Neurol - MedEd - Stroke Flashcards
Stroke - pathology (general) and 3 types of strokes
Brain attack
Ischemia - infarction to brain
Brain doesn’t regenerate
1) Embolic stroke - thrombus forms and flicks off and causes a stroke. No diseased vessels in brain. Thrombus from somewhere - i.e. carotid artery, in heart (Afib, bad valve, IE), dissection of carotid
2) Thrombotic - cerebrovascular disease with plaque, plaque ruptures and thrombosis and distal tissue dies. Often occurs in patients with Afib, HTN, Dyslipid, CAD, PAD (all same processes)
-Embolic and thrombotic strokes are ischemic
3) Hemorrhagic - blood is irritant to brain, two ways:
-Subarachnoid hemorrhage
-Intraparenchymal hemorrhage
What are the symptoms of stroke?
Mainly: focal neurologic deficits
What are the 4 presentations of stroke?
1) HTN, diabetes, smoker, bad cholesterol, old (>45 for men, >55 for women)
2) Afib, prosthetic valve etc.
3) Young female with neck pain (usually following trauma) - usually written off as concussion. And focal neurologic deficit
4) Thunderclap headache - usually sentinel headache before
- Most importantly - focal neurologic deficits
What does the circle of willis come from and what does it branch out in
Circle of willis comes from internal carotid
Branches off into anterior cerebral, middle cerebral, basilar artery, posterior cerebral
What body areas for anterior cerebral artery?
Feet and legs
What body areas for middle cerebral artery?
Arms, hands, face, speech
What body areas for posterior cerebral artery?
Vision
Cortical blindness
What deficiency with basilar-vertebral stroke?
Syncope
Basilar - locked in syndrome
What deficiency with cerebellar stroke?
Ataxia
Cerebellar signs - dysdiadochinesia, incoordination
Localize the stroke - which arteries are we interested? And is it contralateral?
Yes contralateral ACA MCA Basilar Vertebral Posterior Cerebellar
So what is the first step to do when suspect stroke?
Do imaging - non-con CT of head - to check: is this a brain bleed? (non-con CT of head is basically an x-ray)
What happens if non-con CT of head is positive?
Means there is a bleed
If positive –> hemorrhagic stroke –> then need to drop the BP. Call neurosurgery –> clip, coil, craniotomy (due to limited space in skull, to relieve pressure and prevent herniation)
For medicine: need to lower BP. Need to reverse anticoagulation with FFP
What happens if non-con CT of head is negative?
So no blood….
The next question is - do I give TPA? Basically, to decide TPA needs to be less than 3 hours following stroke syx or last normal AND no c/i of giving TPA
Once it is decided whether or not to give TPA, the acute steps are over
Following the acute steps of stroke treatment, such as TPA, what to do after?
Get ECG
Echo
Carotid US (or CTA, MRA)
-Consult PT/OT/speech therapy
Why do we get an ECG after a stroke?
Check for AFib
Need to be anticoagulated - Afib does not require a heparin to warfarin bridge
Why do we get an echo after a stroke?
Check for heart failure
Check for thrombus formation - need anticoagulation. Will require heparin to warfarin bridge
Why do we get a carotid US after a stroke?
Check for carotid artery stenosis
If >80% stenosis and asymptomatic OR >70% stenosis and symptomatic –> need to intervene at this point!
Need Carotid endarterectomy (surgery) or stent
Stent is not as good as surgery. Stent is for people who cannot undergo surgery
Do not do surgery in acute stroke, wait 2 weeks post-stroke for procedure
If <70% stenosis or no carotid stenosis –> treat with medical management aggressively
If there is a question of TIA vs. CVA?
Do MRI - to identify dead brain
TIA?
Like a stroke lasting < 24 hours
Resolves
No evidence on MRI
What are the treatments to consider:
1) TPA
2) Heparin
3) Warfarin
4) Antiplatelets
5) Risk factor modification (BP, DM, statins)
How to use TPA - acute and chronic
TPA acute - < 3 hours following symptom onset (or < 4.5 hours in reality)
Big risk of TPA is hemorrhage - converting an ischemic stroke to hemorrhagic
When to count hours: from symptoms starting or last time seen normal (i.e. when went to sleep)
Before giving TPA… control BP <180/105
Who can you NOT GIVE TPA? Has a ICH, bleeding risk (i.e. GI bleed), recent surgery
Do we give heparin in acute stroke?
Not really
Do we give warfarin in acute stroke?
Not really
Do we give aspirin in acute stroke?
Yes ASA 325 mg
How do we control BP in stroke
Do permissive hypertension
BP > 220/120
Penumbra is area at risk
To maintain cerebral perfusion pressure to perfuse the penumbra - so let BP stay high
Do statins help in acute stroke
No
Can start as need to go home on statins
How to manage stroke chronically?
No role for TPA
No role for heparin
Warfarin - maybe if Afib, use CHADS2 score. So if had stroke –> CHADS2 at least 2. Either use Warfarin or NOAC
Antiplatelet - use baby aspirin if not previously on aspirin. If had stroke on aspirin, then add plavix
BP control - ACEi, diuretics, <140/<70
DM - A1C < 7
Statins - high-potency,
