Stroke 1- SG Flashcards
64 y/o R hand dom female w/ PMHx of HTN/HLD awakes w/ slurred speech and R arm wkness. Presents to ED within 30 mins, what is next step in tx?
CT scan of head without contrast (look for head bleed)
Which vessel provides large part of blood to brain?
MCA superior division
(Middle Cerebral aa)
Sudden focal neurological deficit or acute impairment caused by the interruption of blood flow to a specific region of the brain
- Sudden brain damage
- Lack of blood flow
Stroke
2 types of stroke
- Hemorrhagic
- Ischemic
- 85% of strokes are _____.
- 50 - 80% of all strokes are ____ through risk factor management
- 5th leading cause of death in US.
- Leading cause of serious disability in US w/ over 7 million survivors
- ischemic
- preventable
- FAST
- List the prevalence of stroke by race (3)
- F: Face drooping
- A: Arm weakness
- S: Speech difficulty
- T: Time to call 911
- Blacks
- Hispanic/Latino
- White
- Which race compared to Caucasians have nearly double the incidence of strokes?
- And suffer more extensive physical impairments
- And are twice as likely to die from stroke
African Americans
5 risk factors of African Americans for Stroke
- HTN
- Obesity
- DM
- Smoking
- Sickle Cell Anemia
(HODSS)
- Which race has a higher incidence of strokes as compared to Caucasians, but not as much as African Americans?
Hispanics
Which race?
- Increased risk for all types of stroke and Transient Ischemic Attacks (TIA) at younger ages than Caucasians?
Hispanics
Which race are less likely to know the stroke sxs?
Spanish-speaking Hispanics
Males or females suffer strokes more often?
Which age range?
Females (only slightly more)
80+ yrs
The 3 R’s
- Reduce: stroke risk
- Recognize: stroke sxs
- Respond: at first sign of stroke, call 911 immediately
3 components of the Cincinnati Pre-Hospital Stroke Scale
What is the sensitivity/ specificity if pt has all 3?
- Facial Droop
- Arm Drift
- Abnormal Speech
Sens: 100% Spec: 88%
- Unilateral weakness
- Unilateral numbness / tingling
- Incoordination / clumsiness on one side of body
- Sudden speech/language change
- Acute confusion
- Loss of vision in both or esp. ONE eye
- Diplopia
- Sudden/Severe HA
Focal sxs of stroke
When taking a focused hx of stroke, ask what 3 things to which 3 people?
- When was pt last at neuro baseline (normal)
- Pattern of onset (sudden or gradual)
- Sz at onset w/ associated bladder/bowel incontinence
5 goals of examination
- ABCDEFG’s (glucose)
- R/o mimics of stroke
- Localize lesions (focal vs diffuse) (UMN/LMN)
- Identify comorbidities
- Identify conditions which may influence tx decisions (recent surg/trama/active bleed/infection)
6 components of focused physical exam of stroke pt
-What scoring system should be used?
- Level of consciousness
- Language
- Visual fields / eye movements
- Strength / drift / reflexes
- Coordination
- Sensation
NIHSS (National Institutes of Health Stroke Scale)
- Standardized method used by health care professionals to measure level of impairment caused by stroke
- Used to see if tPA needs to be given
- Usable for research (objective comparison of efficacy of diff stroke txs)
- Determines if change in exam has occurred
- Scores are totaled to determine level of severity
National Institiute of Health Stroke Scale
(NIHSS)
- NIHSS is a ___ item scoring system w/ a __ minute exam.
- Integrates ____ exam components
- 6 components of exam?
- Minimal score is ___ (normal)
- Max score is ___ (severe stroke)
- Scores greater than ___ to ___ are more severe
- 13 / 7
- neurologic
- CN (visual), motor, sensory, cerebellar, inattention, language, LOC
- 0
- 42
- 15-20
NIHSS Interpretation
- Score for no stroke
- Score for Severe Stroke
- 0
- 21 - 42
- < ___ to ___ will have an 80% good/excellent outcome
- ___ to ___ will have a less than 20% good/excellent outcome
- _____ pts had the BEST outcomes**
- 12 - 14
- 20 - 26
- Lacunar Infarct
National Institute of Neurological Disorders & Stroke
- Benefit at ___ hours is not significant
- ____ dependent
- Tx pts are ___ % more likely to have minimal/no disability at ___ months.
- 24 hours
- Time (earlier the better)
- 30% / 3 months
Stroke Types:
- Clot occluding artery
- Bleeding INTO brain
- Bleeding AROUND brain
Which ones cause focal brain dysfunction?
Which ones cause diffuse brain dysfunction?
- Ischemic stroke (MC at 85%)
- Intracerebral Hemorrhage (10%)
- Subarachnoid Hemorrhage (LC at 5%)
Focal: Ischemic / Intracerebral
Diffuse: Subarachnoid / Intracerebral
2 Types of Stroke
- Caused by blocked blood vessel in brain or vessel that feeds brain
- Caused by ruptured blood vessel in brain
- Ischemic
- Hemorrhagic
Most common type of ischemic stroke, and results from the occlusion of small penetrating arteries that provide blood to the brain’s deep structures.
Lacunar Infarct / Stroke
What is the most common vascular obstruction leading to thrombosis?
(thrombotic stroke)
Atherosclerosis
What are the 2 most common sources of emboli?
(embolic stroke)
- Left sided cardiac chambers
- Artery to artery stroke (detachment of a thrombus from ICA-internal cardotid artery at site of plaque)
3 etiologies of Ischemia Stroke
- Cardioembolic
- Large Vessel Disease (atherosclerosis)
- Small Vessel Disease (Lacunar infarction)
- Sudden onset
- Focal neuro sxs
- Interuruption in blood supply to part of brain
- >24 hrs
- Typically >1 hr
- Permanent damage
Acute Ischemic Stroke (AIS)
- Sudden onset
- Focal neuro sxs
- Transient lack of blood supply & focal ischemia
- <24 hours
- Typically <1 hr (90%)
NO permanent damage to brain
Transient Ischemic Attack (TIA)
TIA
- Originally defined as a focal neurologic event lasting <24 hours
- Revised guidelines change this to consider _____, NOT _____.
- Consider amount of injury, NOT timeline
TIA
- _____ can lead to permanent brain damage
- Will injury show up on MRI?
- What is the pathophys of TIA?
- Brief ischemia
- Up to half of traditionally defined pts w/ TIA show injury on MRI
- Similar to stroke, but unknown why similar events produce TIA only
What % of people who experience TIA do not report it?
50%
AHA - Endorsed Revised Definition of TIA
- A transient episode of neurological dysfunction caused by focal ___, ___, or _____ischemia, WITHOUT acute infarction
- The reference to _____ was not helpful as is does not demarcate events with and without tissue infarction.
- brain, spinal cord, or retinal
- a 1 hour time point
One quarter to one half of strokes that occur within 3 months of TIA occur within what time frame?
Within the first 2 days
Which 2 risk stratifications predict short term risk of stroke well in independent popualations of pts presenting acutely after a TIA?
- The California score
- ABCD score
What is the newer score which provides a more robust prediction standard and incorporates elements from both the prior scores?
- ABCD2
ABCD2
- Age ___ or older
- BP ___/___ or over on first evaluation
- Clinical sxs of ___ or ____
- Duration of ___ minutes or greater or __ - ___ mins
- D?
- 60+
- 140/90
- Focal weakness w/ spell or Speech impairment w/o weakness
- 60 mins / 10-59 mins
- Diabetes
- What dx test (including diffusion sequences), should be considered a preferred test in investigation of pt w/ potential TIAs?
- May confirm focal ischemia as cause of pt’s deficit improves accuracy of dx of vascular localization & etiology of TIA
- Assesses extent of pre-exisiting cerebrovascular injuries
MRI
Class 1 Recommendations:
- Pts w/ TIA should preferably undergo ____ within ____ hours of symptom onset.
- What is the preferred brain dx imaging modality?
- What is second best brain dx imaging?
- neuroimaging evaluation / 24 hrs
- MRI, including DWI (diffusion weighted imaging)
- Head CT
Class 1 Recommendations of TIA
- What should be performed routinely as part of evaluation of pts w/ suspected TIAs?
Non-invasive imaging of the cervicocephalic vessels
Class 1 Recommendations of TIA
- ___ reliably excludes the presence of intracranial stenosis
- Pts w/ suspected TIA should be evaluated as soon as possible after event
- Non-invasive testing of the intracranial vasculature
Class 2 Recommendations
- Initial assessment of extracranial vasculature may involve what 4 tests? (depending on local availability and expertise)
- Carotid US
- TCD (transcranial doppler)
- MRA
- CTA
Class 1 or 2? (TIA)
- Electrocardiography should occur as soon as possible after TIA
- Prolonged cardiac monitoring (Holter Monitor) is useful in pts w/ unclear etiology
2
Class 2 Recommendations of TIA
- _____ is reasonable in eval of pts w/ suspected TIAs, esp when pt has no cause identified by other elements of work up.
- Is useful in identifying Patent Foramen Ovale and Aortic Arch Atherosclerosis, and Valvular disease
- Echocardiography (at least TTE)
- TEE
Zone of reversible ischemia around the core of irreversible infarction
(salvageable in first few hours after ischemic stroke onset)
Penumbra
Penumbra is damaged by what 4 things?
- Hypoperfusion
- Hyperglycemia >400
- Fever
- Seizure
