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N351: Pathophysiology I > Module 12 > Flashcards

Module 12 Flashcards

1
Q

What is a Stroke

A

clinical syndrome consisting of a constellation of neurologic findings, sudden or rapid in onset, which persist for more than 24 hours and whose vascular origins are limited to thrombotic or embolic occlusion of a cerebral artery resulting in infarction or a spontaneous rupture of a vessel resulting in intracerebral or subarachnoid hemorrhage”

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2
Q

Syndrome

A

compilation of signs and symptoms going together

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3
Q

Each person has a different looking __

A

stroke

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4
Q

Key Aspects of a Stroke

A
  1. Pathologic process affecting blood vessels that results in occlusion or rupture of blood vessels
  2. Resultant damage to brain tissue in area served by occluded or ruptured vessel
  3. Neurologic sequelae as a result of interrupted blood flow
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5
Q

A stoke is also known as a …

A

Brain Attack (a vascular disorder that injures brain tissue)

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6
Q

___ is one of the leading causes of morbidity and mortality in the US

A

Stroke

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7
Q

The longer the wait and delay in stroke treatment…

A

the more likely for irreversible damage

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8
Q

What are the 2 different types of strokes?

A
  1. Ischemic Stroke
  2. Hemorrhagic Stroke
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9
Q

___ Strokes are more common and make up 80% of strokes

A

Ischemic

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10
Q

Ischemic strokes are caused by ..

A

an interruption of blood flow in a cerebral vessels of thrombotic (50%) or embolic (30%) origin

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11
Q

Hemorrhagic strokes are caused by ..

A

bleeding into brain tissue d/t hypertension (10%), aneurysms (6%), AV Malformations, head injury, or blood dycrasias

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12
Q

___ strokes are less common BUT have a higher fatality rate

A

Hemorrhagic

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13
Q

Most ischemic strokes have embolisms come from somewhere between…

A

the left heart and brain (heart –> neck –> mid cerebral artery) since the path is of least resistance and is a straight line

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14
Q

The goal for an ischemic stroke is to …

A

return perfusion as fast as possible

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15
Q

What are examples of ischemic stroke treatments?

A

Anticoagulants

Removal of atherosclerosis/Arteriosclerosis

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16
Q

Coiling

A

treatment for ischemic strokes involving retrieving the clot and restoring perfusion

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17
Q

Blood Dyscrasias

A

abnormal amounts of other elements in the blood

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18
Q

Which stroke type is harder to treat?

A

Hemorrhagic

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19
Q

Strokes are the ____ leading global cause of death behind ___ ___

A

2nd; Heart Disease

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20
Q

Potential Stroke Sequelae?

A
  1. 22% of men and 25% of women die within
  2. stroke within 6 years of an MI
  3. half of men and women <65 die within 8 years
  4. 14% of TIA or stroke will have recurrence in first year
  5. 50-70% regain functional independence BUT 15-30% are permanently disabled
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21
Q

Modifiable Risk Factors for Strokes?

A

HTN

Cigarettes

High chol

Alcohol Use

Obesity

heart disease

diabetes mellitus

cocaine and other drugs

sedentary lifestyle

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22
Q

Non Modifiable Risk Factors for Strokes?

A

Age

Gender

Race

family history

Sickle cell disease

Polycythemia

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23
Q

What is the most important and common precursor to stroke?

A

Hypertension

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24
Q

Most common warning signs for stroke?

A

Sudden numbness, weakness, or facial/arm/leg paralysis - usually unilateral

Loss of speech, trouble walking, or trouble understanding speech

Sudden blurred or decreased vision, usually in one eye

Dizziness, loss of balance, or loss of coordination

sudden, severe headache with no apparent cause

difficulty swallowing

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25
Q

Usually people have what in regard to common stroke warning signs?

A

some but not all of them at once

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26
Q

Embolus

A

moving clot

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27
Q

thrombus

A

clot`

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28
Q

F A S T

A

Facial drooping Arm weakness Speech difficulty Time

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29
Q

Types and Frequency of Ischemic Strokes

A

16% - Atherosclerotic or Non Atherosclerotic Large Cerebral Artery Disease

27% - Penetrating artery disease

19% - Cardioembolic strokes

40% - strokes of undetermined origins

8% - misc (sickle cell or migraine)

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30
Q

Atherosclerotic Strokes cause what kind of strokes/damage?

A

Watershed Strokes (Border damage)

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31
Q

Penetrating Artery disease Strokes cause what kind of strokes/damage?

A

laminar strokes/lacunar necrosis

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32
Q

Cardioembolic strokes cause are due to waht?

A

embolus traveling from the carotid to (usually) the mid cerebral arteries

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33
Q

Transient Ischemic Attack (TIA)

A

Ischemic stroke characterized by focal ischemic cerebral neurologic deficits that last <24 hours (temporary and has little to no damage after)

person may not even realize it happened

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34
Q

Causes of TIA

A

Atherosclerosis Disease

Emboli

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35
Q

TIA may provide a warning for …

A

impending stroke

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36
Q

Early diagnosis of TIA may permit what …

A

early intervention and prevent extensive damage

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37
Q

TIA imaging shows…

A

NO necrosis of tissue in the brain (no area of central infarction)

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38
Q

S/S of TIA

A

Depend on cerebral vessel involved!!!:

Numbness and mild weakness on one side that persists briefly then resolves

Forearm, hand, and angle of mouth commonly affected

Transient visual disturbances (graying out, blurring, fogging of vision)

Rarely: Vertigo, dizziness, confusion, amnesia, seizures

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39
Q

Ways to Dx a TIA

A

CT Scan

Cerebrovascular Arterial Imaging (CAI)

cardiac Imaging

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40
Q

CT Scan

A

always used for strokes of suspected strokes

tells if the stroke is due to bleeding or a clot

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41
Q

CAI looks at

A

arteries (related to stroke)

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42
Q

Cardiac Imaging reveals…

A

reasoning for embolus formation

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43
Q

How is TIA treated?

A

Depending on the type and location via pharmacologic, medications, avoidance, and surgery

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44
Q

Pharmacologic treatments for TIA

A

Aspirin, Antiplatelet drugs, Anticoagulants

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45
Q

Can we use the same pharmacologic treatments (ex: anticoagulants) on a hemorrhagic stroke?

A

NO, it will thin the blood and make bleeding worse

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46
Q

Why is it important to avoid dehydration and hypotension when treating TIA?

A

the two can further compromise blood flow to the brain thus increasing ICP

(therefore be careful when lowering Bp with Meds for HTN)

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47
Q

Its important to use medications that lower BP for HTN judiciously when dealing with TIA because …

A

the hypotension could cause increased ICP and complicate blood flow to the brain

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48
Q

How does surgery treat TIA?

A

via removal of atherosclerotic plaques

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49
Q

Carotid Endarterectomy

A

surgery for removal of atherosclerotic plaque

Indicated by one or more TIA or mild stroke in the last 6 months and carotid stenosis >70%

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50
Q

Extracranial-Intracranial Bypass

A

surgery for redirecting blood flow from an artery in the scalp through the cranium to cerebral arteries (treatment for TIA)

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51
Q

Thrombotic Stroke

A

Ischemic Stroke type

It is the gradual blockage of a vessel usually occurring in atherosclerotic blood vessels - primarily at bifurcations

often accompanied by evidence of arteriosclerotic heart disease

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52
Q

The most common cause of ischemic stroke is …

A

Thrombotic Stroke

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53
Q

Thrombotic strokes are ___ ___ with activity and ___ occur at rest

A

not associated with activity and CAN occur at rest

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54
Q

Thrombotic strokes most often occur at …

A

bifurcations (areas of high stress and turbulent blood flow)

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55
Q

Thrombotic strokes tend to occur in ___ persons

A

older

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56
Q

How do thrombotic strokes relate to consciousness>?

A

consciousness may or may not be lost

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57
Q

Lacunar Infarcts

A

Type of ischemic stroke

small to very small (1.5-2 cm or 3-4 mm) infarcts in deeper noncortical parts of the brain or the brain stem

Found in area of deep penetrating arteries supplying the internal capsule, basal ganglia or brain stem

occlusion of smaller branches occur here

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58
Q

Most common arteries for lacunar infarcts?

A

middle or posterior cerebral arteries

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59
Q

Lacunar Infarcts are also known as …

A

Pinpoint death of tissue

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60
Q

Lacuna

A

small cavities after healing from lacunar infarcts revealing pinpoint areas of tissue death

function is lost here

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61
Q

What are the deficits like in lacunar infarcts?

A

Usually not profound, more specific/defined (ex: cannot multiply but can still add, subtract, divide, etc)

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62
Q

Causes of Lacunar Infarcts

A

Embolism

HTN

Small vessel occlusive disease

hematologic abnormalities

small intracerebral hemorrhages

vasospasms

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63
Q

Cardiogenic Embolic Stroke

A

Cardiogenic = coming from heart ; embolism stroke (ischemic in nature)

Sudden onset, immediate maximum deficit strokes usually coming from the left heart or the carotid

An embolism travels into a vessel and causes lack of blood supply to an area leading to brain tissue death

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64
Q

Cardiogenic Embolic Strokes usually affect …

A

smaller cerebral vessels, often at bifurcations

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65
Q

Most frequent site for cardiogenic embolic strokes?

A

middle cerebral artery distribution (offers path of least resistance from left heart or carotid)

66
Q

Predisposing conditions for Cardiogenic Embolic Stroke

A

Rheumatic heart disease

Atrial fibrillation

recent MI

ventricular aneurysm

bacterial endocarditis

67
Q

Cardiogenic embolic stroke incidence decreases with …

A

increased treatment of heart disease

68
Q

Penumbra

A

In ischemic strokes, a central core of dead/dying cells exist past clots

The core is surrounded by ischemic area of minimally surviving cells known as the penumbra (halo)

cells here get marginal blood flow, altered metabolism, and undergo electrical failure, BUT structural integrity is maintained

ITS STILL ALIVE (For now)

69
Q

Survival of penumbra depends on…

A

return of adequate circulation

volume of toxic products released

degree of cerebral edema (since viscous blood as a result makes it hard to get blood flow)

alterations in local blood flow

70
Q

With ischemic penumbra, we want to …

A

restore blood flow to the penumbra area ASAP

71
Q

Hemorrhagic Stroke

A

Stroke due to the rupture of a blood vessel and bleeding into the brain

72
Q

Most common predisposing factor for hemorrhagic strokes is …

A

hypertension

73
Q

Attempts by the brain to compensate for hemorrhagic stroke?

A

Edema

compression of brain contents

spasm of adjacent blood vessels

(does not help)

74
Q

Causes for Hemorrhagic Stroke?

A

Aneurysm

Spontaneous intracerebral hemorrhage

AV malformations

Others: Trauma, erosion of the vessels by tumors, coagulopathies, vasculitis, drugs

HTN

75
Q

We do not use anticoagulants like aspirin on hemorrhagic stroke patients since…

A

it can extend bleeding

76
Q

Hemorrhagic strokes occur …

A

suddenly; usually when a person is active (unlike thrombotic which is at rest)

77
Q

___ is common at onset of a hemorrhagic stroke, sometimes with ___

A

vomiting; headache

78
Q

Focal symptoms of hemorrhagic stroke depend on…

A

which vessel is involved

79
Q

Hemorrhage into the internal capsule (deep brain) leads to …

A

contralateral hemiplegia with initial flaccidity progressing to spasticity (of reflex arcs)

80
Q

Clinical course of hemorrhagic stroke often progresses rapidly to …

A

coma and frequently to death

81
Q

There is ___ treatment for hemorrhagic stroke

A

little treatment ; most treatment is supportive in nature

82
Q

Acute Manifestations of strokes are determined by ..

A

Affected Cerebral Artery

Area of brain Supplies

Adequacy of collateral circulation

83
Q

Acute Manifestations of Stroke may include ..

A

Loss of Consciousness

cognitive and motor disorders

specific motor or sensory impairment

aphasia

hemi-neglect syndrome

84
Q

Aphasia

A

partial or total loss of written and verbal communication

85
Q

Hemi-neglect syndrome

A

do not recognize half of the body

86
Q

Anterior Cerebral Artery can have effects on what parts of the brain if occluded d/t stroke?

A

Infarction of medial aspect of 1 frontal lobe (if distal to communicating artery)

Bilateral frontal infarction (if flow in other anterior cerebral artery is inadequate)

87
Q

S/S of Anterior Cerebral Artery Stroke

A

Paralysis of contralateral foot or leg

Impaired gait

Paresis of contralateral arm

Contralateral sensory loss over toes, foot, and leg

Problems making decisions or performing acts voluntarily

Lack of spontaneity, easily distracted

Slowness of thought

Aphasia depends on the hemisphere involved

Urinary incontinence

Cognitive & affective disorders (emotion and personality changes)

88
Q

Middle Cerebral Artery can have effects on what parts of the brain if occluded d/t stroke?

A

Massive infarction of most of the lateral hemisphere and deeper structures of the frontal, parietal, and temporal lobes; internal capsule; basal ganglia

89
Q

The middle cerebral artery feeds…

A

a lot of the brain

90
Q

____ is the most common area for infarction

A

Basal Ganglia

91
Q

Anterior and Middle Cerebral Arteries feed ___ and ____ ___ which is important to think about in regard to stroke manifestations

A

motor and sensory cortexes

92
Q

S/S of Middle Cerebral Artery Stroke

A

Contralateral hemiplegia (face & arm)

Contralateral sensory impairment

Aphasia

Homonymous hemianopsia

Altered consciousness (confusion to coma)

Inability to turn eyes toward paralyzed side

Denial of paralyzed side or limb (hemi-attention)

Possible acalculia (inability to perform calculations)

Alexia (word blindness)

Finger agnosia (inability to identify fingers)

Left-right confusion

Vasomotor paresis & instability

93
Q

S/S of the middle cerebral artery strokes often cause issues in the ___ side

A

contralateral

94
Q

Posterior Cerebral Artery can have effects on what parts of the brain if occluded d/t stroke?

A

Occipital Lobe (vision)

Anterior and Medial portion of temporal lobe

Thalamus and Cerebral Peduncle

95
Q

S/S of Posterior Cerebral Artery stroke affecting the Occipital lobe and anterior & medial portion of the temporal lobe

A

Homonymous hemianopsia

Color blindness

Loss of central vision

Visual hallucinations

Memory deficits

Perseveration (repeated performance of same verbal or motor response)

96
Q

S/S of Posterior Cerebral Artery stroke affecting the Thalamus

A

Loss of all sensory modalities

Spontaneous pain

Intentional tremor

Mild hemiparesis

Aphasia

(YOU COULD LOSE ALL SENSORY MODALITIES (except smell))

97
Q

S/S of Posterior Cerebral Artery stroke affecting the Cerebral peduncle

A

oculomotor nerve palsy (CNIII) with contralateral hemiplegia

(cannot maintain normal alignment of eyes when looking straight ahead, can give drooping eyelid or double vision)

98
Q

Basilar and Vertebral Arteries can have effects on what parts of the brain if occluded d/t stroke?

A

Cerebellum and Brain Stem (vision and balance greatly effected)

99
Q

S/S of Basilar and Vertebral Artery Stroke

A

Visual disturbances

diplopia

dystaxia

vertigo

dysphagia

dysphonia

100
Q

Diplopia

A

double vision

101
Q

Dystaxia

A

difficulty with muscle coordination

102
Q

Vertigo

A

disturbances of equilibrium; sensation of everything moving around in space

103
Q

Dysphagia

A

Difficulty swallowing

104
Q

Dysphonia

A

difficulty speaking (hoarseness, excessively breathy sounds since they cannot use vocal organs correctly)

105
Q

Most common signs fo stroke

A

sudden severe headache

weakness of one side

impaired balance

loss of speech

confusion

FAST

106
Q

Most common predisposing factor for stroke is …

A

untreated HTN

107
Q

Ways to d/x stroke?

A

Complete History and physical with thorough neurologic exam

CT (computed tomography)

Arteriography

MRA

PET

SPECT

US

108
Q

Arteriography

A

looks at blood flow to the brain

109
Q

MRA

A

magnetic resonance arteriography

looks at blood flow and condition of the vessels

110
Q

PET

A

positron emission tomography

look at glucose uptake to the brain (glc metabolism)

111
Q

SPECT

A

single photon emission computed tomography

112
Q

US

A

Doppler Ultrasound

what kind of flow is in the carotids

113
Q

Emphasis of stroke treatment is on…

A

salvaging brain tissue and minimizing long term disability

114
Q

Treatment for ischemic stroke involves a “window of opportunity” meaning what?

A

use of thrombolytic agents (clot breaking drugs) in early treatment should be used (streptokinase, urokinase, TPA)

115
Q

Contraindications for Thrombolytic agents in the treatment of ischemic stroke?

A

oral anticoagulant use

history of GI bleeding

Recent MI

stroke or head injury in the past 3 months

surgery in the last 14 days

BP greater than or equal to 200/120 mmHg

116
Q

What is treatment for hemorrhagic stroke like?

A

Less dramatic

More supportive, educate people on how stroke is like a heart attack and to seek immediate medical treatment, do NOT wait for Sxs to subside

focus on early rehabilitation

117
Q

Anticoagulants do what in comparison to Thrombolic treatment?

A

Anticoagulants prevent clots while thrombolic lyses or breaks a clot

118
Q

Important Potential Long Term Disabilities due to Stroke

A

Motor Deficits

Language and Speech Issues

Aphasia

Other: Dysarthria, Ataxia, Agnosia, Alexia, Anomia, conduction Aphasia, receptive/Fluent Aphasia

Denial or Hemi-Attention

119
Q

If a stroke affects the corticospinal tract, what can occur?

A

profound weakness can occur on the contralateral (opposite) side

120
Q

Areas affected by stroke leading to motor deficits?

A

Motor cortex

posterior limb of internal capsule

medullary pyramids

121
Q

S/S of Motor Deficits due to Stroke

A

decrease/absence of normal muscle tone

immediate loss of fine manipulative skills

affected limbs tend to move as a hole –> foot drop, outward rotation of leg

dependent edema in affected extremity –> PROM

122
Q

Why is it important to do PROM for people with stroke related motor deficits?

A

You need to help them do the ROM they cannot so the joint does not freeze

123
Q

When muscle tone returns after a stroke, what happens

A

flaccidity is replaced by Spasticity (no control over the movement occurring 6-8 weeks) –> altered limb posturing ( shoulder adduction, forearm pronation, finger flexion, knee/hip extension) –> PROM

124
Q

What is language?

A

Involves higher order integrative functions of the forebrain (speech, writing, math)

Used to communicate thought and feelings through use of symbolic formulations (words or numbers); information i9s transmitted vocally (spoken) or visually (written)

125
Q

What is speech?

A

Involves mechanical act of articulating language = “motor act” of verbal expression

Depends on functional integrity of peripheral musculature and its control

126
Q

Broca’s Area

A

Production of speech and flow from mouth (SPEECH)

127
Q

Wernicke’s Area

A

interpretation and understanding of speech (LANGUAGE)

128
Q

Dysarthria

A

imperfect articulation of speech sounds or changes in voice pitch or quality

caused by disturbed motor control

dysfunction of moving parts of speech; neurologic injury

129
Q

Ataxia

A

defective muscular coordination

*difficulty walking

130
Q

Agnosia

A

inability to recognize an object - may be tactile, visual, or auditory

involves structural damage to association centers of parietal, temporal, and occipital lobes

structural damage

131
Q

Alexia

A

word blindness

132
Q

Anomia

A

Difficulty recognizing or naming objects or colors

133
Q

Conduction Aphasia

A

Inappropriate word use despite good comprehension

Results from destruction of fibers connecting Wernicke’s and Broca’s Areas

134
Q

Neologism

A

invented words

occurs with receptive/fluent aphasia

135
Q

3 Major Language and Speech Problems due to Stroke

A

Aphasia
Dysarthria
Apraxia

136
Q

Disturbances of the central processing mechanisms of language is ___

A

Aphasia

137
Q

Dysfunction of the larynx, pharynx, palate, tongue, lips or mouth is ___

A

Dysarthria

138
Q

Inability to sequence voluntary movements needed for speech despite absence of motor deficits is ___

A

Apraxia

139
Q

Aphasia encompassess.

A

varying degrees of inability to comprehend, integrate, and express language

140
Q

Most common cause of Aphasia during stroke?

A

Occlusion of middle cerebral artery of the dominant hemisphere

141
Q

The left hemisphere is dominant in ___% of right handed persons

A

90%

142
Q

The right hemisphere is dominant in __% of left handed persons

A

70%

143
Q

Receptive/Fluent Aphasia

A

Represents a sensory agnosia or inability to comprehend spoken words - may be visual or auditory

Affected area: Posterior temp[oral or lower parietal lobe - Wernicke Lesion

Motor intact, cannot receive and process info, so it comes out as nonsense

Also known as “Wernicke’s Aphasia”

144
Q

Expressive or Nonfluent Aphasia

A

“Broca’s Aphasia”

characterized by inability to translate thoughts or ideas into meaningful speech or writing

Motor not intact

Affected area: Broca’s area (precentral gyrus) of the dominant frontal lobe

145
Q

Where is Broca’s Area

A

Temporal region, left sideq

146
Q

Where is Wernicke’s Area

A

occipital area, both right and left side

147
Q

Damage of the bundle of fibers connecting Broca and Wernicke areas leads to…

A

conduction aphasia where language is understood but speech does not make sense as they cannot produce words

148
Q

Denial or Hemi-attention

A

inability to analyze and interpret sensory info and internal production of abnormal signals –> denial of illness and denial of 1/2 body and surrounding environment

It is impaired spatial orientation with difficulty localizing stimuli, their own limbs, and objects in space

ex: they only eat half a tray of food and do not process the other half is there

149
Q

Denial or Hemi-attention is most common in strokes that …

A

affect the non dominant side of the brain (right hemisphere) which is usually involved in spatial orientation, body image, and inductive reasoning

150
Q

hemi-attention is a ___ AND ___ problem

A

vision and processing problem

151
Q

Effects of Stroke on the Right Side

A

Motor - effects contralateral side (left):

Weakness (hemiparesis), paralysis (hemiplegia), or lack of coordination of face, arm, leg on left side

lack of feeling and position on the left side of the body

decreased ability to judge distances, size, positions, rate of movement, and form

inability to think clearly

loss of awareness of forgetting objects on the left side (left sided neglect). the neglect is usually more severe with strokes on the right side of the brain

quick and impulsive behavior

difficulty drawing, dressing, or following a map

152
Q

Effects of Stroke on the Left Side

A

Motor - effects contralateral side (right):

Weakness (hemiparesis), paralysis (hemiplegia), or lack of coordination of the face, arm , or leg on the right side of the body

lack of feeling and position on the right side of the body

difficulty speaking (slurred or distorted speech), listening, writing, reading, calculating with numbers, or understanding what others say (aphasia)

Behavioral changes (slow, cautious, and somewhat disorganized)

Loss of awareness or forgetting objects on the right side

153
Q

Symptoms of stroke on left and right side depend on…

A

which side of the brain is “dominant”. Some left handed people have speech and language difficulties with right sided strokes

154
Q

Strokes make you lose…

A

A LOT of QOL - so be educational, patient, and kind

Teach the patient to pay attention to the side being neglected and the risk of running into things and falling that they may not see

155
Q

Homonymous Hemianopia

A

Nasal and Temporal Visual Field Issues due to lesion in various areas

visual field defect depends on the location

Lesions can occur before chiasm, at chiasm, after chiasm

156
Q

If there is a lesion of the optic nerve prior to the chiasm, what occurs?

A

You lose both nasal and temporal pathway/sight for that eye

*so if its a lesion on the right side, you go blind in the right eye

157
Q

If there is a lesion of the optic nerve at the optic chiasm, what occurs?

A

2 things can occur: half the fields disappear, or you go blind everywhere

So you can either lose L and R nasal fields, lose L and R temporal fields, or go completely blind

158
Q

If there is a lesion of the optic nerve after the chiasm, what occurs?

A

Homonymous Hemianopia

Homonymous means fibers are interrupted and the vision originating in the same side of both eyes is lost (ex: lose left nasal field and right temporal field which is right side of both eyes)

Hemianopia means tehre is a loss of vision from half of each field

Hemi-attention occurs from this

159
Q

Stroke on the left visual field (post-chiasm) leads to what? what about the right visual field?

A

Left - loss of right visual field (right side vision on both eyes)

right - loss of left visual field (left side vison on both eyes)

160
Q

What would cause and be seen by someone with left homonymous hemianopsia?

A

A stroke occurred post-chiasm on right side

They would only see the right side of both eyes (so their left visual field in both is blind)

161
Q

Homonymous Hemianopsia can lead to what other condition?

A

Hemi-attention/denial

162
Q

When interacting with a Homonymous Hemianopsia patient, it is important to do what?

A

Approach them on the side they can see you from to help, do not startle them, and help them relearn processes

you have to be patient and teach as its both a visual and processing disorder when hemi-attention occurs

N351: Pathophysiology I (11 decks)

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