neuro Flashcards
pathophys of stroke
-CVA -> is it venous or arterial
-Arterial:
-hemorrhagic or ischemic
-ischemic -> embolism, hypoperfusion (shock), thrombosis
-this is why shock can present with focal deficit
ischemic stroke (aka CVA)
-thrombosis or embolism
-2nd leading cause of death
-2nd MC disability
-MCC embolic- afib, thromboembolism
-RF- HTN, HLD, DM, smoking, TIA
-Negative sx and neuro deficits
-dysfunction is localized to brain area -> focal neuro deficit
-Onset- multiple sx (weakness AND sensory) occur simultaneously!
-thrombotic- gradual with stuttering pattern
-embolic or SAH- sudden and progressive
-weakness- raise arms 10s, pronator drift, weakness/paralysis
-CN- field cut, diplopia, blind, neglect (visual, sensory), pupillary size, EOM, expressive aphasia, receptive aphasia
-Reflex / cerebellar- finger to nose, heel to shin, reflex, babinski, gait
LVO syndromes
-Anterior cerebral artery (ACA)- contralateral WEAKNESS IN LEG > arm/face
-Middle cerebral artery (MCA)- contralateral WEAKNESS IN ARM/FACE > legs
-dominant side (MC left) = aphasia
-non-dominant side (MC right) = hemineglect
-Posterior circulation stroke-
-posterior cerebral, basilar, vertebral arteries
-dizzy/vertigo, ataxia, nausea, diplopia, dysarthria
-contralateral homonymous hemianopsia
POSTERIOR vascular territories
-Vertebral artery supplies brain stem and cerebellum
-Branches of vertebral artery: AICA, Basilar artery, PCA, PICA
-Crossed-findings are classic = Ipsilateral CN palsy + contralateral hemiplegia
-!5 D’s: dizziness (vertigo), dysarthria, dystaxia, diplopia, dysphagia
-!LOC, nausea/vomiting, ataxia, nystagmus are other common findings
-Require MRI for dx!!!!
-“Locked in syndrome”
-Basilar artery infarction
-Quadriplegia, can’t speak or swallow. Eyes are spared, and patients are awake and cognitively ware.
-Posterior inferior cerebellar artery (PICA) = Wallenberg’s syndrome
-Dysphagia, dysphonia are common
-Ipsilateral cranial nerve deficits with contralateral pain/temp loss
-Horner syndrome, Ataxia with a tendency to fall to affected side, nystagmus, vertigo can also be seen
wallenberg syndrome
-Lateral medullary infarct- Posterior inferior cerebellar artery syndrome (PICA) comes off vertebral artery
-Dizziness, nystagmus, N/V, dysarthria, dysphagia, diplopia, hiccoughs
-CROSSED findings
-Ipsilateralfacial numbness (CN V)
-IpsilateralHorner’s syndrome(sympathetic)
-Ipsilateralgait ataxia (cerebellum)
-Contralateralloss of pain & temperature sensation in limbs (spinothalamic)
-Cerebellar findings on neuro exam:
dysmetria- failure of finger to nose
chart
alerted level of consciousness
-broad differentials
-if sus of stroke -> can be due to:
-increased ICP 2ndary to stroke- ICH, SAH, CVT, massive ischemic stroke
-large posterior circulation stroke
-thalamic or pontine hemorrhage
acute ischemic stroke diff dx
-hypoglycemia
-TIA
-hemorrhagic stroke
-epidural or subdural hematoma
-abscess of brain mass
-migraine
-todd’s post-ictal paralysis
-carotid or vertebral artery dissection
-cerebral venous sinus thrombosis
ischemic stroke presentation
-Ask amount of time passed since sx onset
-hx- family members or caregivers
-wake up stroke- last known normal = when they went to bed
-ask about cardiac hx, previous CVA, MI or TIAs, meds
door to needle time
-0 mins- suspected stroke arrives at ED
-<10 min- ABCs and POC glucose
-last known well
-exams
-<15 mins- notify stroke team
-<25- Head CT or MRI
-<45- interpretation of scan
-review eligability of tPA
-review labs
-<60- IV alteplase within 3-4.5 hours from sx onset
initial eval stroke
-AIRWAY:Can they clear oral secretions & maintain airway?
-BREATHING:Provide supplemental O2 if oxygen saturation is <94%
-CIRCULATION:Are they hemodynamically stable?
-Hypotensionwith evidence of poor perfusion (shock state) can mimic stroke especially in elderly patients and should be appropriately managed.
-Hypertension:Patients with cerebrovascular accidents frequently have high blood pressure. The approach to blood pressure management in ‘AIS’ is inherently different from the approach in acute hemorrhagic stroke. For this reason, a neuroimaging study (CT or MRI) is critical to help guide blood pressure therapy in patients with acute stroke.
-IV Access:Obtain peripheral intravenous (IV) access andavoid unnecessary lines, and ABGsince minor vascular trauma in patients with ischemic CVA who are deemed to be candidates for thrombolysis may become a real problem.
-Initiate labwork: Coagulation tests, CBC, BMP, lipid panel, A1C, T&S
-DISABILITY:Perform a focused neurological exam and obtain a point-of-care glucose!
-The focused exam is structured around relevant data gathered during the medical history and is catered to the differential diagnosis. The examiner should be focused on determining whether (1) there is a lesion and (2) where the lesion is localized.
-At the same time, neuro-stroke team should be called, and patient brought to the CT/MRI scanner, an IV is placed as labs are drawn, and pharmacy is alerted that tPA may be needed
NIH stroke scale and NINDS
-Quantitative measure of stroke-related neurologic deficit
-Must be uniformly administered each and every time!
-Important ideas:
-Administer scale items in their exact order
-Avoid coaching the patient
-Accept patients first effort
-Score only what the patient does (not what you think they can do!)
-Be consistent
-Include all deficits (even from previous strokes)
-1a – Level of Consciousness
-1b – LOC questions
-1c – LOC commands
-2 – Best gaze
-3 – Visual
-4 – Facial palsy
-5 – Motor arm
-6 – Motor leg
-7 – Limb ataxia
-8 – Sensory
-9 – Best language
-10 – Dysarthria
-11 – Extinction / inattention
-Each item is scored from 0 to a max of 4
0 = no deficit
4 = completely impaired
Highest possible score = 42
The higher the score, the worse the impairment
ischemic stroke: initial tests
-Non contrast CT head:
-Determines if hemorrhagic stroke
-Acutely ischemic zones are not usually visualized until 6-12 hrs after sxs
-If negative CT head
-Suggests an ischemic stroke
-Obtain immediate CTA head/neck for causative vascular lesions
-MRI / MRA head and neck
-Not routinely available
-Can detect earlier and smaller strokes
-Better for posterior strokes (vertebrobasilar, occipital, cerebellar strokes)
-ECG
-Look for atrial fibrillation . Large strokes may see deep TWI and prolong QT
ECG
-12-lead ECG of a pt with acute stroke, showing large deeply inverted T-waves.
-Large inverted T waves can be a sign of increased intracranial pressure (ICP) from ischemic stroke and edema, intracerebral hemorrhage etc.
If an older patient with multiple cardiovascular risk factors presents with new onset vertigo and a stroke is suspected, what is the best imaging modality?
MRI
ischemic stroke management
-Assess for reperfusion therapy with IV thrombolytic (tPA) within 60 min of arrival:
-Ischemic stroke diagnosis causing neurologic deficits that are not improving
-!< 3 hours since onset of symptoms (<4.5 in select individuals)
-!≥ 18 years of age
-See contraindications/precautions for tPA on next slide
-IV tPA dose:
-0.9 mg/kg, max dose 90mg
-Divided 10% as IV bolus over 1 minute, and 90% slow infusion over 60 minutes
-Dual anti-platelet therapy
-Minor strokes (NIHSS ≤5) do not always receive tPA
-Initiate DAPT within 24 hours of symptom onset
-ASA + clopidrogel/ticagrelor
-Endovascular therapy (EVT)/ Intra-arterial thrombectomy
-Embolectomy or angioplasty with catheters
-Indicated in LARGE VESSEL OCCLUSIONS! (LVO) in the ANTERIOR CIRCULATION!
-Can be done up to 24 hours! after symptom onset
-Can be done even if patient received tPA
-Indications:
-<6 hours from symptom onset (but up to 24 hrs)
-High baseline function prior to symptom onset
-Minimal tissue damage on CT
-NIHSS score > 6
tPA
-Absolute CI to thrombolytics:
-!Intracranial hemorrhage on CT
-Clinical presentation suggestive ofsubarachnoid hemorrhage
-!Neurosurgery,head trauma, or stroke in the previous 3 months
-Uncontrolled hypertension (SBP> 185mmHg or DBP >110mmHg)!
-!History ofintracranial hemorrhage
-Known intracranialarteriovenous malformation, neoplasm, or intracranialaneurysm
-!Active internal bleeding
-Suspected or confirmedendocarditis
-Knownbleeding diathesiswith platelet count < 100,000/μL
-Elevated PTT with heparin administered in the last 48 hours or with the use of oralanticoagulants
-Glucose< 50 mg/dL or >400mg/dL
-Relative CI:
-Recent GI orurinary tractbleeding (past 21 days)
-Minor or rapidly improving stroke symptoms
-Major surgery or serious nonhead trauma in the past 14 days
-Seizure at stroke onset
-Recent arterial puncture at a noncompressible site
-Recentlumbar puncture
-Post-MIpericarditis
-Pregnancy
thrombolytics complications
-Hemorrhage (intracerebral)
-Consider if: sudden neurologic deterioration, ↓ LOC, new headache, N/V, sudden rise in blood pressure
-STOP INFUSION
-STAT CT HEAD
-10U cryoprecipitate and 6U of platelets
-Hemorrhage (systemic)
-Minor bleeds do not require cessation: oozing from IV, ecchymosis, gum bleeding
-Major bleeds require cessation: GIB, GU bleed
-Seizure
-Angioedema (~2%)
increased ICP
-A deadly complication of intracranial bleeds and massive ischemic strokes
-New or worsening headache
-Altered level of consciousness
-Nausea vomiting
-Visual changes
-Papilledema
-Cushing’s reflex: Bradycardia, Hypertension, Abnormal respiratory pattern
-CT scan to look for cause and/or signs of ↑ICP (See Neuro 3 lecture)
-Management to decrease intracranial pressure
-Call neurosurgery and neuro ICU!
interventions to lower ICP
A 34-year-old male with no significant past medical history presents to the ED with worsening left sided neck pain, headache, ringing in his left ear, and his left eye looks more “droopy” than normal.
Symptoms occurred after riding on the “scariest rollercoaster” in the amusement park two days ago.
No other neuro symptoms
Vitals signs are stable
Neuro: GCS 15, A&Ox3
Left eye ptosis, miosis
Strength 5/5
Sensation intact
Normal gait, neg Romberg, Cerebellar intact
Neck: no ecchymosis, bruising, bruits, tenderness
cervical artery dissection
-MCC of stroke in people < 50 years old
-RFs:
-Any trauma (even minor, especially rotary) can stretch/torque the cervical artery
-Post-chiropracter manipulation, hair washing at salon, massage, shaving, swimming, coughing, sneezing, yoga, MVA
-Connective tissue disorder
-Migraines, Infections, OCP use, smoking, pregnancy post-partum
-Tear in the wall of the arterial wall
-Can lead to intramural hematomas and even emboli -> TIA/CVA symptoms
-sudden
-Sx can vary greatly depending on location
-!Head/face/jaw pain seen in 74%
-!Headache and/or neck pain 57-90%
-Horner’s syndrome 25% (just miosis/ptosis)
-CN palsy 8-16% (mostly CN 12,9)- rare
-Signs of ischemic stroke (weakness, numbness, vision changes)
-Pulsatile tinnitus 16-27%
cervical artery dissection: carotid artery dissection vs vertebral artery dissection
-Carotid artery dissection:
-Anterolateral aspect of the neck
-Radiates to jaw/face/head
-Neuro findings are often contralateral
-Partial Horner’s syndrome
-Cranial neuropathy 9 and 12 (contralateral)
-MCA/ACA stroke symptoms
-Transient monocular blindness (amaurosis fugax)
-Retinal artery occlusion
-Vertebral artery dissection:
-Unilateral, posterolateral neck and occiput
-Neuro findings can be contralateral or bilateral
-Posterior circulation stroke sxs
-Vertigo, diplopia, visual field deficits
-Wallenberg syndrome- Dysmetria, ataxia, ipsilateral hemiplegia, contralateral loss of pain and temperature sensation
cervical artery dissection: dx and tx
-Gold standard for imaging = digital subtraction angiography (rarely used)
-!!Because they tend to present as a stroke:
-!Will get a non con CT head first
-!Followed by a CTA neck ± MRA neck to determine the involved vessel
-Management of extracranial cervical artery dissections:
-Antiplatelet (ASA) or anticoagulation (LMWH)
-Consider endovascular stenting
-Intra-cranial do NOT get anticoagulated (no heparin/warfarin) due to risk of subarachnoid hemorrhage , can still get anti-platelets
