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Stroke Flashcards

1
Q

If thrombolytics are administered, what is the BP goal PRIOR to administration

A

Prior to administration, lower BP to <185/110

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2
Q

If thrombolytics are administered, what is the BP goal AFTER

A

Maintain BP <180/105 for 24 hrs

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3
Q

If thrombolytics are not indicated what is the BP goal?

A

allow permissive HTN

lower extreme BP by 15% in 1st 24 hrs so if SBP>220 or DBP>120

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4
Q

1st line therapy for eligible pts after a stroke is

A

alteplase or IV thrombolytic therapy

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5
Q

When is tPA given for ischemic stroke?

A

within 4.5 hrs of symptom onset

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6
Q

If pt presents outside 4.5 hr window then what to do?

A

give ASA and evaluate for mechanical thrombectomy which can happen within 24 hrs of stroke onset

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7
Q

Name criteria for strict exclusion of tPA

A

hemorrhage or multilobar infarct which includes >33% of cerbral hemisphere
CVA or head trauma in last 3 months
hx of ICH or neoplasm or vascular malformation
Recent intracranial or spinal surgery
active bleeding or arterial puncture in past 1 wk at a non-compressible site
BP>185/110
Plts<100K or glucose <50
AC use INR>1.7 or PT>15 or high active PTT

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8
Q

Name relative contraindication to tPA

A 
minor or rapidly improving neurodeficits
major surgery or trauma in last 2 wks
MI in the past 3 months
GU or GI bleeding in last 21 days
seizure at stroke onset
pregnancy
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9
Q

Indications for mechanical thrombectomy

A

large artery occlusion in anterior circulation and persistent neurodefects

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10
Q

Can mechanical thrombectomy happen if TPA was given

A

Yes it can, and don’t delay it to see if TPA worked

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11
Q

Additional imaging with evaluation of mechanical thrombectomy

A

CT or MR angiography

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12
Q

Role of aspirin in ischemic stroke

A

lowers risk reoccurrent ischemic stroke and should be given within 24-48 hrs
however if given TPA don’t give ASA within 24 hrs

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13
Q

How long to allow permissive hypertension

A

48 hrs

ONLY if not candidates for thrombolytic or mechanical thrombectomy

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14
Q

When to treat patients who have high BP after stroke

A

only extremely elevated SBP >220 or DBP>120 or active CAD, HF, aortic dissection, or hypertensive encephalopathy, acute renal failure or preeclampsia or eclampsia

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15
Q

Cerebellar stroke presentation

A

headache, vertigo, nystagmus, vomiting, gait ataxia, limb incoordination.

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16
Q

If someone has A fib and they got a TPA for their stroke, when do you start IV heparin?

A

at least 24 hrs after IV tpa if CT head shows no hemorrhagic transformation or diffusion weighted MRI of brain shows no evidence of a large completed infarct

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17
Q

when can a person post TPA and stroke eat?

A

need to remain NPO for at least 24 hrs post TPA in case there’s hemorrhagic conversion and need surgery to lower ICP.

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18
Q

Post TPA in a stroke besides adhering to BP goals, what stroke treatments should be delayed

A

Goal BP is <180/105 and need to delay feeding, AC and antiplatelets for at least 24 hrs until repeat CT scan shows no hemorrhagic conversion.

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19
Q

symptomatic pts with TIA or ischemic stroke with a CEA of 70-99% should have

A

carotid endarterectomy

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20
Q

when should a carotid enarterectomy CEA be offered after a ischemic stroke or TIA?

A

1-2 weeks after a non disabling stroke or TIA helps improve outcomes for surgery

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21
Q

how long to delay enarterectomy or CEA in large strokes with cerebral edema or hemorrhagic complications?

A

4-6 WEEKS,

in high grade stenosis prefer CEA over carotid artery stenting due to lower periprocedural mortality and stroke rates.

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22
Q

what is the role of anticoagulation with warfarin after ischemic stroke

A

none. no benefit and it can increase risk for hemorrhagic transformation

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23
Q

do we use nimodipine after ischemic stroke?

A

No it’s used as post aneurysmal subarachnoid hemorrhage and used to protect against vasospasm. not used in ischemic stroke.

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24
Q 
Name the type of stroke/head bleed based on presentation: severe headache at onset
meningeal irritation (neck stiffness) 
focal deficits are uncommon
A

spontaneous subarachnoid hemorrhage.

bleeding from arterial saccular aneurysm or AVM

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25
Q

Name the type of stroke/head bleed: history of uncontrolled HTN, coagulopathy, illicit drug use
symptom progression over minutes to hours
focal neurological symptoms appear early and followed by features that are seen with increased intracranial pressure.
See headache, vomiting, bradycardia, and reduced alertness

A

intracerebral hemorrhage. - seen with worsening symptoms and see progression with symptoms concerning for ICP.

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26
Q

Name the type of stroke/head bleed: history of cardiac dx (a fib or endocarditis,) or carotid atherosclerosis,
onset of symptoms is abrupt and maximal at start
multiple infarcts in different vascular territories

A

ischemic or embolic stroke

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27
Q

Name the type of stroke/head bleed: atherosclerotic risk factors (uncontrolled HTN, DM) with history of TIA. See local obstruction of an artery and symptoms may alternate with periods of improvement (stuttering progression)

A

ischemic (thrombotic) stroke

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28
Q

MCA stroke deficits are:

A

see contralateral somatosensory and motor weakness (face, arm, leg) and people will also have conjugate eye deviation toward side of infarct called contralateral homonymous hemianopsia (superior and inferior optic radiations).

There will be hemineglect (if stroke affected non dominant hemisphere).

There will be aphasia if stroke affected dominant hemisphere.

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29
Q

acute subdural hematomas (SDH) presentation

A

lucid interval before progression to coma within 24-48 hrs after onset. Chronic SDH may be present with progressive cognitive impairment and headaches and seizures weeks after onset.

30
Q

acute spontaneous subdural hematomas occur from

A

rupture of bridging vein

seen in elderly where there’s volume loss and more bridging vein can get ruptured.

31
Q

when do we see VTE after a stroke?

A

generally sen in 13-25% of pts about 2-4 weeks after stroke onset.

32
Q

after TPA is given what is management for ischemic stroke:

A

keep BP < 180/105, get MRI/CT head after 24 hrs. Meantime hold feeding, ASA, or lovenox until after 24 hrs and imaging shoes no signs of intracranial hemorrhaging. start statin.

Ok to give thigh high pneumatic compression devices.

33
Q

Midbrain stroke is also known as

A

Weber syndrome

34
Q

Ipsilateral cranial nerve 3 palsy and contralateral lower facial weakness and hemiplegia

A

midbrain stroke or Weber syndrome

35
Q

midbrain stroke or Weber syndrome deficit

A

Ipsilateral cranial nerve 3 palsy and contralateral lower facial weakness and hemiplegia

36
Q

lateral medulla stroke is also known as

A

Wallenberg stroke

37
Q

ipsilateral Horner’s syndrome (ptosis, miosis, anhidrosis), loss of facial pain and temperature,

contralateral loss of body pain and temperature

hoarseness and dysphagia

A

Wallenberg stroke / lateral medulla stroke

38
Q

ipsilateral tongue weakness

contralateral hemiplegia and decrease positional sense

A

medial medulla stroke

39
Q

Cerebellar stroke

A

nystagmus, ataxia, nausea and vomiting

40
Q

medial medulla stroke symptoms

A

ipsilateral tongue weakness

contralateral hemiplegia and decrease positional sense

41
Q

Wallenberg stroke / lateral medulla stroke symptoms are:

A

ipsilateral Horner’s syndrome (ptosis, miosis, anhidrosis), loss of facial pain and temperature,

contralateral loss of body pain and temperature

hoarseness and dysphagia

42
Q

brain stem involves your cranial nerves and so you have the

mid brain
pons
medulla oblongata

A

mid brain corresponds to CN 3-4 (oculomotor and trochlear)

pons corresponds to CN 5-8 (trigeminal, abducens, facial, vestibulocochlear)

medulla oblongata (CN 9-12) glossopharyngeal, vagus, and spinal accessory and hypoglossal

43
Q

Where to CN1 and 2 originate?

A

originates in the cerebrum and are not affected in brainstem strokes

44
Q

acute cortical stroke in MCA would result deficits of:

A

contralateral hemiplegia and sensory loss

aphasia happens if dominant hemisphere is involved.

45
Q

acute stroke in posterior limb of internal capsule would result in

A

lacunar stroke and can see contralateral hemiparesis and sensory loss and occasional facial weakness.
NO cranial nerve deficits or cogwheel rigidity.

46
Q

TIA is a

A

transient episode of neurological impairment (of CNS origin) without acute infarction.

Prior TIA or minor stroke without residual deficits require immediate evaluation for risk for recurrent stroke

47
Q

what is the ABCD2 score

A

prognostic tool to predict risk for ischemic stroke in the first TWO days following TIA. anyone with 3 or more points should be hospitalized.

48
Q

ABCD2 score stands for:

A

Age>60 yrs (1)
Blood pressure>140/90 (1)
Clinical presentation: unilateral weakness (2) , isolated speech impairment (1) , other (0)
Duration of TIA symptoms: >60 min (2) , 10-59 min (1), <10 min (0)
D presence of diabetes (1)
>3 moderate and >6 is high

49
Q

National stroke association criteria for TIA to get hospitalized is if they have the following with a TIA in the last 24-48hrs

A

duration of symptoms >1hr
symptomatic internal carotid artery stenosis >50%
multiple recurrent TIAs
afib or other known cardiac source of embolus
hypercoaguable state
high risk of stroke after TIA as determined by ABCD2 score

50
Q

Initial TIA work up is:

A

ultrasound of the carotids, CT or MR angiography of brain and EKG

Negative initial studies should undergo TTE to rule out cardiac cause.

51
Q

After having a TIA what should be started on pt?

A

aspirin and statin.

52
Q

young female without risk factors has a stroke (or VTE) what do check for?

A

APS

start on DAPT for first 48 hrs and get MRI. don’t start anticoagulation if presenting with stroke.

53
Q

Complication of stroke is

A

DVT which can happen up to 15% of people in the 1st 30 days with PE accounting for 25% of early death after stroke

54
Q

when can DVT develop after a stroke?

A

24 hrs after stroke and peak incidence is 2-7 days after stroke

Risk factors: hemiparesis, a fib, immobility and advanced age

55
Q

what is indicated in pts who have ischemic or hemorrhagic stroke to prevent DVT

A

ischemic stroke: pharmacological DVT prophylaxis

Hemorrhagic stroke: contraindicated pharmacological. can use intermittent pneumatic compression stockings or IPC within 72 hrs of acute stroke to prevent DVT

56
Q

when can you start pharmacological DVT prophylaxis for hemorrhagic stroke?

A

can start pharmacological DVT prophylaxis within 1-4 days as long as repeat CT imaging doesn’t show any further signs of further bleeding.

57
Q

recrudescence is

A

acute exacerbations of prior neurological deficits can happen in acute infectio nor metabolic derangement
hard to distinguish from new ischemic event

Need diffusion weighted brain MRI

58
Q

carotid artery dissection is caused by:

A

trauma or spontaneously

risk factors: HTN, smoking and connective tissue disorders

59
Q

acute trauma, thunderclap headache <1 one minute in onset and see ipsilateral horner’s syndrome
ipsilateral MCA stroke like symptoms

A

think carotid artery dissection

need to get a MRA or CTA to show the ICA with a tapered flame shaped appearance

60
Q

Treatment of internal carotid artery dissection

A

prompt recognition needs to be treated with:
anticoagulation, antiplatelet therapy, endovascular or surgical endovascular repair

can decrease stroke, neurological stability and death

61
Q

carotid artery dissection presentation varies in that it can prsent as:

A

TIA, ischemic stroke or embolic stroke

see partial ipsilateral horner’s - partial ptosis, miosis without anhidrosis
can see ipsilateral MCA stroke

62
Q

what happens in an internal carotid artery dissection

A

blood enters the inner and outer arterial layers which form clots and can also lead to embolic stroke.

63
Q

cerebral venous sinus thrombosis presents as a

A

thunderclap or gradual headache with focal neurological signs.
no horner’s syndrome

64
Q

vertebral dissection presentation:

A

thunderclap headache, Horner’s syndrome if there’s infarction to lateral medulla (Wallenburg syndrome) loss of sensation to face and contralateral body and nystagmus and ataxia

65
Q

what to do after an acute ischemic stroke and someone gets TPA and BP is within goal?

A

get a CT angiography to evaluate if they are also a candidate for endovascular therapy

People who get TPA for acute stroke can also get endovascular therapy and benefit from it. Unlikely they will have recanalization with TPA with large vessel stroke.

66
Q

ABCD2 score needed to be admitted to the hospital for work up

A

3 or more

age
BP
clinical presentation
duration of symptoms
diabetes
67
Q

if strongly suspicious for a stroke what is the FIRST imaging study to order?

A

CT head - rule out hemorrhagic stroke resulting in neurological detrioriation.

Highest mortality and this is a rapid test

68
Q

if you see a cerebellar hemorrhage on CT scan in someone who is acting like they have a stroke, when do you get surgery involved to treat pt?

A

when you see cerebellar hemorrhages with diameter >3 cm

they need emergent surgical decompression

69
Q

what medications is contraindicated in intracerebral hemorrhages

A

TPA
ASA
plavix

70
Q

what is the most effective short term intervention for secondary stroke prevention?

A

combination of aspirin and plavix if started in 24 hrs of TIA or minor stroke.

Continue DAPT for 10 to 21 days followed by ASA monotherapy.

71
Q

do we ever use prasugrel for treatment or secondary prevention for stroke?

A

no prasugrel (efient) has been associated with high risk of hemorrhage when used in CAD pts and history of stroke. should be avoided.

72
Q

what is the best long term antiplatelet drug for secondary stroke prevention:
aspirin monotherapy
plavix (clopidogrel) monotherapy
ticagrelor monotherapy?

A

plavix monotherapy

more likely than aspirin to prevent recurrent stroke, MI, or vascular death after noncardioembolic ischemic stroke.

if pt had a ischemic stroke in internal capsule with a lacunar infarct, this will help the most.

pharm (28 decks)

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