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Foundations 4 SG > Stroke 2 > Flashcards

Stroke 2 Flashcards

1
Q

In AIS (arterial ischemic stroke), what is a normal response of the body? What should you do about it?

A

High BP, DO NOT lower it

  • BP increases due to arterial occlusion (in effort to perfuse the penumbra)
  • Lowering BP will starve the penumbra and worsens outcome!
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2
Q

Cerebral Blood FLow to Save Penumbra

(ml/100g/min)

  • Over 18
  • 8-18
  • Below 8
A
  • Normal function
  • Neuronal dysfunction
  • Neuronal death
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3
Q

Extent of Ischemic Injury

Window of Opportunity - Ischemic Penumbra

  • Viability of brain tissue is preserved if perfusion is restored within a critical time period of ____.
A

2 - 4 hours

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4
Q

What is a complication of stroke from suddenly restoring blood flow/pressure?

A

Hemorrhagic Stroke (Red Infarct)

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5
Q

Pathophys of AIS & TIA

  • Usually ____ (blood clot forms in vascular system, travels downstream, plugs the ____)
A
  • thromboembolism / cerebral artery
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6
Q

What is the acute therapy for AIS & TIA?

A

Thrombolysis or Thrombectomy

(DO NOT LOWER BP)!!!***

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7
Q
  • No infarction and no sequaelae
  • Infarction w/ sequelae
A
  • TIA
  • Ischemic stroke
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8
Q

4 options for secondary prevention of AIS & TIA

A
  • Antithrombotic therapy
  • Vascular risk factor therapy
  • Carotid endarterectomy (CEA)
  • Carotid angioplasy
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9
Q
  • what is tPA?
  • What do you need to know before administering?
A
  • Tissue Plasminogen Activator
  • Time of onset & Contraindications
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10
Q

What is the time frame for administering tPA?

A

3 - 4.5 hours

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11
Q

3 inclusion criteria for tx Acute Ischemic Stroke w/ tPA

A
  • Clinical dx of ischemic stroke causing measurable neurologic deficit
  • Onset of sxs <4.5 hrs (if exact time not known, defined as last time pt was normal)
  • 18 years of age or older
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12
Q

Historical Contraindications for giving tPA

A
  • Stroke or head trauma in the past 3 months
  • Previous intracranial hemorrhage
  • Intracranial neoplasm, arteriovenous malformation, or aneurysm
  • Recent intracranial / intraspinal surgery
  • Arterial puncture at non-compressible site in previous 7 days
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13
Q

Clinical Contraindications of giving tPA

A
  • Sxs suggestive of subarachnoid hemorrhage
  • Persistent BP evelation 185/110
  • Serum glucose <50
  • Active internal bleeding
  • Acute bleeding diathesis (hematologic)
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14
Q

Hematologic contraindications of giving tPA

A
  • Platelet count <100,000
  • Current anticoagulant use
  • Heparin use within 48 hrs
  • Current use of direct thrombin inhibitor
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15
Q

Findings on head CT Contraindications for giving tPA

A
  • Evidence of hemorrhage
  • Extensive regions of obvious hypodensity consistent w/ irreversible injury
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16
Q

Contraindications for giving tPA

  • Minor / isolated neuro signs
  • Rapidly improving sxs
  • Major surgery / serious trauma in previous ___
  • GI or urinary tract bleed in previous ___
  • MI in previous ___
  • Sz at onset of stroke w/ post-ictal neuro impairments
  • Pregnancy
  • Age ___
  • Severe stroke of NIHSS score >___
  • Combo of both previous ischemic stroke and ___.
A
  • Surg: 14 days
  • Bleed: 21 days
  • MI: 3 months
  • over 80 y/o
  • NIHSS score >25
  • DM
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17
Q

BP and Stroke

  • Perfusion pressure distal to obstruction is ___ and dependent on systemic BP
  • BP is usually ____ in acute stroke & may maintain perfusion to borderline ischemic areas
  • BP >____ increases risk of recurrent ischemic stroke
  • BP <____ is associated w/ excess deaths***
A
  • low
  • elevated
  • >200
  • <120 –> deaths (from coronary disease)
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18
Q
  • Acute MI
  • CHF
    Aortic dissection
  • HTN encephalopathy
  • Candidate for thrombolysis & BP >185/110
A

Indications to decrease BP emergently in AIS

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19
Q

Intracranial hemorrhage occurs most often in NIHSS score over ___.

A

20

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20
Q

3 contraindications of treatment w/ tPA

A
  • Over 80 y/o
  • On Warfarin
  • NIHSS >25
21
Q

3 things to do within 10 mins at triage

A
  • Review tPA criteria
  • Page acute stroke team
  • Draw pre-tPA labs, but do not let this delay care
22
Q

4 things to do within 25 mins for Medical Care

A
  • O2 / BP / Weight / NIHSS
  • 2 IVs
  • 12 lead ECG
  • CT
      • bleed (no tPA)
      • bleed (give tPA)
23
Q

What should be completed within the first 45 mins?

A

CT and Labs

  • obtain lab results
  • read CT
  • return pt to ED
24
Q

What should be completed within the first 60 mins?

A

Treatment

  • Start IV tPA (if indicated)
  • Monitor for ICH sxs (HTN, HA, N/V, decreased neuro status)
25
Q
  • Often used in adjunct w/ tPA
  • MERCI retrieval system is corkscrew like apparatus designed to remove clots from vessels
  • PENUMBRA system aspirates the clot
A

Mechanical Thrombolysis

26
Q

What is the biggest predictor of Hemorrhagic Transformation? 5 total

(ischemic –> hemorrhage)

A
  • Size of infarction #1
  • A-fib
  • NIHSS score high
  • Hyperglycemia
  • Thrombocytopenia (low platelets)
27
Q

Hemorrhagic Stroke (15% of all strokes)

  • What is the primary cause (70-90%)
  • What is secondary cause (10-30%)
  • Manifests w/ sxs of _____
A
  • Primary: HTN
  • Secondary: Vascular malformation (aneurysm, AVM, tumor, amyloid angiopathy, thrombolytic agents)
  • Increased ICP (intracranial pressure)
28
Q

Which stroke?

  • Non-contrast CT + for bleed
  • 50% mortality (80% w/ permanent disability)
  • ICP monitoring
  • Neurosurgical intervention
A

Hemorrhagic

29
Q
  • Directly diverts blood from arteries –> veins
  • May bypass brain tissue & cause chronic ischemia
  • Congenital, but not genetic!
  • Concern of weakened wall –> dilation–> increased risk of rupture
A

Arteriovenous Malformations (AVMs)

30
Q
  • Enlargement of blood vessel due to wall weakening
  • >___ y/o
  • 4 sizes
A

Cerebral Aneurysm

  • >40 yrs
  • small, medium, large, giant
31
Q

What are the most common sites of Cerebral Aneurysms?

A

At bifurcations

(anterior communicating artery) –> optic chiasm

(Posterior communicating artery)

32
Q

Sxs of Hemorrhagic or Ischemic?

  • Diastolic BP >110
  • HA
  • Vomiting
  • Coma
  • Neck stiffness
  • Seizures
A

Hemorrhagic / aneurysms?

33
Q

3 common CNS Herniations

A
  • Subfalcine
  • Transtentorial
  • Tonsillar
34
Q

Which CNS Herniation?

  • Common, HA, contralateral leg weakness
A

Subfalcine

35
Q

Which CNS Herniation?

  • Oculomotor (CN 3) paresis w/ ipsilateral dilated pupil, abnormal EOM’s
  • Contralateral hemiparesis
A

Transtentorial

36
Q

Which CNS Herniation?

  • Obtundation
A

Tonsillar

37
Q

Brain Herniation

  • Life threatening
  • Increased ICP may cause ____.
    • Triad?
A

Cushing reflex

  • HTN
  • Bradycardia
  • Abnormal respirations
38
Q

2 tx options for cerebral aneurysm

A
  • Endovascular (coil embolization)
  • Surgery (clip)
39
Q

2 causes of SAH

A
  • Aneurysm in Circle of Willis
  • AVM since birth
40
Q

Presentation of SAH

  • Often w/o warning, but may have had prior ___ or ____
  • Sudden increases in ____
  • Maybe associated w/ ____
  • NOT ____
A
  • bleeds / HAs
  • ICP
  • Valsalva
  • ICH
41
Q

Dx for SAH

A
  • CT w/o contrast
    • if negative (no bleed), then get an LP
42
Q

Hemolyzed blood in CSF (golden yellow) indicating the presence of bilirubin in the cerebrospinal fluid (CSF) and is used by some to differentiate in vivo hemorrhage from a traumatic LP.

  • Takes how long to lyse and change color?
A

Xanthochromia

  • 1-2 hours
43
Q

Tx of SAH

  • Decrease ICP w/ what 6 things?
  • Treat and monitor vasospasm w/ what med?
A
  • stool softeners
  • cough suppressants
  • anxiolytics
  • analgesics
  • antiemetics
  • Keep HOB elevated (head of bed)

Vasospasm: CCB

44
Q
  • “crescent shape”
  • Blood outside of brain, but in skull (pushes on brain)
A

Subdural hematoma

45
Q

“lemon”

A

Epidural hematoma

46
Q

1st or 2nd tier of Acute Stroke Management?

  • CBC, BMP, Glucose, PT/PTT, ESR
  • EKG
  • Head CT w/o contrast
A

1st

47
Q

1st or 2nd tier of Acute Stroke Management?

  • Non-invasive imaging of carotids (doppler US)
  • TTE or TEE (localize where clot came from)
  • MRI/MRA
  • CSF eval
  • Cerebral angiogram
A

2nd

48
Q

Hyperglycemia & Acute Stroke / DM & secondary stroke prevention

  • Peri-stroke hyperglycemia is associated w/ ____ clinical outcomes
  • Inpatient goal of BG is <____
  • Chronically, each decrease in % in Hgb A1C results in significant reduction of what 4 things?
  • Outpatient goal of Hgb A1C is < __
A
  • worse
  • 150
  • death, MI, vascular complications, stroke risk
  • 7.0

Foundations 4 SG (19 decks)

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