Stroke Flashcards
Define stroke
Acute focal injury are the central nervous system by vascular cause → deficit
(irreversible brain damage, brain cell death)
Two main different types of stroke
- Ischemic ~80% (TOAST)
- Hemorrhagic ~20% (SAH & ICH)
New criteria for dx stroke
TOAST
stroke is the _______ MC cause of death in the US
3rd
Types of ischemic Strokes
- Large artery
- Lacunar
- Cryptogenic (unknown origin)
Difference between a ischemic stroke and “mini stroke”
- TIA = “mini stroke”: FND (focal neurologic deficit) resolves in minutes, imaging normal
- Ischemic stroke: permanent, irreversible FND
Modifiable risk factors for stroke (5)
- HTN
- Hyperlipidemia
- DM
- Heart: CAD, A-fib
- Diet/lifestyle: Tobacco
Stroke: non-modifiable risk factors (4)
- Age (increases every year, 60+)
- Sex (young male & 65+ females MC)
- Genetics
- Fam Hx
What is included in the ABCD2 score?
- Age
- BP >140/90
- Clinical feature: weakness 2 points, speech=1
- Duration
- Diabetes 2
3 Types of TIA
- Embolic
- Lacunar
- Large artery
2 Types of hemorrhagic stroke
- Intraparenchymal
- Subarachnoid hemorrhage
(star of death: aneurysm)
Watershed stroke looks like ______ on imaging
linear pattern
2 Causes of ischemic stroke
- cardio (clots from heart or emobli from sepsis)
- atherosclerosis
What is an important reference for determining where the acute ischemic stroke is in the brain?
Motor homunculus
ACA territory stroke: symptoms (5)
- Contralateral leg weakness
- Urinary incontinence
- Akinetic Mutism
- Tactile agnosia
- Gait impairment
(supplies frontal lobe & parietal lobe)
MC LVO’s
MCA territory stroke
(usually dominant (left) hemisphere)
PCA territory stroke: presentation
- Contralateral homonymous hemianopia
- Hemisensory loss
(occipital lobes
MCA territory stroke: symptoms
- Contralateral hemiparesis
- Contralateral hemisensory loss
- Hemianopia
- Aphasia: depends on location/size
- Hemispatial neglect (cannot preceive one half of the world around them)
Thalamic stroke (aka Lacunar Strokes (means “little lake”)) is a _____ etiology.
hypertensive
Pure motor stroke (lacunar stroke syndrome): deficit
Contralateral hemiparesis: weak face, arm, leg
(pure sensory is numb face, arm, leg)
Thalamic stroke sensory deficits (aka Pure sensory stroke or lacunar stroke syndrome) & nuclei involved.
- VPL of thalamus (L for Limb)
- VPM nucleas for face (M for mask, meaning face)
Pure sensory stroke (lacunar stroke syndrome): presentation
Contralateral hemisensory loss: numb face, arm, leg
(pure motor is contralateral hemiparesis: weak face, arm, leg)
Thalamocapsular stroke (aka sensorimotor stroke or lacunar stroke syndrome) is combined ____ deficits. Damage to the ____ (2).
- Contralateral paresis and sensory loss
- Internal capsule + thalamus
(mix between pure motor & pure sensory)
Dysarthria-Clumsy Hand (lacunar stroke syndrome): presentation (2)
- Slurred speech
- Weakness of contralateral hand; decreased fine motor skills
Dysarthria-Clumsy Hand (lacunar stroke syndrome): damage to _____
pons (CN V-VII)
(it can localize anywhere outside the CNS)
Ataxia-Hemiparesis (lacunar stroke syndrome): presentation
- Weak leg
- incoordination of ipsilateral arm & leg
(Contralateral hemiparesis and ataxia)
CADASIL is due to a ______ mutation
notch 3
(AD)
Fabry’s Disease genetic inheritance
X-linked
Fabry’s disease causes stroke and is due to _______.
lysosomal alpha-galactosidase A deficiency
CADASIL patients have recurrent ______
small vessel strokes
Initial evaluation: Stroke code
- Straight to the scanner! (“time is brain”~ 2 million neurons die/min)
- CT head
- MRI
- CBC, PT/INR, CMP, glucose
- TTE
(don’t need contrast for CT or MRI, only w/angio)
What is one of the most important questions when working up a patient with a possible stroke?
“When was the patient last known well?”
(we need to know when the symptoms started)
What is evaluated in an NIHSS score?
Define ischemic penumbra
Potential irreversible brain tissue injury caused by hypoperfusion after a stroke
(can be calculated and mapped)
What is this (image to the right)?
- this identifies the ischemic penumbra
- green = penumbra
- red = ischemic core
Acute stroke therapy: 2 options
- Thrombolysis: TPA, tenecteplase
- Endovascular
Thrombolysis (TPA): inclusion criteria (2)
NIH>2 or disabling sx
tPA relative contraindications
glucose < 40
(make sure the sx aren’t due to hypoglycemia)
Thrombolysis: exclusion criteria (5)
- Intracranial hemorrhage (last 3 mo.)
- Hypertensive (SBP must be <185/110)
- Active internal bleeding
- Bleeding at non-compressible site
- symptoms for >4.5 hrs
Endovascular therapy (mechanical thrombectomy) indications (2)
- Can be performed up to 24 hours after onset of symptoms
- NIH > 5
Endovascular (mechanical thrombectomy): inclusion criteria
- Evidence of large vessel occlusion on CT angio / perfusion
- Sizable ischemic penumbra relative to ischemic core
Post-acute stroke therapy management (after thrombectomy) (2)
- CTP
- CTA
Post-acute stroke therapy management (after tPA) (4)
- Close neurologic monitoring in ICU for 24 hours
- BP control between 160-185 mmHg
- no anti-platelet or anti-coagulation for 24 hours
- repeat CT
Post-acute stroke therapy: blood pressure must be ________.
between 140-185
(can reduce by 20 mmHg over the next 24 hours)
Define young stroke
Strokes in patients less than 50 years old
Workup for patients who present with a stroke who are less than 50 years old (3).
- Hypercoagulable panel
- Transesophageal echocardiogram (Patent foramen ovale)
- Long-term cardiac monitoring (A fib)
Hypercoagulable panel includes (5)
- factor deficiency
- protein deficiency
- mutations
- antiphospholipid Ab syndrome
- lipoprotein
Gold standard for ischemic stroke evaluation
MRI
(more detail of brain tissue, stroke territory, edema)
Left:
Right:
- Diffusion-weighted: white = ischemia
- Paired diffusion co-efficient map: black = ischemia
(confirms stroke: if white on diffusion-weighted and dark or “drop out” on co-efficient map)
Acute stroke management after TPA or thrombectomy (3)
- PT/TOT
- speech therapy
- screen for depression
Stroke complications (3)
- cerebral edema
- epilepsy
- depression
Stroke: prevention recommendations
- Diet (Mediterranean diet: fruit, veggie, lean meat, nuts)
- Exercise: 150 min moderate/week or 30 min x 5 days
- Blood pressure control
- Blood glucose control
- Weight control
hyperhomocysteinuria can cause stroke and is due to _______.
impaired cystathionine B-synthase
(AR)
Fibromuscular dysplasia can have a stroke due to _______.
arterial dissection
polycystic kidney disease is associated with ______ & _____.
- berry aneurysms
- SAH
Marfan’s orr Ehlers-Danlos type IV is associated with stroke due to _____.
dissection
MELAS can cause stroke and is due to ________.
mitochondrial disease w/metaboic stroke-like brain lesions
FAST
- Face : can they smile
- Arms : can they raise arms
- Speech
- Time
Right-hemisphere stroke deficits (2)
- left side movement & sensation
- analytical & perception tasks
Left-hemisphere stroke deficits (2)
- right-sided movement/sensation
- speech/language ability
Gaze preference
they look toward the side of the stroke
cerebellar stroke patients will present with ______.
balance & coordination deficits
Brain stem strokes will present with ______ (4) deficits.
- eye movement
- hearing
- speech
- swallowing
Dominant hemisphere stroke sx (2)
- aphasia
- contralateral hemiplegia: arm/face>leg
Non-dominant hemisphere stroke sx (2)
- contralateral hemi-neglect
- contralateral hemiplegia arm/face>leg
Parietal-occiptal stroke deficit (3)
- visual
- sensory
- language
Stroke/lesion location: facial numbness, weak jaw, lateral rectus palsy, facial weakness
- CN V – facial numbness, weak jaw movement
- CN VI – lateral rectus palsy
- CN VII – facial weakness
Stroke/lesion location: vertigo/hearing loss, dysphagia, weak palate or tongue weakness
- CN VIII – vertigo, hearing loss
- CN IX, X – dysphagia, weak palate
- CN XII – tongue weakness
metabolic workup for stroke patient (5)
- lipid panel
- HbA1C
- TSH
- Blood glucose
- T/PTT/INR
