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Neuromuscular management > Lecture 4 - Stroke > Flashcards

Lecture 4 - Stroke Flashcards

1
Q

Ischemia vs Infarction

A

Ischemia - Decreased blood flow (reversible)

Infarction - death of tissue due to lack of blood low

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2
Q

Thrombosis vs embolism

A

Thrombosis - formation of clot in vessel

Embolism- blot clot travels elsewhere and lodges in smaller vessel

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3
Q

Stroke vs TIA

A

Stroke - Disruption of blood flow resulting in change in neurological function (lasting more than 24 hours.)

TIA- Transient Ischemic Attack - Usually less than 1 hour, up to 24 hours.

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4
Q

T or F: a TIA will not show evidence on an MRI

A

T, it is a breif episode of dysfunction in the brain without evidence of an acute infarction on an MRI

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5
Q

When is the highest risk of a stroke after a TIA?

A

1st 30 days after

90 day risk after a stroke is 3-17%

Those with TIA have an 18.8% strok risk in the next 10 years

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6
Q

What are the categories of the ABCD tool used for evaluating the risk after a TIA ?

A

Age 60+ - 1pt

Blood pressure 140+ or DBP 90+ 1pt

Clinical features- unilateral weakness or speech impairment - 1 pt

Duration? 60+ minutes : 2 pt , 10-59 mins : 1 pt

Diabetes 1pt

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7
Q

ABCD2 score interpretations?

What is it used for?

0-7

A

Used to assess risk of stroke after someone had a TIA

7 total points

6-7: high risk of stroke in 2 days: 8%

4-5: Moderate risk of stroke in 2 days: 4%

0-3: Low risk of stroke in 2 days: 1%

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8
Q

What conditions can mimic a stroke?

A

Hypoglycemia/hypoxia

seizure

migraines

multiple sclerosis attacks

brain tumor/swelling

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9
Q

Why is weakness in both hands or both legs likely not indicative of a stroke

A

Because it cannot be localized to a single blood vessel

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10
Q

What is NOT an ischemic stroke?

A

Sudden loss of conciousness (note: this is true for a hemmorhagic stroke)

Pre-syncope/syncope

numbness in both feet

waxing/waning confusion

diffuse weakness

numbness in one and or foot

pain

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11
Q

Stroke is the ___ leading cause of death in the US

Globally it is the __ leading cause of death

A

5th

2nd

Note: it is the leading cause of serious disability in the US

There has been a decline in stroke mortality over past decades

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12
Q

What are considered modifiable risk factors for stroke

A

Hypertension

Diabetes

High Cholesterol

Heart disease

Smoking

Drug Abuse

Pregnancy

OCP(oral contraceptives)

Alcohol

Obesity

Physical Activity

Sleep Apnea

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13
Q

Nonmodifiable risk for stroke

A

Older age

Male

Family History

Race (Blacks > Whites)

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14
Q

Most strokes are :

A

Ischemic (87% of stroke)

note: 25-30% have undetermined etiology

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15
Q

An ischemic stroke will appear ______-dense on a CT

A

Hypo-dense

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16
Q

A hemorragic stroke will appear as _____dense on a CT scan

A

Hyperdense

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17
Q

Most ischemic strokes are ________, the second most common is ________

A

Undetermined Etiology

Small Vessel Disease

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18
Q

Of all thrombotic infarctions, –% had a warning episode

A

50%

Note: Thrombotic infarctions ofen happen during sleep, pt awakens w/ deficit

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19
Q

MCA infarctions mainly affect the ______

A

Hemiparesis of contralateral face/arm

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20
Q

MCA strokes can cause aphasia if which side of the brain is affected?

A

The dominant

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21
Q

If an MCA stroke happens on the _______ side, your neglect is more significant

A

Non-Dominant side

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22
Q

MCA strokes can cause _____ sensory loss and homonymous hemianopsia

A

Cortical

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23
Q

MCA strokes can cause a loss of conjugate gaze to the _____ side

A

Opposite side

(trouble looking away from the weak side)

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24
Q

Aphasia often starts as _______ and turns into only wernickes or broca’s aphasia overtime

A

Global Aphasia

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25
Q

The anterior MCA supplies what language area?

Posterior MCA?

A

Broca’s

Wernicke’s

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26
Q

ACA strokes (rare) will cause deficits where?

A

Leg > arm

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27
Q

ACA can cause urinary incontinence usually only w/

A

bilateral infarcts

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28
Q

PCA infarcts often cause what?

A

Homonymous hemianopsia

visual hallucinations

cortical blindness

inability to read (alexia)

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29
Q

Ischemia of Which cerebral artery can cause problems w/ motivation/organization behaviors

A

ACA

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30
Q
A
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31
Q

Symptoms of vertebrobasilar ischemia

A

Sensory/motor abnormalities in face/extremities

vertigo/clumsiness/ataxia

diplopia/dysarthria, dyphagia

nausea/vomiting

hearing loss/hiccups

32
Q

Basilar strokes can cause cranial nerve problems on the _________ side and weakness in the body on the _______

A

Ipsilateral side

Contralateral

33
Q

cerebral emboli arise in the heart from:

A

Mainly atrial Fibrillation

myocardial infarction

akinetic segment

endocarditis

34
Q

How will a cardioembolic stroke appear on an MRI?

A

Diffuse throughout bran

35
Q

_____(heart condition) can increase stroke risk x5 and x2 increase risk of death

but ____________ therapy can reduce the risk of stroke by 2/3

A

A fib

Oral anticoagulation therapy

36
Q

What is Warfarin (coumadin)

A

An oral anticoagulant used to treat a-fib

37
Q

3 places an embolic infarct can come from?

A

Aorta

Large intracranial arteries

Patent foramen ovale

38
Q

What is a “lacunes”

What are they usually related to/caused by?

They typically affect what structures?

A

Small artery occlusion

hypertension/diabetes

Putamen/caudate/internal capsule/thalamus/corona radiata, pons

39
Q

What are the classes/classic symptoms of lacunar infarctions

Pure motor:

Pure sensory:

Sensorymotor:

Dysarthria+ clumsy hand syndrome:

Ataxia-Hemiparesis:

A

Pure motor - Hemiparesis (Internal capsule base of pons)

Pure sensory stroke- (Posterolateral thalamus) - note: think dorsolateral column for sensory

Sensorimotor stroke: Thalamus + internal capsule (anything motor includes internal capsule)

dysarthria and clumsy hand syndrome: base of pons

Ataxia-hemiparesis - Pons + Internal capsule or subcortex

40
Q

+ Thalamic strokes cause ____________ sensory loss to all modalities

+ They may develop what syndrome?

+ Mild hemiparsis

A

Contralateral sensory loss

May develop Thalamic pain syndrome

41
Q
A
42
Q

Hearing loss, facial weakness, ataxia, horner syndrome

What (artery) stroke can cause these?

A

AICA

43
Q

PICA/Vertebral artery strokes can cause ______ syndrome

A

Lateral medullar/wallenberg syndrome

44
Q

ipsilateral ataxia and scanning/explosive speech

Strokes of what artery can cause this?

A

Superior Cerebellar artery

45
Q

What are rare causes of a stroke

A

Inherited disease

inflammatory disorders

hematologic disorders

46
Q

What are the 6 steps to approaching a patient w/ an acute stroke?

  1. _______
  2. Categorize _______
  3. Determine _______
  4. Calculate ________
  5. Determine ________
  6. Determine ______
A

Stabilize patient

Categorize as ischemic vs hemorrhagic

Determine last known normal

Calculate NIHSS score

Determine if theyre a candidate for acute thrombolytics

Determine if theyre a candidate for endovascular intervention

47
Q

What is the goal of door to needle time

(time they enter hospital to time they get clotbuster (TPA)

A

45 mins

note: the standard time is 60 mins

48
Q

For every ______ delay in TPA administration, there is a 10% decline in probability of a good outcome

A

30 min delay

49
Q

What is the most important aspect of the history of someone who’s had an acute stroke?

A

Time of onset

50
Q

11 Categories to the NIHSS

A

Conciousness

Best gaze- horizontal eye movemnent

visual field- determine if there’s hemianopia or blindless

Facial palsy - ask them to make faces

Motor (arm)- ask them to raise arms

Motor (leg)- ask them to raise leg in supine for 5 seconds

Limb Ataxia - check finger to nose

Sensory- use safety pin

Language

Dysarthria

Extinction/neglect

51
Q

What is the only FDA approved medicine for acute strokes?

A

TPA

Tissue plasminogen activator

52
Q

Contraindications for TPA:

_____ hours from last known normal

hemorrage

head trauma or stroke in last 3 months

severely high BP

Endocarditis

Bleeding disorder

High Glucose 50+

A

4.5 hours from last known normal

53
Q

T or F: TPA has no benefit to mortality of acute strokes

A

T

No benefit to mortality

However it does increase the likelihood of a good outcome within 3 months

54
Q

For patients who have received TPA, BP must be measured ____________ for the first 24 hours

A

Check every 15 mins for first 2 hours

every 30 mins for first 6 hours

Every hour for next 18 hours

55
Q

Patient’s who have taken TPA need to maintain a bloodpressure of what?

A

Under 180/105, however it’s suppose to be high, its bad if it’s low or normal

56
Q

BP goal for patient w/ TPA vs without?

A

With TPA: 180/105

Without? 220/110

Why? Because we want the higher BP in order to reestablish perfusion to the ischemic areas

57
Q

If a patient is worsening after receiving TPA what should the medical team do?

A

Repeat imaging

keep BP up

Keep patient supine

NO PT

May do craniotomy to reduce swelling

58
Q

What is a carotid endarterectomy?

A

Surgical procedure to remove plaque build up from carotid artery

59
Q

An ischemic stroke on a DWI will appear :

An ischemic stroke on an ADC will appear:

A

Light area on DWI

Dark area on ADC

60
Q

On a DWI, a new stroke will appear as a :

An old stroke will appear as a:

A

New stroke: Light hyperdense area

Old stroke: Dark hole

61
Q

The highest rate of recovery for a stroke is seen when?

A

1st 3-6 months

but can have improvement (small) for several years

62
Q

What abilities usually recover quicker after a stroke?

A

Swallowing/facial movements/ gait

note: recovery tends to begin proximally

63
Q

What abilities recover more slowily after a stroke?

A

Language, spatial attention, dominant hand movement

64
Q

What are signs of an intracranial hemorrhage?

A

Very rapid onset

Intracranial pessure symptoms: Headache, vomiting, decreased conciousness

CT scan will show blood fast

65
Q

T or F, you can tell an ischemic and hemorrhagic stroke apart using a physical exam

A

F

U need imaging

66
Q

What are the causes of an intracerebral hemorrhage?

Most common?

A

Most common: Hypertension

Trauma

Rupture of Arteriovenous malformation

aneurysm

tumor

hemorrhagic conversion

67
Q

Common locations of an intracerebral hemorrhage?

A

Putamen, cerebral hemisphere, thalamus, cerebellum, pons

68
Q

A higher score on the glasgow coma scale means what?

A

More conscious

note: 3 is minimum score

69
Q

How to treat intracerebral hemorrhage?

A

Treat intracranial pressure (Craniotomy/ectomy)

Intubate

reversal of antiplatelet or anticoagulation

Aggressive BP management

70
Q

80% of subarachnoid hemorrhage are caused by what

A

Rupture of intracranial aneurysm

Note: 10% die b4 medical attention

40% die in 3 months

50% of survivors have disabilities

71
Q

Symptoms of aneurysm rupture?

A

Sudden explosive headache

loss of conciousness

stiff neck/light sensitivity

nausea/vomiting

Note: 50% of patients have a warning leak with more subtle signs b4 a rupture

72
Q

What kind of stroke is the leading cause of death and disability

A

Aneurysmal subarachnoid hemorrhage

73
Q

How can vasospasm from a hemorrhage lead to an ischemic stroke?

A

The blood irritates the smooth muscles of vessels and leads to vasospasm

74
Q

Signs of a venous stroke?

A

Headache

Focal neurological signs

Hemorrhage

Altered mental state/seizures

Diagnose w/ CT or MRI

75
Q

Who does a venous stroke usually occur in?

A

Pregnant woman/ women on birth control

Neuromuscular management (19 decks)

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