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Nayla Foundations Exam 4 > Stroke > Flashcards

Stroke Flashcards

1
Q

What is the left brain responsible for

A

logic
language
science and math
analytic thought

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2
Q

What is the right brain responsible for

A

intuition
creativity
art and music
holistic thought

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3
Q

What is a stroke

A

sudden focal neuro deficit due to interruption of blood flow, MC ischemia

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4
Q

What are modifiable stroke RF

A 
HTN
obesity
AFib
cardiac disease 
dyslipidemia 
high alcohol intake 
smoking
stress
diet
physical inactivity
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5
Q

What are non-modifiable stroke RF

A 
age
gender
family history 
ethnicity
Hx CVA 
vascular anomaly
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6
Q

Who has worse and more strokes and why

A

Black have worse
d/t RF of HTN, DM, obesity, smoking, and sickle cell anemia
Hispanic have more and at younger ages

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7
Q

What stroke test is 100% sensitive

A

Cincinnati pre-hospital stroke scale, when all 3 are present

  1. Facial droop (unilateral)
  2. Arm drift (unilateral)
  3. Abnormal speech
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8
Q

Focal stroke symptoms include

A 
unilateral weakness
numbness and tingling 
vision loss
incoordination 
sudden speech changes/HA 
acute vision loss or double vision 
**NO PAIN**
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9
Q

What is the NIHSS

A 
measures the level of impairment due to stroke, need for TPA, if a change has occurred, and level of severity 
-7 minutes, 13 items 
-Min= 0 (normal) 
1-4 is minor
5-15 is moderate
>15-20 is severe
-Max= 42 (very severe)
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10
Q

What should a focused stroke PE include

A 
LOC 
language
strength
DTR
EOM
coordination
sensation
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11
Q

What patients have the best outcomes

A

Lacunar infarcts (small vessels)

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12
Q

Who has improved outcomes

A

Those who get earlier treatment

>24 hours has no benefit

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13
Q

What are the types of strokes

A

Focal brain dysfunction: ICH, ischemic stroke

Diffuse brain dysfunction: ICH, SAH

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14
Q

What is the MC vascular obstruction leading to thrombosis

A

Atherosclerosis

also GCA, hypercoaglable, vessel dissection

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15
Q

What are the 2 MC sources of emboli (smaller strokes than from thrombi)

A

Left cardiac chambers

artery to artery (thrombus detaches from ICA)

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16
Q

Embolic strokes usually become

A

hemorrhagic strokes

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17
Q

What are causes of an ischemic stroke

A

atherosclerosis (large vessel)
lacunar infarct (small vessel)
cardioembolic (AFib, MI, patent foramen ovale)

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18
Q

What is a TIA

A

sudden onset transient lack of blood and focal ischemia lasting <24 hours (usually 1 hr) with focal neuro symptoms
+/- permanent

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19
Q

What is an Acute Ischemia Stroke

A

sudden onset total interruption of blood to a part of the brain lasting >24 hours (usually >1 hr) w/ permanent focal neuro Sx

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20
Q

How have TIA guidelines been revised

A

No longer about time (<24 hr) but now about the amount of injury-
AHA now says a TIA is a transient episode of neuro dysfunction due to focal brain, S.C. or retinal ischemia WITHOUT acute infarct (1 hr time is not helpful to tissue infarct)

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21
Q

What is a patients short term stroke risk

A

> 10% will have a stroke in first 90 days after a TIA

of that 10% 1/4 to 1/2 will have a stroke in the first 2 days

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22
Q

What is the ABCD2 score

A

Better prediction of stroke risk s/p having just had a stroke- incorporates Cali and ABCD scores

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23
Q

Explain the ABCD2 scoring system

A

1 point: 60+, BP >140/90, DM, 10-59 min duration, speech impairment (no weakness)
2 points: Focal weakness, lasts 60+ min

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24
Q

Interpret ABCD2 risk scores

A

0-3: 1% stroke risk (in 2 days)
4-5: 4.1%
6-7: 8.1%

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25
What is preferred imaging for a potential TIA
MRI (confirm focal ischemia) | +/- vessel imaging, heart eval, labs (based on AHA)
26
What is a class 1 Recommendation
1. S/p TIA need MRI w/ DWI w/in 24 hours (CT if you cant do MRI) 2. Noninvasive imaging of cervicocephalic vessels if susp. of TIA (CT head+neck) 3. CT H+N to r/o stenosis (intracranial vasculature)- if abn, do cath angiography to confirm 4. Susp. TIA= immediate evaluation!
27
What are class 2 recommendations
1. Use carotid US/MRA/CTA to view extracranial vasculature 2. consider catheter angiography prior to endartectomy 3. role of plaque characteristics and detection of microemboli not yet defined 4. Do ECG asap after TIA 5. EEG (or TEE) in susp. TIA if no other cause identified. (TEE for PFO/aortic arch) 6. Routine blood tests for susp. TIA 7. Hospitalize pt w/ TIA if they present w/in 72 hours, or if; ABCD2 >3, or ABCD2 0-2 and cant be worked up w/in 2 days/evidence of focal ischemic cause
28
What is the Penumbra
zone of reversible ischemia (25-50% of normal CBF) around irreversible infarct. Can salvage in first few hrs after ischemic stroke onset
29
What can damage the penumbra
Hypoperfusion (lowering BP) Hyperglycemia fever seizure
30
What happens during an AIS
BP increases d/t arterial occlusion and trying to perfuse the penumbra Lowering BP starves the penumbra= worse outcome
31
What are cerebral blood flow levels
50-60 is normal 20-30 is no electric activity 10 is neuron death
32
What is a complication of restoring blood flow after an artery occlusion
Hemorrhage (red infarct) d/t Ischemic vessel rupture | anemic infarct; embolism breaks up and goes into one branch
33
What is the acute Tx of TIA/AIS
Thrombolysis or thrombectomy | DONT decrease BP
34
What is secondary prevention of AIS/TIA
anti-thrombotic therapy vascular RF therapy +/- carotid endartectomy or angioplasty
35
What is your TPA window
3.5-4 hours (slight ICH risk)
36
What is tPA inclusion criteria
18+ y/o | <4.5 hours from onset
37
What is tPA exclusion criteria
``` s/p stroke w/in 90 days Hx ICH brain cancer SAH Sx glucose <50 active bleeding/ hemorrhage Heparin w/in 48 hr/ on oral anticoags Platelet <100 pregnant 80+ y/o NIHSS 25+ BP > 185/110 ```
38
Explain BP in a stroke
BP distal to obstruction: low overall BP: high BP >200= high risk of stroke recurrence
39
What are Vasopressors (ADH) used for
to keep BP high until deficits improve
40
When SHOULD you decrease BP in AIS
AMI CHF aortic dissection HTN encephalopathy
41
What does AIS care consist of
Triage (10 min)- tPA criteria and prelabs, page stroke team Med care (25 min)- O2, 2IV, NIHSS, ECG CT/labs (45 min) Tx (60 min)
42
What is often used with tPA
Mechanical thrombolysis - MERCI is the cork screw - PENUMBRA is the clot aspiration
43
What are predictors of hemorrhagic transformation
``` **Size of infarct AFIB NIHSS hyperglycemia thrombocytopenia ```
44
What causes hemorrhagic strokes
**HTN | Vascular malformation
45
How does a hemorrhagic stroke manifest
vessel rupture and surrounding tissue damage with high ICP symptoms
46
What are key points with a hemorrhagic stroke
check non-con CT (blood?) high mortality (50%) monitor ICP neurosurgery intervention
47
What is a congenital AVM's
defect delivering blood from an artery directly to a vein bypassing the brain causes chronic ischemia high risk of rupture due to weak dilated wall
48
What is a cerebral aneurysm
``` enlarged vessel due to a weak wall <5mm small 6-15 med 16-25 large 25+ massive ```
49
What is the MC saccular aneurysm
berry aneurysm in the circle of willis (usually anterior communicating, also posterior communicating)
50
How do you treat a cerebral aneurysm
endovascular coli/stent | surgical clip
51
What causes a SAH
1. Aneurysm in circle of willis | 2. Congenital AVM
52
How do SAH present
sudden increased ICP +/- valsalva association (not the same as ICH)
53
How do you diagnose a SAH
CT non-con | Xanthochromia (yellow CSF after 1-2 hrs d/t hemolyzed blood)
54
How do you treat SAH
``` decrease ICP (stool softener, cough suppressant, anxiolytic, analgesics) CCB for vasospasm ```
55
What is first tier testing for stroke patient
CBC BMP glucose PT/PTT +/- ESR | ECG, non-con CT
56
What is second tier testing for stroke patient (usually neuro)
``` Doppler US to carotids TTE or TEE MRI/MRA CSF cerebral angiogram ```
57
What is peri-stroke hyperglycemia associated with
worse clinical outcomes (inpatient BG goal <150) (outpatient HgbA1C goal <7) (each 1% drop in HgbA1C= 12% decrease in stroke risk
58
What possible complications can occur s/p stroke
``` Aspiration (NPO until eval) DVT (compression) UTI (avoid cath) Constipation (laxatives for all) UGI bleed (ppi/H2 antag) Fever (APAP +/- abx) ```
59
What is post stroke depression
When Sx persist 1-2 wk after stroke - Give SSRI - If on warfarin, give Lexapro, celexa, zoloft
60
What is secondary stroke prevention w/ RF modification
dont discontinue statins (LDL 100+, high dose)
61
Is carotid endartectomy beneficial
YES if 70-99% stenosed | <6% complication rate
62
When should a carotid angioplasty be used
high risk for restenosis, or contralateral artery occlusion
63
Who benefit most from a carotid endartectomy
men elderly recent cerebral ischemia ulcerated plaque
64
What is secondary stroke prevention with lifestyle RF modification
alcohol <2oz men, <1oz women stop smoking CPAP low sat fat diet, low Na, mediterranean diet 20+ min aerobic exercise 3+ days/wk Normal BMI (18.5-24.9) maintain HgbA1C <7, BP <120/80 (w/ ACE/ARB), LDL <70 (statin)
65
What drugs can stroke pts take
antithrombotics | statins
66
What drugs should stroke pts avoid
``` estrogen sympathomimetics NSAID ppi (if on plavix) -can take ppi in acute phase to prevent GI bleed ```
67
What can mimic a stroke
``` encephalitis hypoglycemia migraine seizure TIA toxic/metabolic tumor conversion disorder psychogenic cause ```
68
A stroke in this area can cause unilateral weakness
ACA MCA anterior choroid artery to internal capsule Basilar artery to midbrain and medulla oblongata
69
A stroke in this area can cause unilateral loss of sensation
ACA MCA PCA to thalamus Basilar artery to medulla oblongata
70
A stroke in this area can cause visual deficits
MCA
71
A stroke in this area can cause nystagmus
Basilar artery to pons and medulla oblongata
72
A stroke to this area can cause aphasia
MCA
73
A stroke to this area can cause ataxia
Basilar artery to pons | hemiataxia is medulla oblongata
74
A stroke to this area can cause hypokinesia
Anterior choroid to basal ganglia

Nayla Foundations Exam 4 (15 decks)

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