Lecture 4: Stroke Flashcards
Stroke
Nontraumatic brain injury caused by occlusion or rupture of cerebral blood vessels that result in sudden neurologic deficit.
Transient Ischemic Attack
- Reversible neurologic deficit within a few, up to 24, hours
- Brain injury likely if beyond 1 hour
Most strokes are
- Ischemic
- thrombotic (60%)
- Embolic (20%)
- Vasculitic, hypercoaguable
Hemorrhagic strokes
- Intracerebral (10%)
- Subarachnoid (5%)
Pathophysiology Ischemia
Thrombosis (at the site)
- Plaque
- Fatty streaks at an early age
- Lipid core
- Vessel narrowing
- Small/large vessel
- could become embolic
Pathophysiology Embolic
(clot travels)
- A-fib, cardiomyopathy, valve disease, patent foramen ovale
- Calcified plaque
- Infectious endocarditis
- Rheumatic Heart disease
- Breaak off part of thrombus
Pathophysiology Hypercoaguable
- Sickle cell anemia
- Polycythemia vera
- Protein C & S defecient
- Factor V
- Antithrombin III defecieny
- Antiphospholipid syndrome
- Hyperhomo.
- Essential throbocytosis
- Prothombin gene mutuation
- Lupus
- Anticardiolipid antibodies
Thrombotic stroke clinical presentation
Ischemic
- Slower
- Stuttering
Embolic stroke clinical presenation
Ischemic
- Sudden onset
Hemmorhagic stroke presenation
- Severe headache
- Worst headache of my life
- Sudden
Risk factors for stroke
Nonmodifiable
- Age
- risk doubles every decade after 55
- Sex: female/older age
- Race
- Previous stroke
- Family history
- Coronary artery disease: modifiable?
Risk factors for stroke
modifiable
- HTN
- Hyperlipids
- A fib
- Diabetes
- Smoking
- Oral contraceptives
- physical inactivity
- Diet
- Sleep apnea
Allow permissive ___ first few days after stroke
HTN
Exercise, diet and logevity
- Protecting your tolemeres (caps on your DNA)
- Plant based diet
Primary treatment of CVA
- Reverse or limit impact
Secondary treatment of CVA
- Prevent the recurrence
BEFAST
- Balance
- Eyes
- Face
- Arm
- Speech
- Time
First thing you do to diagnose a stroke
CT Scan
Primary treatment of stroke
- Alteplase (TPA)
- Symptoms less than 4.5 hours
- No hemmorrhage
- SBP less than 185; DBP less than 110
- No recent surgery, MI, bleeding
- No minor or improving defecits
- Given IV
Things that may be given with alteplase
- Throbectomy
- Large vessel occlusion
- At times up to 24 hours
Asprin and primary stroke treatment
IF NOT GIVEN ASPRIN → HIGH RISK OF EXTENSION OF ISCHEMIC STROKES IN THE FIRST WEEK
Secondary prevention of stroke
- asprin
- not reccommended if no previous CVA/TIA
- Clopidrogel (plavix)
Carotid Endartarectomy
- Indicated for 70-99% stenosis in men
- Not indicated for less than 50% stenosis
- Risk is perioperative stroke
Stroke outcomes
- Mortality
- 20% overall
- Higher in hemorrhagic
- Strength: 3 months
- Language/Cognition: 6 months
- Function: early or late
- Cortical involvement: worse outcome
4 pillars of care
- quality
- safety
- efficiency (cost)
- satisfaction (relationships)
How to improve care
DMAIC
- Define
- Measure
- Assess
- Improve
- Control
Post stroke care
- Prevent deconditioning
- Splinting/positioning
- Spastic reduction
- Swallow assessemnt
- Monitor clinical stauts
- Functional training
- Braching
Antidepressants & SSRI in post stroke care
- Improves motor recovery
- Given in first 3 months
Left MCA
Right MCA
Posterior cerebral arteries
4 D’s
- Diplopia
- Dizziness
- Dysphagia
- Dysarthria
1 goal of patients after a stroke
- Gait
- Need balance
- Need hip flexion
- Braces can help; they are not a “crutch”
acute impatient
- Intensive: 3hrs/day, 5-6x/weel
- short stay
subacute impatient
- longer term, less intense caare
TBI
Definition: physical injury to brain tissue that temporarily or permanently impairs brain function
TBI population
- more common in men
- peak incidence teens and elderly
- most common causes
- falls: under 17 or over 55
- MVA: 18-55
- Sports
- Violence
most common cause of TBI
falls of ppl > 75
fall prevention
- address polypharmacy, balance impairments, orthostatic hypotension, minimze sedating meds
Glascow Coma scale
Mild: > 12
Moderate: 9-12
Severe: 8 or less
Diffuse axonal injury
- Leading cause of morbidity → primary injury stroke (cognitive, behavioral, and arousal defecits in TBI)
- Occurs during acceleration and deceleration events
Imaging and TBI
CT vs MRI
CT: acute blood and bone injury
MRI: diffuse axonal injury
Epidural hematona
- Buildup of blood occurring between the dura mater (the brain’s tough outer membrane) and the skull
- Results from a blow to the side of the head leading to a fracture of the temporal bone tearing the middle meningeal artery (high pressure → bleed quickly)
Subdural hematoma
Build-up of blood between the dura and the arachnoid (the middle layer of the meninges)
- Caused by head injury where velocity changes within the skull may stretch and tear small bridging veins (low pressure → slow bleeds)
- Common in the elderly and alcoholic due to cerebral atrophy
- “Crescent shaped”
- Shaken Baby Syndrome
Subarachnoid Hemorrhage
- Bleeding into the subarachnoid space-the area between the arachnoid membrane and the pia mater.
- Cause by traumatic and nontraumatic brain injury (ruptured aneurysm)
- Thunderclap headache-“Worst headache in my life.”
Epidural hematoma pic
Subdural hematona pic
Subarcahnoid hemmorhahe pic
hemorrhagic contusions
AVM
Congenital disorder of the connections between veins and arteries in the vascular system
- “Tangle of Spaghetti” on arteriogram
- Can bleed with devastating-stroke-like effects
Sugical management of AVM
- Craniotomy
- Epidural Hematoma
- Subdural Hematoma
- Burr hole drainage
- ICP monitoring
- Ventricular drain
Medical management of AVM
- Close observation
- Prevent hyperthermia which has poorer outcome
- Elevated ICP
- Hyperventilation
- Osmotic diuretics: mannitol
- Elevate head
- Cerebral perfusion pressure goal: 70-100 mm Hg
- ICP goal: 5-15 mm Hg
- SBP goal 100-180 mm Hg
- Ventricular drain
- Sedation to prevent ICP spikes
Complications of TBI
- DVT/PE
- Pneumonia
- Skin breakdown
- Pain
- Bowel/Bladder dysfunction
- Spasticity
- Contractures
- Deconditioning
TBI sequlae
- Neurologic findings
- Cognition
- Executive function
Spasticity Management
- Cold
- Prevent noxious stimuli
- Manual techniques
- Splinting/ serial casting
- Botulinum Toxin and Phenol Injections
- Baclofen Pump
- Medications
- Baclofen, Zanaflex, dantrium, clonidine, valium
Botulinum Toxin
- Different types
- Best for focal spasticity
- Indications
- Medication failure
- Improve function
- Improve hygiene
- Prevent Pain
Baclofen Pump
- Indications
- Lower extremity spasticity
- Improve function, hygiene
- Lessen pain
- Procedure
- Test dose
- Surgical implantation
- Refill every 3 months
