left side weakness

Question 1

when pt is weak on one side

Answer 1

define: numbness, tingling, unable to hold/lift things
-where is the weakness; i.e. fingertips-whole arm
“christmas lights” CNS or peripheral, impinging nerve by sleeping with neck “kinked”- nerve palsy

Question 2

5 most common causes of left-sided weakness

Answer 2

CVA-stroke
TIA
Intracranial bleed
Intracranial mass
Migraines (hemiplegic-presents like a stroke, N/V)

Question 3

other causes

Answer 3

radiculopathy i.e. pressure on brachial plexus while drunk

dissection (subclavian, another–>hematoma)

C-spine arthritis/herniation (compresses nerve–>injury) -trauma

AVM (AV malformation)-“jumbled BVs”

Todd’s paralysis (hemiplegia after seizure)-usually self-resolving

MS

Psychiatric (anxiety/panic attack)

drugs-vasospasm of BVs

Question 4

Life threatening conditions with left sided weakness

Answer 4

Acute CVA
Intracranial bleed
Aneurysm
Meningitis-intracranial abscess
Intracranial mass

(stroke, blood, vessel bulge, infection, tumor)

Question 5

stroke mnemonic

timing

prevelance

Answer 5

FAST
face, arm, speech, time

clock starts at onset of symptoms
1/6 ppl ww will have stroke

Question 6

CVA: thrombotic stroke

Answer 6

thrombus in BV-occlusion to part of brain

-destroy clot

Question 7

CVA: embolic stroke

Answer 7

dislodged embolus from a fib–>to small BV in brain
*from somewhere else

“fix” heart
ventral septal defect–>to brain

Question 8

CVA: hemorrhagic stroke

Answer 8

bleeding is cause

subarachnoid or intraparenchymal bleed

Question 9

risk factors for CVA

Answer 9

DM
HTN
smoking
afib
hyperlipidemia
obesity
fam risk factors
CAD 
previous strokes
OCPs
*similar to MI risk factors*

Question 10

TIA

Answer 10

• resolved symptoms
• high risk for CVA development-may have thrombus/emobolus present–>admit
• need to find risk factors and tx
• opportunity to prevent CVA

Question 11

CVA imaging: CT scan

Answer 11

initial (inflammation-deviation)

6 mos: goes back, swelling goes down

helps determine: is there a mass or bleed?
-can be done v. quickly, 10 min

Question 12

CVA imaging: MRI

MRA

Answer 12

can see more detail of injury

Magnetic resonance angiography, see BVs-can see occlusions-thrombus, where no perfusion

*both take longer than CT and $$
not all pts require

Question 13

intracranial mass

Answer 13

see inflammation, pushes opposite ventricle-deviation

Question 14

intracranial bleed

Answer 14

INR 3.6 (high, on blood thinner) HTN–>aneurysm–>may have spontaneous bleed

Question 15

hemiplegic migraine

Answer 15

unilat. musc. wkness, and/or paralysis

familial hemiplegic migraine- mult. fam members
vs. sporadic: gene mutations

*stroke (esp. ischemic) pts don’t typ. present with ha unless “popped” BV-aneurysm

IC mass may have ha

Question 16

MS

Answer 16

demyelination of brain/SC

may present as stroke symptoms-photophobia, optic neuritis, painful EOM, weakness, pain on one side, other neural exam abnormalities

usually in younger pts-may have no risk factors

dx: MRI- shows plaques, brain atrophy-enlarged ventricles, spots
tx: high dose steroids (i.e. 1000 mg)

Question 17

AVM

Answer 17

jumbled up BVs compress brain tissue–>symptoms

Question 18

radiculopathy

Answer 18

C-spine arthritis, disc herniation

observe dermatome pattern

MRI

PT, steroids, surgery

Question 19

carpal tunnel syndrome

Answer 19

transverse carpal ligament

numbness, tingling in arm, moves proximally

what dermatome pattern?

peripheral prob if specific fingers, NOT stroke

Question 20

dx: NIH stroke scale

Answer 20

LOC

best gaze
visual fields
facial palsy
motor
limb ataxia
sensation
best language
dysarthria
extinction and inattention
*see scale
*tPA advised?

Question 21

dx modalities

Answer 21

Imaging
CT scan
MRI/MRA

Labs

EEG-seizure, may have stroke-like symptoms

Invasive techniques

Question 22

when change in mental status,

Answer 22

call stroke alert

Question 23

complications of stroke

Answer 23

chronic pain, disability, death

Question 24

left side weakness questions

Answer 24

stroke?
ischemic(meds) or hemorrhagic (OR)?

onset of symps?

candidate for tPA? (3 hr)- TOU-time onset unknown, can’t use tPA

CIs for tPA? inc. bleeding risk

need consent? pt w. in time frame (3 hr)?

what are possible legal risks? -lawsuits, more lawsuits for NOT giving tPA

Question 25

stroke centers

Answer 25

acute stroke ready center: rural, basic, may use tele medicine–>neurologist

primary stroke center: standard, stroke unit, tPA

comprehensive stroke center: academic

Question 26

stroke certification is a big deal for hospitals

Answer 26

high volume, insured, high risk pts–>$$$ for hospitals

Question 27

tPA

Answer 27

3-4.5 hrs
*may extend from 3 hrs
Hussain stops at 3, may be sued if given after 3 hrs

Question 28

more invasive clot tx: intra-arterial

Answer 28

take catheter to thrombus and give small dose tPA

• dec. risk factor for bleeding
• up to 6 hr time window

Question 29

more invasive tx: if see clot on MRA

Answer 29

clot retraction- take out in situ with suction

-v. specialized centers

Question 30

CIs to tPA

Answer 30

bleeding anywhere
trauma, chest compressions
anemia
blood thinners
HTN
platelets low
recent sx
hx of IC hemorrhage

Question 31

tx

Answer 31

Depends on the etiology
Antiplatelet agents
Thrombolytics
Invasive techniques
Pain control
Treating the underlying medical conditions

Question 32

ischemic stroke

Answer 32

ASA/plavix (anti-platelet)
tPA
invasive: clot retraction
supportive: BP, glucose control