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Older Adult Exam 2 > Stroke > Flashcards

Stroke Flashcards

1
Q

What is a stroke?

A
  • An acute, rapidly-developing focal neurological dysfunction due to an abnormal perfusion
  • Interruption of the normal blood supply to the brain (ischemia), resulting in neuro dysfunction and the death of brain cells
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2
Q

What are the two emphases and the de-emphasis of the AHA/ASA definition of stroke?

A
  1. Imaging
  2. Neurological deficits

De-emphasis of temporal aspects, like sx lasting for greater than 24 hours

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3
Q

What types of infarctions does the definition of stroke include?

A
  • Cerebral infarctions
  • Spinal infarctions
  • Retinal infarctions

Clinically, stroke continues to be used to refer to cerebral infarctions

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4
Q

What is the most common type of stroke?

A

Ischemic stroke, about 87% of all strokes

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5
Q

What is an ischemic stroke?

A

A stroke due to thrombosis, embolism, or systemic hypoperfusion

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6
Q

Where is the most common site of an ischemic stroke?

A

Middle cerebral artery (MCA)

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7
Q

What is an important warning signs of a stroke?

A

Transient ischemic attacks (TIA)

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8
Q

What are some cardioembolic causes of ischemic stroke?

A 
***AFIB***
Ventricular thrombus
Prosthetic valves
Rheumatic heart disease
Other cardiac sources
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9
Q

What is the second most common type of stroke?

A

Intracerebral hemorrhage (ICH), about 10% of all strokes

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10
Q

What is an intracerebral hemorrhage?

A

Bleeding inside the brain

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11
Q

What is the third most common type of stroke?

A

Subarachnoid hemorrhage (SAH), about 3% of all strokes

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12
Q

What is a subarachnoid hemorrhage?

A

Bleeding in the subarachnoid space

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13
Q

Stroke is the what # leading cause of death in the United States?

A

Fifth leading cause of death

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14
Q

What is the leading cause of disability?

A

Stroke

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15
Q

Who has a higher lifetime incident of stroke: females or males?

A

Females

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16
Q

Of younger people, who is more likely to have a stroke: a female or male?

A

Male

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17
Q

What is a major risk factor for stroke?

A

Age, particularly 75 and older

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18
Q

Who is more likely to die from a stroke?

A

Non-Hispanic black Americans and those living in the southern state “stroke belt”

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19
Q

What is the cause of the decline in stroke deaths?

A

A decrease in both stroke incidents and stroke mortality

  • Improved blood pressure control
  • Reduced smoking
  • Improved diabetes control
  • Improved lipid control
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20
Q

What are the different clauses of the stroke?

A
  • Thrombus
  • Embolus
  • Small vessel disease
  • Hypoperfusion
  • Hyper viscous blood
  • Cryptogenic
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21
Q

Where and how does a thrombus occur?

A
  • Within cerebral vasculature

- Usually starts when atherosclerotic plaque becomes unstable, similar to MI

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22
Q

What causes an embolus formation, and where are these typically found when someone has a stroke?

A
  • Usually of cardiac or carotid origin
  • Atrial fibrillation
  • Large cerebral artery occlusion is typically embolic
  • Valvular thrombi: mitral stenosis, endocarditis, or prosthetic valve
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23
Q

What kinds of infarcts are associated with small vessel disease?

A

Lacunar Infarcts

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24
Q

What are some causes of cerebral hypoperfusion?

A

Low blood pressure

Decreased cerebral perfusion pressure

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25
Q

What are some hyperviscous blood state/conditions?

A

Sickle cell disease

Polycythemia vera

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26
Q

What is the cryptogenic stroke?

A

And ischemic stroke for which no probable causes identified after adequate diagnostic evaluation

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27
Q

What is the standard diagnostic work up for a stroke?

A
  • MRI or CT of brain
  • CTA or MRA of the brain, neck, and thoracic arteries; ultrasound if CTA and MRA contraindicated or unavailable
  • TTE, TEE
  • ECG, Holtor monitor, 30 day event monitor, loop recorder
  • Hematologic testing for hypercoagulable states
  • Occult “low burden” paroxysmal AF maybe found: significance unclear
  • Patent foramen ovale (PFO) maybe found
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28
Q

What is the risk of closing a PFO?

A

New onset atrial fibrillation

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29
Q

What are the nonmodifiable risk factors for stroke? What is the single most important nonmodifiable risk factor?

A
  • Age: single most important nonmodifiable risk factor
  • Sex: higher lifetime incidence older females > older males
  • Race and ethnicity: AA, Latino, Native Americans > Non-Latino white, Asian) - These populations can be more risk for sickle cell disease as well
  • Family history: an ischemic stroke in either parent by the age of 65 is associated with a 3 fold increased risk of stroke in offspring
  • A prior stroke or TIA
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30
Q

What are some modifiable risk factors for stroke?

A

The things that keep hearts healthy keep brains healthy

  • Hypertension: BP > 140/90
  • Diabetes: Doubles risk, particularly increases risk of stroke a younger age, Duration of diabetes also matters
  • Atrial fibrillation: Increases risk fivefold
  • Carotid artery stenosis: Risk doubles
  • Hyperlipidemia: Relationship to stroke risk unclear, especially in those that are older
  • Smoking: 2 to 4 times greater risk
  • Heavy alcohol use: Low and moderate use is associated with decreased risk
  • Physical inactivity
  • Chronic kidney disease: Proteinuria and albuminuria are better predictors of stroke risks than GFR
  • Obesity: Unclear, Most likely related to other risk factors present with obesity
  • Sleep apnea: Relationship is bidirectional, as stroke increases the risk of sleep apnea as well
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31
Q

In those with atrial fibrillation with had a stroke, where are the blood clots most commonly formed?

A

Left atrial appendage of the heart

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32
Q

What is the most important modifiable risk factor in preventing SAH?

A

Smoking

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33
Q

What are some modifiable risk factors for stroke that are related to females in particular?

A
  • Migraine with aura
  • Use of oral contraceptives
  • Use of HRT
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34
Q

What are some general interventions for primary prevention of stroke?

A
  • Obtain a complete family history
  • Screen for stroke risk using modified Framingham stroke risk calculator
  • BP < 140/90
  • Smoking prevention and cessation
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35
Q

What are some specific primary prevention recommendations for those with diabetes?

A
  • BP < 140/90
  • Staten, not a fibrate
  • General glycemic control
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36
Q

What are some specific primary prevention recommendations for those with Hyperlipidemia?

A
  • Lifestyle changes and treatment with a statin for those with high 10yr ASCVD risk
  • No evidence that fibrates or any other lipid lowering agents reduced risk of stroke
37
Q

What are some specific primary prevention recommendations for those with atrial fibrillation?

A
  • Screen everyone 65+ (Pulse plus ECG is indicated)
  • In nonvalvular AF at high risk, anticoagulation with a DOAC/NOAC, like Pradaxa, Eliquis, Xarelto, Savaysa is preferred over warfarin
  • In nonvalvular AF at moderate risk, no anti-thrombotic therapy, can be considered
  • For those at low risk, aspirin is no longer recommended
  • Watchmen left atrial appendage closure device now available for some patients that would otherwise need long-term warfarin therapy
38
Q

What criteria are used to determine which patients with AF are at high, moderate, or low risk of stroke?

A

CHA2DS2-Vasc

  • Congestive heart failure (1 point)
  • Hypertension (1 point)
  • Age 65-74 (1 point), Age 75+ (2 points)
  • Diabetes (1 point)
  • Stroke or TIA (2 points)
  • Sex (female) (1 point)
  • Vascular disease (MI, PAD, aortic plaque) (1 point)

Low risk: 0 points if male, 1 point if female
Moderate risk: 1 point if male, 2 points if female
High-risk: >2 points if male, >3 points if female

39
Q

What are some specific primary prevention recommendations for those with Carotid artery stenosis?

A
  • Asymptomatic: aspirin plus statin
  • Revascularization is dependent on comorbidities, life expectancy, and other factors
  • Can consider carotid endarterectomy in asymptomatic patients who have >70% stenosis of Internal carotid artery - Effectiveness compared to medical management alone is not well-established
40
Q

What are some specific primary prevention recommendations related to lifestyle changes?

A
  • Diet: Mediterranean diet supplemented with nuts
  • Exercise: Moderate to vigorous intensity aerobic physical activity at least 40 minutes per day for 3 to 4 days a week
  • Obesity: Weight reduction
  • Alcohol: Reduction or cessation by heavy drinkers, one to 2 drinks per day for males and one drink per day for females
41
Q

What are some specific primary prevention recommendations for those with Sleep apnea?

A
  • Screen for sleep apnea

- Treatment

42
Q

What do studies show about prophylactic aspirin’s risk of bleeding versus benefits?

A

Risk of bleeding outweighs the benefits

  • No CVD benefit from Aspirin, but statistically significant higher risk of bleed
  • Increased risk of major bleeding, intracranial bleeding, and major gastrointestinal bleeding
43
Q

What does the NIH stroke scale measure and what do the scores mean?

A

11 items: Level of consciousness, best gaze, visual fields, facial palsy, motor arm, motor leg, limb ataxia, sensory, best language, dysarthria, extinction and inattention

  • Maximum possible score is 42
  • Scores > 20 are considered severe
44
Q

What is the name of the area of the brain that maybe saved if perfusion to brain tissue is restored quickly?

A

penumbra

45
Q

What happens intracellularly during an ischemic stroke?

A
  • Neurons cannot maintain a aerobic respiration –> anaerobic respiration and the accumulation of lactic acid
  • Neurons cannot maintain a ionic balance
  • Glutamate, the chief excitatory neurotransmitter, excessively stimulates the neurons and depolarizes the cellular membrane
  • Sodium, chloride, and water flow into the cell –> cytotoxic edema
  • Calcium flows into the cell –> neuronal death
  • Stroke is not just an event, it is a process that evolves over time*
46
Q

What treatment option can extend the time for reperfusion beyond tPA’s 3-4.5hr hour window?

A

Mechanical thrombectomy

47
Q

What are some characteristics of patients appropriate for mechanical thrombectomy?

A
  • Large vessel occlusion, Either internal carotid or proximal middle cerebral artery
  • Area of infarct that was relatively small, Compare to the penumbra/hyperperfused/ischemic tissue
48
Q

What does the frontal lobe of the brain control?

A
  • Skeletal muscle movement
  • Behavioral expression
  • Broca’s area
49
Q

What does the parietal lobe of the brain control?

A
  • Sensory cortex

- Damage can affect superior contralateral vision

50
Q

What does the temporal lobe of the brain control?

A
  • Smell and hearing

- Damage can affect inferior contralateral vision Wernicke’s area

51
Q

What does the occipital lobe of the brain control?

A

Primarily controls vision

52
Q

What is the difference between Broca’s aphasia and Wernicke’s aphasia?

A
  • Broca’s area is located on the frontal lobe of the left hemisphere = Nonfluent or expressive aphasia
  • Wernicke’s area is located on the temporal lobe of the left hemisphere = Fluent or receptive aphasia
53
Q

What are the 3 parts of the basal ganglia and what is their primary role?

A
  • Caudate, putamen, and globus pallidus

- Coordination of movement

54
Q

What are the 3 parts of the limbic system and what are their roles?

A
  • Amygdala, cingulate gyrus, and the hippocampus
  • Amygdala, cingulate gyrus = Memory and emotion
  • Hippocampus = Memory, especially for converting short-term to long-term memory, and learning
55
Q

What are the 3 parts of the diancephalon, where is it located, and what are their roles?

A
  • Thalamus, hypothalamus, and pituitary and pineal glands
  • Located between the brain stem and the cerebrum
  • Thalamus is crucial to sensory function and is connected to all the major areas of brain
  • Hypothalamus is critical for autonomic and endocrine functions
  • Pineal gland is important in sleep/weeks cycles
  • Pituitary gland controls may normal functions
56
Q

Where is the cerebellum located and what is its role?

A
  • Adjacent to the brainstem
  • Crucial for motor function, especially coordination, balance, and position sense
  • Also affects speech and ocular movement
57
Q

What are the 3 parts of the brain stem and what are their roles?

A
  • Medulla, pons, and midbrain
  • Crucial in controlling breathing, blood pressure, and alertness
  • 10 of the cranial nerves arise in the brain stem
  • In the medulla, the corticospinal tracks traverse midline, decussate, and send impulses to the opposite side of the body
58
Q

The anterior cerebral arteries supply which brain structures?

A
  • Surface branches supply cortex and white matter of inferior frontal lobe and medial surface of the frontal and parietal lobes
  • Penetrating branches supply the deeper cerebrum, diencephalon, and limbic structures
59
Q

The middle cerebral arteries supply which brain structures?

A
  • Surface branches supply all four lobes of the cortex

- Penetrating branches supply deep white matter and part of the diencephalon

60
Q

Occlusion of the MCA predominately affects which parts of the body?

A

The face and upper limb sensory and motor function

61
Q

Occlusion of the ACA predominately affects which parts the body?

A

Lower limb function

62
Q

The vertebrobasilar system (vertebral + basilar artery) supply which brain structures?

A
  • Cerebellum
  • Brainstem (Ponds, Medulla)
  • Thalamus
  • Occipital lobe

The basilar artery branches into 2 posterior cerebral arteries that supply

  • Occipital and temporal lobes
  • Parts of the thalamus and midbrain
63
Q

The superior cerebellar arteries supply which brain structures?

A
  • Cerebellum

- Parts of the midbrain

64
Q

The posterior inferior cerebellar arteries supply which brain structures?

A
  • Cerebellum

- Medulla

65
Q

The anterior inferior cerebellar arteries supply which brain structures?

A
  • Cerebellum

- inner ear (important diagnostic key: sudden deafness)

66
Q

What is the lacunar stroke?

A

The occlusion of a deep penetrating artery branching off of a larger artery, such as the MCA, also known as “small vessel occlusions” or “small vessel disease”

67
Q

What is a major contributing factor of lacunar strokes?

A
  • Hypertension
  • Smoking
  • Diabetes
68
Q

How do lacunar strokes often present?

A

Often clinically silent and discovered incidentally on brain imaging
- Not usually cortical signs, Often just weakness or just numbness

69
Q

What are some other medical problems that may mimic a stroke?

A 
Seizure
Hypoglycemia
Migraine
Hyponatremia
Brain tumor
Meningitis/encephalitis
DKA/HHS
Drug toxicity
Meniere's, labyrinthitis
Bell's palsy
Hypotension
70
Q

What are some common sequelae of a stroke in an older adult?

A 
Hemiparesis
Inability to walk without some assistance
Cognitive deficits
Depressive symptoms
Aphasia
Dependent in some or all ADLs
In a nursing home
71
Q

What are some LESS common sequelae of a stroke in an older adult?

A

Seizures
Pneumonia from dysphasia or immobility
Incontinence
UTI
Spasticity or contracture
Shoulder displacement and/or shoulder pain
Post stroke pain more generally, especially central pain
Pressure wounds, depending on the level of disability

72
Q

What is an important poststroke sequelae to screen for in older adults?

A

Depression

One third of all stroke survivors experienced poststroke depression

73
Q

How can a stroke precipitate or potentiate frailty?

A 
Immobility
Deconditioning
Osteoporosis
Muscle atrophy
Risk for pressure ulcers
Risk for DVT
74
Q

How much rehab must somebody be able to tolerate for admission to an acute inpatient rehabilitation?

A

Three hours per day

75
Q

When does the neurological recovery peak? How long may some improvement be seen?

A
  • Three months

- Three years

76
Q

What is a transient ischemic attack?

A

A transient episode of neurological dysfunction resulting from focal brain, spinal cord, or retinal ischemia, without acute infarction

77
Q

What diagnostic tests should be performed when someone is suspected to have a TIA?

A
  • Diffusion weeded MRI within 24 hours of symptom onset
  • US, MRA, or CTA for extra cranial vasculature
  • Can consider transcranial doppler, but angiography is the gold standard
  • ECG
  • Telemetry or Holter
  • Echocardiogram or TTE
  • CBC, CMP, PT/PTT, lipid panel
78
Q

What should someone be hospitalized for a TIA?

A

Patient present within 72 hours and

  • ABCD2 score > 3
  • ABCD2 score 0-2 and uncertainty that diagnostic workup can be accomplished in two days as an outpatient
  • ABCD2 score 0-2 and other evidence that the TIA was caused by focal ischemia
79
Q

Hot how do you calculate an ABCD2 score?

A
  • Age: 1 point for age 60+
  • Blood pressure > 140/90: 1 point
  • Clinical features: 2 points for unilateral weakness, 1 for speech disturbance without weakness
  • Duration of symptoms: 1 point for 10 to 59 minutes, 2 points for 60+ minutes
  • Diabetes: 1 point

0-3: Low risk
4-5: Moderate risk
6-7: High risk

80
Q

What is the most important intervention for secondary prevention of ischemic stroke?

A

Hypertension, goal <140/90 (lacunar <130)

81
Q

How do we manage hyperlipidemia and secondary prevention of stroke?

A

Intensive statin therapy, even in patients with low cholesterol and no evidence of the other heart disease

82
Q

When should CEA be considered for carotid stenosis and secondary prevention of stroke?

A
  • For ipsilateral severe stenosis of 70 to 99%, CEA recommended if mortality risk less than 6%
  • For ipsilateral stenosisThat is moderate50 to 69%, CEA recommended depending on age, sex, comorbidities, and same morbidity as above
  • If stenosis less than 50%, there’s no indication for CEA
83
Q

How do we manage carotid stenosis for secondary prevention strip?

A

Antiplatelet therapy, statin therapy, and risk factor modification

84
Q

In order adults greater than 70 years old, is CEA or CSA better?

A

CEA is associated with better outcomes

85
Q

For those with atherosclerosis of a major intracranial artery, is aspirin or warfarin recommended? How about clopidogrel?

A
  • Aspirin 325 mg is recommended over warfarin

- Adding clopidogrel for 90 days maybe reasonable

86
Q

What is the secondary prevention treatment of stroke in relation to atrial fibrillation?

A
  • Prolonged rhythm (~30 days) monitoring for those with cryptogenic stroke
  • Anticoagulant (DOAC/NOAC) initiated within 14 days of AF diagnosis
  • For those with CAD, an antiplatelet can be added to anticoagulant
  • If unable to take anticoagulants, aspirin should be initiated and clopidogrel is reasonable to add
  • Is anticoagulant therapy must be interrupted, Bridge with low molecular weight heparin
87
Q

What anti-thrombotic therapy should be used if the stroke was non-cardioembolic?

A
  • Antiplatelet rather than anticoagulation
  • Aspirin + dipyridamole or clopidogrel monotherapy acceptable
  • Aspirin + clopidogrel not recommended, as bleeding risk too high
88
Q

If someone had an ischemic stroke while taking aspirin, will increasing the dose of aspirin help?

A

No, nor will choosing another single agent or combo

89
Q

How do you manage anticoagulation after intracranial hemorrhage or subarachnoid hemorrhage?

A
  • Discontinue all anticoagulants for at least one week

- Decision to restart depends on risk of subsequent thromboembolism or risk of recurrent cerebral bleed

Older Adult Exam 2 (8 decks)

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