Stroke Flashcards
What is the left brain responsible for
logic
language
science and math
analytic thought
What is the right brain responsible for
intuition
creativity
art and music
holistic thought
What is a stroke
sudden focal neuro deficit due to interruption of blood flow, MC ischemia
What are modifiable stroke RF
HTN obesity AFib cardiac disease dyslipidemia high alcohol intake smoking stress diet physical inactivity
What are non-modifiable stroke RF
age gender family history ethnicity Hx CVA vascular anomaly
Who has worse and more strokes and why
Black have worse
d/t RF of HTN, DM, obesity, smoking, and sickle cell anemia
Hispanic have more and at younger ages
What stroke test is 100% sensitive
Cincinnati pre-hospital stroke scale, when all 3 are present
- Facial droop (unilateral)
- Arm drift (unilateral)
- Abnormal speech
Focal stroke symptoms include
unilateral weakness numbness and tingling vision loss incoordination sudden speech changes/HA acute vision loss or double vision **NO PAIN**
What is the NIHSS
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)
What should a focused stroke PE include
LOC language strength DTR EOM coordination sensation
What patients have the best outcomes
Lacunar infarcts (small vessels)
Who has improved outcomes
Those who get earlier treatment
>24 hours has no benefit
What are the types of strokes
Focal brain dysfunction: ICH, ischemic stroke
Diffuse brain dysfunction: ICH, SAH
What is the MC vascular obstruction leading to thrombosis
Atherosclerosis
also GCA, hypercoaglable, vessel dissection
What are the 2 MC sources of emboli (smaller strokes than from thrombi)
Left cardiac chambers
artery to artery (thrombus detaches from ICA)
Embolic strokes usually become
hemorrhagic strokes
What are causes of an ischemic stroke
atherosclerosis (large vessel)
lacunar infarct (small vessel)
cardioembolic (AFib, MI, patent foramen ovale)
What is a TIA
sudden onset transient lack of blood and focal ischemia lasting <24 hours (usually 1 hr) with focal neuro symptoms
+/- permanent
What is an Acute Ischemia Stroke
sudden onset total interruption of blood to a part of the brain lasting >24 hours (usually >1 hr) w/ permanent focal neuro Sx
How have TIA guidelines been revised
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)
What is a patients short term stroke risk
> 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
What is the ABCD2 score
Better prediction of stroke risk s/p having just had a stroke- incorporates Cali and ABCD scores
Explain the ABCD2 scoring system
1 point: 60+, BP >140/90, DM, 10-59 min duration, speech impairment (no weakness)
2 points: Focal weakness, lasts 60+ min
Interpret ABCD2 risk scores
0-3: 1% stroke risk (in 2 days)
4-5: 4.1%
6-7: 8.1%
What is preferred imaging for a potential TIA
MRI (confirm focal ischemia)
+/- vessel imaging, heart eval, labs (based on AHA)
What is a class 1 Recommendation
- S/p TIA need MRI w/ DWI w/in 24 hours (CT if you cant do MRI)
- Noninvasive imaging of cervicocephalic vessels if susp. of TIA (CT head+neck)
- CT H+N to r/o stenosis (intracranial vasculature)- if abn, do cath angiography to confirm
- Susp. TIA= immediate evaluation!
What are class 2 recommendations
- Use carotid US/MRA/CTA to view extracranial vasculature
- consider catheter angiography prior to endartectomy
- role of plaque characteristics and detection of microemboli not yet defined
- Do ECG asap after TIA
- EEG (or TEE) in susp. TIA if no other cause identified. (TEE for PFO/aortic arch)
- Routine blood tests for susp. TIA
- 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
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
What can damage the penumbra
Hypoperfusion (lowering BP)
Hyperglycemia
fever
seizure
What happens during an AIS
BP increases d/t arterial occlusion and trying to perfuse the penumbra
Lowering BP starves the penumbra= worse outcome
What are cerebral blood flow levels
50-60 is normal
20-30 is no electric activity
10 is neuron death
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
What is the acute Tx of TIA/AIS
Thrombolysis or thrombectomy
DONT decrease BP
What is secondary prevention of AIS/TIA
anti-thrombotic therapy
vascular RF therapy
+/- carotid endartectomy or angioplasty
What is your TPA window
3.5-4 hours (slight ICH risk)
What is tPA inclusion criteria
18+ y/o
<4.5 hours from onset
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
Explain BP in a stroke
BP distal to obstruction: low
overall BP: high
BP >200= high risk of stroke recurrence
What are Vasopressors (ADH) used for
to keep BP high until deficits improve
When SHOULD you decrease BP in AIS
AMI
CHF
aortic dissection
HTN encephalopathy
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)
What is often used with tPA
Mechanical thrombolysis
- MERCI is the cork screw
- PENUMBRA is the clot aspiration
What are predictors of hemorrhagic transformation
**Size of infarct AFIB NIHSS hyperglycemia thrombocytopenia
What causes hemorrhagic strokes
**HTN
Vascular malformation
How does a hemorrhagic stroke manifest
vessel rupture and surrounding tissue damage with high ICP symptoms
What are key points with a hemorrhagic stroke
check non-con CT (blood?)
high mortality (50%)
monitor ICP
neurosurgery intervention
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
What is a cerebral aneurysm
enlarged vessel due to a weak wall <5mm small 6-15 med 16-25 large 25+ massive
What is the MC saccular aneurysm
berry aneurysm in the circle of willis (usually anterior communicating, also posterior communicating)
How do you treat a cerebral aneurysm
endovascular coli/stent
surgical clip
What causes a SAH
- Aneurysm in circle of willis
2. Congenital AVM
How do SAH present
sudden increased ICP
+/- valsalva association
(not the same as ICH)
How do you diagnose a SAH
CT non-con
Xanthochromia (yellow CSF after 1-2 hrs d/t hemolyzed blood)
How do you treat SAH
decrease ICP (stool softener, cough suppressant, anxiolytic, analgesics) CCB for vasospasm
What is first tier testing for stroke patient
CBC BMP glucose PT/PTT +/- ESR
ECG, non-con CT
What is second tier testing for stroke patient (usually neuro)
Doppler US to carotids TTE or TEE MRI/MRA CSF cerebral angiogram
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
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)
What is post stroke depression
When Sx persist 1-2 wk after stroke
- Give SSRI
- If on warfarin, give Lexapro, celexa, zoloft
What is secondary stroke prevention w/ RF modification
dont discontinue statins (LDL 100+, high dose)
Is carotid endartectomy beneficial
YES if 70-99% stenosed
<6% complication rate
When should a carotid angioplasty be used
high risk for restenosis, or contralateral artery occlusion
Who benefit most from a carotid endartectomy
men
elderly
recent cerebral ischemia
ulcerated plaque
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)
What drugs can stroke pts take
antithrombotics
statins
What drugs should stroke pts avoid
estrogen sympathomimetics NSAID ppi (if on plavix) -can take ppi in acute phase to prevent GI bleed
What can mimic a stroke
encephalitis hypoglycemia migraine seizure TIA toxic/metabolic tumor conversion disorder psychogenic cause
A stroke in this area can cause unilateral weakness
ACA
MCA
anterior choroid artery to internal capsule
Basilar artery to midbrain and medulla oblongata
A stroke in this area can cause unilateral loss of sensation
ACA
MCA
PCA to thalamus
Basilar artery to medulla oblongata
A stroke in this area can cause visual deficits
MCA
A stroke in this area can cause nystagmus
Basilar artery to pons and medulla oblongata
A stroke to this area can cause aphasia
MCA
A stroke to this area can cause ataxia
Basilar artery to pons
hemiataxia is medulla oblongata
A stroke to this area can cause hypokinesia
Anterior choroid to basal ganglia
