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Emergency Medicine > Stroke and TIA > Flashcards

Stroke and TIA Flashcards

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1
Q

In stroke, secondary injury results from what?

A

Edema, mass effect

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2
Q

TIA definition

A

Transient episode of neurological dysfunction by focal brain, spinal cord, or retinal ischemia without acute infarction

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3
Q

How long does TIA usually last?

A

1-2 hours (usually less than 24)

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4
Q

What percent of TIA will have ischemic stroke and when?

A

10% in 90 days

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5
Q

get early re-perfusion?

A

Quick use of thrombolytics and neuroprotective agents

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6
Q

Will perfusion return to baseline in hemorrhagic stroke?

A

No

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7
Q

Describe arteries of brain

A
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8
Q

Worst HA of life is what?

A

SAH

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9
Q

What is more common type of hemorrhagic stroke and what are causes?

A

ICH-
•Elderly, Hx of Stroke; also ETOH and tobacco use
•Anticoagulation, cocaine, vascular malformation, amyloidosis

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10
Q

What is most important when diagnosing stroke?

A

Timing

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11
Q

On fundoscopic exam, what may papilledema indicate?

A

Mass lesion, HTN crisis

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12
Q

On fundoscopic exam, what may preretinal hemorrhage indicate?

A

SAH

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13
Q

When is NIHSS stroke scale used?

A

Baseline and serial exams (post-CT, 2 hours, 24 hours, 7-10 days, 3 mo)

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14
Q

What percent of TIA becomes stroke within 2 days of ED presentation?

A

50%

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15
Q

Findings of unilateral ACA infarction:

A

•Contralateral sensory & motor sx’s in LE’s
•Sparing of hands & face
•Left sided lesions = akinetic mutism (unmoving / unspeaking)
•Transcortical Motor Aphasia (TMA) = comprehension with non-fluent speech
•Right sided lesions = confusion & motor hemi-neglect
–Bilateral = combination of mutism & incontinence; worsened outcomes

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16
Q

What is most common infarction?

A

MCA

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17
Q

MCA infarction findings:

A
  • Hemiparesis, facial plegia, contralateral sensory loss
  • Face & UE > LE
  • Dominant hemisphere = aphasia (receptive, expressive OR both)
  • Nondominant hemisphere = inattention, neglect, extinction, dysarthria w/o aphasia, constructional apraxia (difficulty drawing complex 2-D or 3-D objects)
  • Homonymous hemianopsia & gaze preference in either
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18
Q

How does PCA infarction classically present?

A

Visual field defects

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19
Q

What is most common presenting complaint with PCA?

A

Unilateral HA

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20
Q

Other findings of PCA:

A

–Light-touch & pinprick deficits
–Alexia w/o agraphia: can’t read but writes
–Cannot name colors & recent memory loss
–Unilateral CN III palsy & hemiballism
–Motor minimally affected: prevents realization that one has had a stroke

21
Q

Most common symptom of vertebrobasilar artery:

A

Vertigo

22
Q

Other findings of vertebroasilar:

A
  • HA, nausea, visual disturbances & oculomotor palsies
  • Ataxia, sensory disturbances, limb weakness, oropharyngeal dysfunction
23
Q

Hallmark presentation of posterior circulation stroke:

A

•Crossed neurologic deficits
–Ipsilateral CN deficits w/ contralateral motor weakness

24
Q

•Basilar Artery Occlusion

A

–Severe quadriplegia, coma, locked-in syndrome

25
Q

Cerebellar Infarct findings

A

–Vertigo, gait disturbance, limb ataxia, HA, dysarthria, nausea, vomiting, CN abnormalities
–Mental Status variable & may deteriorate rapidly
–MRI/MRA better than CT
–Prompt Neurosurgical consultation a must
–Obstructing hydrocephalus = BAD

26
Q

Lacunar Infarction findings:

A

–Pure motor or sensory deficits
–Clumsy hands & dysarthria
–Unilateral leg paresis & ataxia
–Small penetrating artery involvement
–Chronic HTN and age related
–Variable presentation
•May be sub-clinical
–More favorable prognosis

27
Q

What is commonl in Hx of cervical artery dissection?

A

Neck trauma, often trivial

28
Q

Internal Carotid Artery Dissection findings:

A

•Unilateral head pain (1st symptom), face pain, neck pain, partial Horner’s syndrome

29
Q

Vertebral artery dissection findings:

A
  • Posterior neck pain & headache (posterior-occipital)
  • Can be unilateral or bilateral HA; typically occipital
  • Unilateral facial paresthesia, dizziness, vertigo, N/V, diplopia, ataxia, limb weakness, numbness, dysarthria, hearing loss
30
Q

What is a PE finding for cerebellar infarct?

A

Cannot look toward side of bleed

31
Q

What is SAH associated with?

A

Valsalva

32
Q

Within how long should brain imaging occur upon arrival?

A

Within 25 min

33
Q

Treatment decision of stroke should occur within how long of arrival?

A

60 min

34
Q

Treatment approach for stroke

A

•“Safety Net” – don’t forget the D-stick
•Very brief history
•ABCs
•Diagnostic studies
–STAT EKG
–PCXR
–Your labs
–Non-contrast head CT!!

35
Q

Who reads CT for stroke?

A

Most expert interpreter

36
Q

What is therapeutic range of INR?

A

2-3

37
Q

What is ancillary testing for Stroke/TIA?

A

•CBC-look at platelets
•Chemistry
•ECG & Cardiac Enzymes
•Coags-If patient is on blood thinner, what should INR be?
–Therapeutic Range for INR is between 2.0-3.0
•Type and Screen

38
Q

What should be addressed when ischemic stroke?

A

•Dehydration: give IV crystalloids
•Hypoxia: maintain O2 Sats > 92%
•Hyperpyrexia: search for & treat the cause of the fever (sepsis, PNA, UTI, meningitis)
•Hypertension
Hyperglycemia

39
Q

What is go-to drug for HTN?

A

labetalol

40
Q

What is HTN requirement for thrombolytics in ischemic stroke?

A

Must be 185/110 within 2 doses of labetalol. If takes more than 2 doses then no longer candidate for thrombolytics

41
Q

What is the only acceptable CCB for ischemic stroke?

A

Nicardipine

42
Q

What may worsen outcome of ischemic stroke?

A

Vasodilators

43
Q

What thrombolytic is used in ischemic stroke?

A

Recombinant tissue-type plasminogen activator 0.9mg/kg, max dose of 90mg; 10% given as a bolus, 90% infused over 60 minutes

44
Q

What must you do prior to pushing rTPA?

A

Consult but don’t delay

45
Q

rTPA use requirements:

A

–Assessment
•NIHSS score (4-22)**[may be lower if posterior stroke suspected]
–Dose
•Total Dose 0.9mg/kg max dose of 90mg; 10% bolus, remainder over 60 minutes
–Reassess
•Neuro & BP checks Q15min x 2 hrs = ICU Admission

46
Q

Post monitoring for rTPA:

A

–No ASA or heparin for 24 hours
–BP and Neuro exam q 15 minutes for 2hrs post administration
–SBP >180 or DBP>105 (2 consecutive)
•IV Labetalol 10 mg q 10-20 min to 300mg
•Nitroprusside infusion (0.5-1.0 mcg/kg) if no improvement with Labetalol
–If suspected post-rtPA bleed: CT, CBC, coags, fibrinogen, T & C; urgent Neurosurgery, Neurology, & Hematology consult

47
Q

Antiplatelet therapy for TIA:

A

•Aspirin alone: start within 24 to 48 hours of TIA
–significantly reduces 4 week to 6 month mortality
•Dipyridamole & ASA
•Clopidogrel (Plavix)

48
Q
A
49
Q
A

Emergency Medicine (2 decks)

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