23% of people will have a second stroke

Question 9

HTN risk factor

Answer 9

1 most common and most modifiable risk factor for stroke

Question 10

arrhythmias risk factor

Answer 10

increases CVA risk 5x

Question 11

ischemic strokes (cerebral infarct) cause

Answer 11

diminished volume of perfusion

cause: gradual worsening of fatty deposits lining arterial walls (atherosclerosis)

Question 12

thrombotic

Answer 12

blockage caused by clot form within involved artery - occur anywhere

Question 13

embolic

Answer 13

blockage caused by clot that travels from elsewhere in circulatory
smaller arteries

Question 14

hemorrhagic strokes cause

Answer 14

rupture of artery due to weakening of vessel wall

Question 15

intracerebral hemorrhage (ICH)

Answer 15

most common

cause: HTN

Question 16

subarachnoid hemorrhage (SAH) cause

Answer 16

• aneurysm and arteriovenous malformation (AVM)

Question 17

aneurysm

Answer 17

enlargement/ballooning of weakened vessel wall

Question 18

AVM

Answer 18

tangle of abnormal blood vessels connecting arteries and veins

Question 19

transient ischemic attack TIA

Answer 19

• transiet episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia without infarction
• mini stroke, warning stroke
• symptoms last < 24 hrs

Question 20

in the ischemic cascade, the infarct core experiences

Answer 20

necrosis

Question 21

in the ischemic cascade, the penumbra experiences

Answer 21

apoptosis

Question 22

in the ischemic cascade, what happens within minutes

Answer 22

neuronal death in core

Question 23

in the ischemic cascade, what happens within hours

Answer 23

surrounding tissue (penumbra) death

Question 24

onset of symptoms for a thrombotic event

Answer 24

• gradual onset
• days to weeks
• most common in late PM or first thing AM, may see “wake up strokes”

Question 25

onset of symptoms for a embolic event

Answer 25

more abrupt than thrombotic | minutes to hours

Question 26

onset of symptoms for a hemorrhagic event - aneurysm - AVM

Answer 26

- immediate, severe - asymptomatic until rupture - may have preceding symptoms (seizures, etc)

Question 26

onset of symptoms for a hemorrhagic event - aneurysm - AVM

Answer 26

- immediate, severe - asymptomatic until rupture - may have preceding symptoms (seizures, etc)

Question 27

common complaints of CVA

Answer 27

- imbalance - paraesthesias - weakness - blurry or double vision - "worse HA of my life"

Question 28

national institutes of health stroke scale (NIHSS)

Answer 28

- quantitative measure of symptoms associated with cerebral infarcts - 15 items --> consciousness, vision, motor & coordination, sensory & perception, language & fluency, behavior

Question 29

cut off scores for NIHSS

Answer 29

>25: very severe --> frequently require long term skilled care 15-24: severe --> frequently require long term skilled care 5-14: mild to moderatly severe --> typically require acute pt rehab 1-5: mild --> 80% will be discharge home from acute hospital

Question 30

when should a pt get a CT

Answer 30

- head trauma - financial concerns - acute hemorrhage - speed needed - skull fx - calcified lesion - claustrophobic pt - pacemaker or other metallic implant

Question 31

when should a pt get a MRI

Answer 31

- subtle areas of tumor, infarct, demyelination, etc. - brainstem lesion - ischemia - subacute or chronic hemorrhage - anatomy detail needed

Question 32

ischemia stroke major goal

Answer 32

revascularization

Question 33

management of an ischemia stroke

Answer 33

- tPA --> 3-8 hr window - permissive HTN --> <220/110 - antiplatelets for first 24-48 hours --> aspirin

Question 34

major goal for hemorrhagic stroke

Answer 34

reduce intracranial pressure (ICP) | sedation, hyperosmolar agents, hyperventilation

Question 35

management for hemorrhagic stroke

Answer 35

- anti-hypertensive for BP control --> strict BP parameters, <130/80 - vasospasm prevention and management (SAH) - antiseizure prophylaxis (ICH)

Question 36

if a pt has increased intracranial pressure, what are the PT considerations

Answer 36

- monitor for S&S of increase ICP - avoid activity that may exacerbate - mobility contraindicated if >20mmHg

Question 37

if pt has a midline shift, what are PT considerations

Answer 37

- evaluate bilateral symptoms | - monitor closely for neurological decline

Question 38

if pt has brain herniation, what are PT considerations

Answer 38

PT usually not indicated

Question 39

what is a vasospasm

Answer 39

persistent vasoconstriction and dilation of the blood vessels

Question 40

PT considerations for vasospasm

Answer 40

mobility contraindicated with moderate to severe vasospasm - consult MD prior to mobility

Question 41

seizures PT considerations

Answer 41

mobility usually deferred until > 24 hr after quiet EEG, monitor closely for seizure activity

Question 42

what are additional acute CVA complications

Answer 42

- HTN - fever - pressure ulcers - infection - pneumonia - hyperglycemia