Stroke Flashcards
1
Q
Epidemiology for Strokes
A
Males Over 65 years old African Americans > Whites
2
Q
Top Risk factors for Stoke
A
Hypertension Heart Disease Previous Stoke/TIA Carotid Bruit Diabetes/Smoking
3
Q
Modifiable Risk Factors
A
Hypertension Heart Disease Cholesterol
4
Q
Genetic Risk Factors For Stroke
A
Factor V mutation, Elevated Homocysteine Levels(hypercoagubility state)
5
Q
When to suspect Factor V problem?
A
younger patient presenting with stroke
6
Q
Two Main Mechanisms of Stroke
A
Ischemic (85%) Hemorrhagic (15%)
7
Q
Thrombosis Characteristics
A
symptoms gradually appear
8
Q
Embolic Characteristics
A
sudden onset of symptoms
9
Q
Atherosclerosis
A
plaque build up in the walls of the blood vessels
10
Q
Ulcerated Plaque
A
rough plaque that the blood platelets stick and therefore, causes clot formation
11
Q
Cardiogenic Emboli
A
Atrial Fibrillation Rheumatic Heart Disease Acute Myocardial Infarction Thrombus from Previous MI Prosthetic Valve
12
Q
Atrial Fibrillation
A
blood stagnating in the atria that can cause clots
13
Q
Rheumatic Heart Disease
A
platelets can bind to damaged tissue
14
Q
Emboli Sources
A
lungs, heart, aortic arches Clots from A Fib. are the most damaging/severe
15
Q
Which organ do you want to check in stroke patients?
A
heart
16
Q
Mitral Valve Prolapse
A
fair common in people, small increase in risk for producing emboli
17
Q
Nonbacterial Thrombotic Endocarditis
A
seen in cancer patients, the mucin produced by lung/ breast, can coagulate the blood, causes embolic formation (not common)
18
Q
Infective Endocarditis
A
can cause emboli, because the bacteria makes a goo-like bioflim? that can dislodge and plug arteries
19
Q
A
PCA Stroke, caused by A Fib
20
Q
A
Patient should be sent home with an event monitor, keep moinotring the heart even if tests come out to negative (echo, telemonitor)
21
Q
A
Air Emboli in the patient’s brain
22
Q
Old TIA Definition Vs New TIA Definition
A
old: focal brain/eye symptoms resolve in less than 24 hours
new: focal brain/eye issues resolve within an hour, majority within in 30 mins
23
Q
Are TIAs a medical emergency?
A
Yes, and they require a full workup even if the weakness was transient
24
Q
SX for TIA resulting from Carotid Distribution
A
unilaterial weakness/numberbess
monoocular vision loss
aphaisa(depending on which side was effected)
25
SX of TIA resulting from a Vertebrobasilar Distribution
bilateral numbness/weakness, bilateral vision problems
26
Amaurosis Fugax
Sign of? Lasts for? Cause? Presenting SX?
sign of transient TIA, shade over the eye
lasts less than 5 mins
thrombotic or embolic\>
27
Significance of TIA
50% of people will have a stroke in the next year
36% will have stroke in the next month
high probability of stroke, NEED TO BE ADDRESSED
28
TIAs with multiple similar events
Thrombus
29
TIAs with dissimilar events
embolic, because clot is traveling to different locations causing different symptoms
30
Thrombus vs Embolic
thrombus: collateral branches can form, progressive
embolic: suddent onset, seizure at oneset
31
DDX of TIA
focal seizure, hypoglycemica, subdural hematoma, carpal tunnel syndrome, migraine, syncope, labyrinthitis (vertigo), Myasthenia Gravis
32
Somatotopy
33
Hemiplegia
one side of the body is paralyzed
34
Internal Carotid Occlusion Symptoms
generally asymptomatic because there is collateral supply from the circle of willis however, some people have variation in their circle of willis (may be occluded or not formed)
35
Anterior Cerebral Artery (ACA) Occlusion
damages the feet, urinary symptoms
36
Middle Cerebral Artery Occlusion
face and arms affected, possible phasia if the language dominant side is affected
homonomous hemianopia
37
Homonomous Hemiaponia
same visual field lost in both eyes
38
plaque buildup in the MCA
39
Broca's Aphasia
they have difficulty producing speech and comprehension is intact
fontal lobe lesion
40
Wernicke Aphasia
not able to comprehend, able to produce speech but it is senseless
lesion in posterior perisylvian region
41
Paraphasia and Neologisms
Paraphasia: substituting similar words
Neologisms: making new words
42
Conduction Aphasia
unable to repeat phrases due to damage to the arcuate fibers
43
Global Aphasia
MCA occlusion, affects both wernicke and brocas area
44
Posterior Cerebral Artery Occlusion
homonomous hemianopia, hemiplegia
face/arm paralysis and visual defect
45
Lacunar Infarcts
blockage of small vessels
SX: ataxia, dysarthria, sensory/motor impairment,
DX: clinical syndrome
46
Lacunar Infarcts Mortality rate? Reoccurance? Risk factors?
Low bc small vessels
High if bp is not reduced
hypertension
47
Lacunar Infart Treatment
Reduce BP (antihypertensive medication)
Antiplatelet medications
Carotid Endarterectomy (removal of the plaque)
48
Other Causes of Lacunar Infarct
Carotid Dissection, Migraine (pts on Birth control and smokers)
Cocaine/Vasoactive Medications (cold medicine)
49
Weber Syndrome
CN 3 Palsy, contralateral hemiplegia in midbrain stroke
50
Wallenberg Syndrome
Lateral Medullary Syndrome
PICA, vertbral artery
ipsilateral face numbness, and contralateral loss of pain/temp
51
Stroke Prevention
keep blood pressure down , 74% reduction
52
Ischemic Prenumbra
area surrounding the core damaged area, damaged but, viable neurons
53
Salvaging Ischemic Penumbra
Avoid? Things that help?
Avoid
Relative Hypotension(bring down pressure slowly)
hypoxia (swallowing test)
hyperglycemia
hyponatremia
Neuroprotective Agents (GABA, NMDA, NO) none are too effective
54
Workup for Lacunar Infarct
Labs-HgA1C, CBC, platelet count, homocysteine levels
MRI, carotid ultrasound, echocardiogram, angiogram, cardiac monitor
55
CT Scan Angiogram
quick way of vascular imaging
56
Treatment of Lacunar Infarctions
Medications (BP meds, antiplatelets)
Patient Education (call 911 immediately if numbess/weakness occurs)
Surgery
57
Treatment for High homocysteine Levels
folic acid levels
58
Aspirin
reduce changes of stroke by 25%
higher doses can cause GI symptoms
59
Ticlopidine
decreases the chances of clotting,
causes neutropenia (low neutrophil count), thrombocytopenia (decreased platelet count)
requires CBC monitoring
60
Dipyridamole
can be used with aspirin, problem is patient tolerance due to headaches
61
Pravastatin
used to decrease cholesterol levels
62
Candidates for Carotid Endarterectomy
patient with \>60% stenosis of the carotid artery
63
Asymptomatic Carotid Bruit and Stenosis association with TIA
significant amount of TIA/Minor Stroke patients present with a carotid bruit
64
Approach to Asymptomatic Carotid Bruit
control risk factors (hypertension/cholesterol)
cardiac workup
surgery if indicated (greater than 60%)
patient education about TIA
65
Differenece between Warifrin(coumadin) and Heparin
Warifin(long term treatment)
Heparin = acute (injection)
66
Contradications for Heparin
senstivity to heparin, bleeding
unctollable hypertension(gasket ready to blow)
more flow when blood is thinner
large infarcts
67
Complications with Heparin
hemorrhage + thrombocytopenia
68
Heparin Therapy
PTT(clotting time)
Get CT: to rule out bleeding
switch to warfarin after a few days
69
Tissue Plasminogen Activator (TPA)
MOA? When to use? Contraindicated?
converts plasminogen to plasmin
Plasmin cause fibrinolysis
should be given in first 3 hours of stroke
Need CT to r/o bleed however it takes 12 to 24 hours to show up in CT
70
TPA and High Blood Pressure
Bring blood pressure down to 185/110 mm Hg first with labetalol
71
Contraindications for TPA? Interaction with which med?
active internal bleeding
recent trauma, surgery, or stroke
uncontrolled hypertension
intracranial tumor,
on warfarin
72
Hypertensive Encephalopathy Sx? Tx?
uncontrolled hypertension, body loses autoregulation ability
sx: headache, confusion seizure
TX: control blood pressure
73
Transient Global Amnesia
Prognosis? Cause?
sudden loss of memory
benign prognosis, due to vasculature
74
Temporal Arteritis
Affected population? Sx? Treatment? Associated with?
50 years and up
Sx: Headache, blindness, fever, anorexia, tender artery
Treatment: steroids (reduce inflamation which could cause more problems)
Polymyalgia Rheumatica: aching stiff muscles
75
Idiopathic Intracranial Hypertension
Also called? Causes? Tx? Sx?
Pseudotumor Cerebri
idiopathic but, pregnancy, obesity
Tx: self limiting, diuretics (decrease ICP)
SX: inc ICP, inc Cerebral Spinal Fluid (\>250 mm H2O) (during spinal tap)
76
Venous Thrombosis
Causes: idiopathic, pregnancy, trauma (anything that can cause hypercoaguability)
can cause strokes
features: papilledema, seizures, Cn problems, bulging ees (proptosis)
77
suprerior sagital sinus, this is a clot
you can dissolve by adding TPA directly into the brain via a catheter
78
Brain Herniation
brain is squeezed through various structures due to high ICP
79
Cerebral Edema
Sx? Causes?
increased water and sodium in the brain (herniation)
major cause of death and morbidty
caused by: hypoxia, stroke, tumor, trauma
80
Vasogenic Edema
located in the white matter
caused by tumor
increased extracellular fluid due to increased capillary permeability
81
Where is the white matter and the gray matter located in the brain?
the gray is more on the periphery with the expection of the core
the white matter is more on the interior
82
Vasogenic Edema, Gray White Junction
83
Cytotoxic Edema
Areas affected? Causes? SX?
affects both the gray and white areas (not just at the junction)
cellular swelling
caused by hypoxia, infarction
84
Cytotoxic Edema
affects both gray and white areas equally
85
Interstitial Edema
due to CSF obstruction (blocked aqueduct)
hydrocephalus, increased periventricular extracellular fluids
86
Interstitial Edema, enlarged ventricles
87
Cushing's Effect
increased systolic blood pressure
decreased pulse
(they should be in opposite directions)
sign of something wrong in the brain
88
Treatment Cerebral Edema
steroids (only for vasogenic)
diuretics(only buys you time)
Osmotherapy (need intact blood flow i.e. tumor)
pulls fluid via concentration gradient
89
Intraparenchymal Hemorrhage
caused by hypertension and ruptures a small penetrating artery
treatment depends on location
more interior: no tx
more external: surgery
90
Subarachnoid Hemorrhage
Where is blood? Majority of cases? Defect in?
Clinical Features?
blood in CSF,
majority of cases located in the anterior circulation
Defect: internal elastic lamina/vessel bifurcation
clinical: worst headache of their life, may have warning leak/headache
91
Hess and Hunt Grading Scale
higher on the scale worse the headache/less conscious
92
Subarachnoid Hemorrhage Dx
HP
CT Scan newer ones are fairly accurate
Lumbar puncture
Angiogram 4 Vessel Study (Gold Standard)
93
Subarachnoid Hemorrhage Tx
Bed Rest
Sedation
NMDA/Nimodipine (Ca2+ blocker: prevents cell death)
control blood pressure, stool softener, Antifibrinolytic
Coiling
94
Subarachnoid Hemorrhage Prognosis? Course?
Patients who rate on the Hess and Hunt scale I-III should be given surgery with a chance of an excellent outcome
Patients IV-V should be given supportive care
95
Mycotic Aneurysms
septic emboli usually caused by bacterial endocarditis
should not be treated anticoagulants but antibiotics for infection
96
Vascular Malformations
Presenting age?
Treatment? Sx?
should treat when they become symptomatic
seen before age of 30
hemorrhage, seizure
97
Epidural Hematoma
Damage to what vessel?
Sx? Dx?
middle meningeal artery
lucid interval
CT Scan ( see bone fracture as well)
98
Subdural Hematoma
Vessels damaged? Sx?
comatose from the start
tearing of bridging veins
blown pupil, cushing reflex, altered respirations
99
Chronic Subdural Hemorrhage
seen in eldery patients with brain atrophy
100
