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3.1 midterms > stroke > Flashcards

stroke Flashcards

1
Q

which is most significant in precipitating a haemorrhagic stroke?

hypertension
hyperlipidemia
old age
previous stroke

A

hypertension, d/t vessel weakening, aneurysm formation, microbeeds, BBB breakdown

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2
Q

haemorrhagic stroke onset

A
  • upon exertion
  • sudden onset
  • often a/w severe headache, vomiting, seizures
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3
Q

how would a thalamic bleed lead to personality changes

A
  • impact emotional regulation
  • impact limbic system (responsible for mood control)
  • involved in cognitive & executive functioning (may be impaired)
  • effect on frontal lobe connection (higher-order functions eg planning & judgement) → impulsivity, disinhibition
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4
Q

decorticate vs decerebrate posture

A

decorticate: elbows extended
decerebrate: elbows flexed

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5
Q

ICH neurological complications [4]

A
  • brainstem compression
  • cerebellar herniation
  • hydrocephalus
  • recurrent haemorrhage within 24h
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5
Q

ganglionic haemorrhage presentation

A

contralateral hemiplegia worsening to drowsiness & coma

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6
Q

thalamic haemorrhage presentation

A

contralateral hemiplegia with 3rd nerve involvement (oculomotor)

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6
Q

pontine haemorrhage presentation

A

quadriplegia, pin-point pupils, death

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7
Q

cerebellar haemorrhage presentation

A

ataxia, altered sensorium, death

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8
Q

common causes of SAH

A
  • aneurysm rupture (usually arterial bleed)
  • trauma eg RTA (usually venous)
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9
Q

SAH presentation

A
  • thunderclap headache
  • vomiting
  • possible LOC
  • usually no focal neurological deficits
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10
Q

haemorrhagic stroke: med management [5]

A
  1. stop antiplatelet & antocoag, reverse antithrombotic effect
  2. BP control
  3. monitor neuro condition
  4. control ICP
  5. BG 6-10
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11
Q

BP management for haemorrhagic stroke

A

ICH: SBP 120-160
SAH: MAP 80-130

post surgery: SBP 120-140

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12
Q

surgical management for Haemorrhagic stroke

A
  1. EVD [hydrocephalus, ↓ ICP d/t swelling, monitor ICP]
  2. aneurysm clipping
  3. aneurysm coiling
    [prevent re-bleed]
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13
Q

post-surgical management of haemorrhagic stroke

A
  1. ↓ re-bleeding risk: maintain SBP 120-140
  2. prevent vasospasm: nimodipine
  3. prevent seizure: phenytoin, valporate
  4. control ICP, BG, temp
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14
Q

broca’s aphasia vs wernicke’s aphasia

A

broca: expressive (2: slurred speech, incomprehensible sounds)

wernicke’s: receptive (3: inappropriate words)

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15
Q

extracranial factors affecting stroke

A
  • systemic BP (MAP)
  • cardiac output
  • viscosity of blood
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16
Q

intracranial factors affecting stroke

A
  • intracranial pressure
  • atherosclerosis
  • blood vessels eg aneurysm?
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17
Q

which type of stroke is most common

A

ischaemic sroke

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18
Q

causes of ischaemic stroke

A
  1. thrombotic (atherosclerosis, MCA infarct, lacunar infarct) [arterial disease, blood disorders]
  2. embolic (dislodged blood clots d/t AFib, carotid paque, atherosclerotic plaque)
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19
Q

causes of ICH

A
  • hypertension
  • thrombolytic drugs
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20
Q

Nursing management in A&E [13]

A
  1. ABC, vitals
  2. O2 if hypoxemic
  3. airway support (if gcs<8)
  4. obtain IV access (18G x2)
  5. bloods: BGM, RP, clotting, d-dimer, cardiac enzymes, BNP, thyroid profile)
  6. neuro assessment
  7. monitor temp
  8. activate stroke team, stat CT
  9. 12 lead ECG
  10. fluid & electrolyte management (give isotonic fluids)
  11. NBM, NGT?
  12. weight
  13. history taking (AMPLE)
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21
Q

diagnostic tests for stroke [6]

A
  1. CT brain
  2. MRI
  3. angiogram
  4. carotid ultrasound
  5. 2d echo
  6. EEG
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22
Q

CT: pros & cons

A

+ overview of structures, identifying haemorrhage
+ quick to obtain
+ bone injury
– does not immediately show ischaemia
– radiation

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23
Q

CT angio: pros & cons

A

+ identify thrombosis in major vessels
+ identify vascular malformations
+ “spot sign” → shows active bleeds
– contrast: allergy/kidney injury

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24
Q

MRI: pros & cons

A

+ MRI > CT for acute ischaemic stroke w/in 12h

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25
Q

stroke: supportive measures

A
  • Airway & ventillation
  • temp management [TTM (targeted temp management) — therapeutic hypothermia, controlled normothermia, fever treatment]
  • BG control
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26
Q

indications of carotid artery involvement

A
  • transient unilateral vision loss
  • hemiparesis
  • inability to speak
27
Q

indication of vertebrobasilar artery involvement

A
  • tinnitus
  • vertigo & blurred vision
  • hemiparesis
28
Q

what is stroke-in-evolution

A

increasing obstruction → involve proximal branch of artery → increase deficit

29
Q

anterior cerebral artery superficial branch involvement: presentation

A

prefrontal lobe: confusion, disorientation

medial surface: paralysis, sensory loss in opp. leg

apraxia, abulia, urinary incontinence in bilateral lesions

30
Q

anterior cerebral artery deep branch involvement: presentation

A

well tolerated d/t collateral flow: hardly any clinical features

31
Q

middle cerebral artery deep branch involvement: presentation

A

contralateral paralysis

32
Q

middle cerebral artery superficial branch involvement:

A

superior: facial & hand paralysis, conjugate gaze paralysis, motor aphasia
inferior: conduction/sensory aphasia, construction/dressing apraxia

33
Q

manifestations: right brain damage (isch) [5]

A
  • L sided paralysis
  • spacial-perceptual deficits
  • behavioural style: quick, impulsive
  • memory deficits: performance
  • indifference to disability
34
Q

manifestations: left brain damage [5]

A
  • R sided paralysis
  • speech-language deficits
  • behavioural style: slow, cautious
  • memory deficits: language
  • distress & depression r/t disability
35
Q

tPA MOA

A
  • bind to fibrin → convert plasminogen to plasmin → fibrinolysis → ↓ region affected by stroke
35
Q

nursing considerations: IV alteplase [6]

A
  1. swirl, not shake
  2. double check dose w/ 2nd clinician
  3. check neuro status within 15min before administration [NIHSS>4]
  4. BP goals:
    - before: <185/110
    - after: <180/105 for 24h
  • permissive hypertension up to 220/110
  • avoid sudden reduction of BP, decrease gradually w/ IV labetalol (onset 5min) or nicardipine
  • 15% lowering over 24h
  • ACS/HF/ARF/hypertensive encephalopathy → treat BP
36
Q

tPA inclusion criteria [4]\

A
  1. > 18 y/o
  2. <4.5h from last seen well
  3. ischaemic stroke
  4. significant neurological deficit (NIHSS>4)
37
Q

tPA exclusion criteria

A
  1. evidence of bleeding (ICH, SAH, internal)
  2. stroke/HI/intracranial/intraspinal surgery w/in last 3/12
  3. persistent BP elevation (>185/110)
  4. on anticoagulants, INR>1.5, PT>15
  5. platelet < 100,000
  6. heparin w/in 48h, ↑ aPTT
  7. BG <2.7/>22.2
38
Q

preventive/alternative treatment for ischaemic

A

anticoagulants
- warfarin (short term 3/12)
- heparin

antiplatelets:
- aspirin — 81-325mg/day
- clopidogrel — 75mg/day

endovascular thrombectomy (surgically remove plaque)

angioplasty/stenting

39
Q

EVT (endovascular thrombectomy) inclusion criteria

A
  • large vessel obstruction
  • symptom onset <6h
  • NIHSS>6
40
Q

EVT management

A
  • CRIB 6h for groin puncture site
  • monitor bleeding, swelling, haematoma, pain
  • keep leg straight
  • neurovascular chart
41
Q

EVT complications

A
  • retroperitoneal haematoma
    [hypotension, flank pain]
  • arterial occlusion
    [leg parasthesia, pain, pallor]
42
Q

warfarin counselling
[4]

A
  1. consistent vit K
  2. monitor INR, 2-3
  3. monitor bleeding S/E
  4. special precaution: pregnant, PUD, alcohol, blood disorders
43
Q

which of the following may not be present in cerebral stroke

hemiplegia
monoplegia
quadroplegia
paraplegia

A

paraplegia (lower limbs) [spinal cord injury]

hemiplegia: one-sided
monoplegia: one arm
quadroplegia: all limbs

44
Q

clopidogrel vs aspirin

A

aspirin has lower bleeding risk

45
Q

GCS scoring

A

eye opening
1. none
2. pain
3. speech
4. spontaneous

best verbal response:
1. none
2. incomprehensive sounds
3. inappropriate words
4. confused
5. orientated

best motor response:
1. none
2. extension to pain
3. abnormal flexion
4. flexion to pain
5. localised pain
6. obeys command

46
Q

what is d-dimer

A

protein that breaks down clots.

high d-dimer: clots present in body.
if pt is on antiplatelets/coag, question pt’s med compliance

47
Q

frontal lobe responsible for

A
  • movement
  • intelligence
  • behaviour
  • memory
48
Q

parietal lobe responsible for

A

intelligence
language
sensation
reading

49
Q

nurse is assessing pt’s ability to obey commands, asks him to raise his left hand and touch his nose. pt raised is left hand 5cm above bed before resting it back on bed. the nurse should:

  • chart his best motor response as 6
  • chart his motor strength for R arm as 3
  • ask him to do the same with his R
  • ask him to resist the nurse’s hands hen she presses down on his L hand
A

ask him to do the same with his R

50
Q

haem stroke –> increased ICP management

[7]

A
  1. head of bed >30
  2. hypertonic saline (3%) if Na is normal
  3. osmotic diuretic (mannitol)
  4. CSF drainage (EVD)
  5. surgical decompression
  6. hyperventilation (PCO2 25-30mmHg)
  7. analgesics for headache
51
Q

complication of major rupture

A
  • vasospasm
  • hydrocephalus & increased ICP
  • rerupture
52
Q

dilated pupils is a sign of

A

brainstem (midbrain) involvement (contains CNIII oculomotor

one pupil: ipsilateral compression OR incal herniation d/t temporal lobe bleed

53
Q

signs of increased ICP [8]

A
  1. pupillary changes (brainstem involvement)
  2. GCS<8 (thalamic/brainstem involvement)
  3. decreased SpO2 (respi compromise d/t brainstem [medulla oblongata] involvement)
  4. headache, photophobia
  5. n&v
  6. altered level of consciousness
  7. papilloedema (swollen optic disc)
  8. cushing reflex
  9. decorticate/decerebrate position

** 4, 5, 6 –> early

54
Q

EVD indications [4]

A
  1. hydrocephalus
  2. relieve/monitor increased ICP
  3. drain infected/bloodstained CSF
  4. administer meds (abx, thrombolytics)
55
Q

EVD contraindications [2]

A
  1. anticoag therapy/coag problems
  2. scalp/brain infx
56
Q

EVD complications & management [5]

A
  1. mechanical (blockage, dislodgement)
  2. infection
  3. under drainage –> increase ICP, brain damage
  4. over drainage –> ventricular collapse –> subdural haematoma –> change in pressure gradient –> brain herniation
  5. trauma –> intraventricular haemorrhage, parenchymal haemorrhage, aneurysm rupture
57
Q

how often to perform levelling/verification of EVD [3]

A
  • receiving patient
  • taking over patient
  • patient moves/repositions
58
Q

care of EVD system [7]

A
  1. catheter & tubing coiled
    [prevent traction, secure, no kinks, clots, bubbles. leaks –> prevent dislodgement & blockage]
  2. ensure patency
    [ EVD column oscillation, ICP waveform pulsation, observe for drainage]
  3. label
  4. prevent infection
    [1. aseptic technique
  5. sterile, closed system
  6. insertion site care eg change dressing
  7. monitor infection s&s]
59
Q

importance of levelling/verification of EVD

A
  • ensure accurate pressure level
60
Q

epidural haemorrhage causes & presentation

A

head trauma > fracture > laceration of arterial vessels (meningeal artery)

triphasic presentation: \
1. brief LOC > lucid interval >
2. headache > altered consciousness, contralateral hemiparesis >
3. ipsilateral pupillary dilation

  • large force is req `
61
Q

subdural haemorrhage presentation

A

nonspecific: AMS, hemiparesis, headache, nonconvulsive seizure

62
Q

intraparenchymal haemorrhage cause & presentation

A

damage BV d/t
- hypertension
- trauma
- aneurysm
- atherosclerosis

FAST + headache
without warning

63
Q

what is cushing reflex

A

indicates increased ICP
1. bradycardia (/initial tachycardia)
2. widening pulse pressure
3. altered breathing pattern

64
Q

what is CPP and what is the target range for haemorrhagic stroke

A

cerebral perfusion pressure
maintain >60 mmHg

65
Q

craniotomy vs craniectomy

A

craniectomy: bone flap not replaced immediately
craniotomy: bone flap replaced

3.1 midterms (7 decks)

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