Neurol - MedEd - Stroke

Question 1

Stroke - pathology (general) and 3 types of strokes

Answer 1

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

Question 2

What are the symptoms of stroke?

Answer 2

Mainly: focal neurologic deficits

Question 3

What are the 4 presentations of stroke?

Answer 3

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

Question 4

What does the circle of willis come from and what does it branch out in

Answer 4

Circle of willis comes from internal carotid

Branches off into anterior cerebral, middle cerebral, basilar artery, posterior cerebral

Question 5

What body areas for anterior cerebral artery?

Answer 5

Feet and legs

Question 6

What body areas for middle cerebral artery?

Answer 6

Arms, hands, face, speech

Question 7

What body areas for posterior cerebral artery?

Answer 7

Vision

Cortical blindness

Question 8

What deficiency with basilar-vertebral stroke?

Answer 8

Syncope

Basilar - locked in syndrome

Question 9

What deficiency with cerebellar stroke?

Answer 9

Ataxia

Cerebellar signs - dysdiadochinesia, incoordination

Question 10

Localize the stroke - which arteries are we interested? And is it contralateral?

Answer 10

Yes contralateral
ACA
MCA
Basilar
Vertebral
Posterior
Cerebellar

Question 11

So what is the first step to do when suspect stroke?

Answer 11

Do imaging - non-con CT of head - to check: is this a brain bleed? (non-con CT of head is basically an x-ray)

Question 12

What happens if non-con CT of head is positive?

Answer 12

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

Question 13

What happens if non-con CT of head is negative?

Answer 13

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

Question 14

Following the acute steps of stroke treatment, such as TPA, what to do after?

Answer 14

Get ECG
Echo
Carotid US (or CTA, MRA)
-Consult PT/OT/speech therapy

Question 15

Why do we get an ECG after a stroke?

Answer 15

Check for AFib

Need to be anticoagulated - Afib does not require a heparin to warfarin bridge

Question 16

Why do we get an echo after a stroke?

Answer 16

Check for heart failure

Check for thrombus formation - need anticoagulation. Will require heparin to warfarin bridge

Question 17

Why do we get a carotid US after a stroke?

Answer 17

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

Question 18

If there is a question of TIA vs. CVA?

Answer 18

Do MRI - to identify dead brain

Question 19

TIA?

Answer 19

Like a stroke lasting < 24 hours
Resolves
No evidence on MRI

Question 20

What are the treatments to consider:

Answer 20

1) TPA
2) Heparin
3) Warfarin
4) Antiplatelets
5) Risk factor modification (BP, DM, statins)

Question 21

How to use TPA - acute and chronic

Answer 21

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

Question 22

Do we give heparin in acute stroke?

Answer 22

Not really

Question 23

Do we give warfarin in acute stroke?

Answer 23

Not really

Question 24

Do we give aspirin in acute stroke?

Answer 24

Yes ASA 325 mg

Question 25

How do we control BP in stroke

Answer 25

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

Question 26

Do statins help in acute stroke

Answer 26

No

Can start as need to go home on statins

Question 27

How to manage stroke chronically?

Answer 27

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,