Stroke For Oral

Question 1

Definitions for stroke

Answer 1

Ischemic stroke: a reduction or loss of blood flow - limited auto regulation, critical perfusion, ischemia, and infarction

Hemorrhagic: rupture that causes a bleed

Can be local obstruction from thrombosis or distant from an embolism where material travels from another area and lodges causing an occlusion

Perinatal stroke is between 20 weeks gestation to 28 days after birth. Childhood stroke is considered after one month

2 main parts are the carotid arteries (anterior) and vertebral arteries (posterior)
Vertebral artery joins the basilar artery to form the circle of Willis that connects the posterior and anterior arteries

Question 2

Neuropathology of stroke

Answer 2

Neuronal damage occurs after 6-8 minutes of lack of oxygen

Results in intracellular and extracellular damage - with ischemia lack of oxygen and nutrients causes damage

Causes many metabolic changes in the intracellular space - including elevated lactate levels and acidosis that may result in cell death

Typically the center zone does not recover but surrounding penumbra contains neurons that can recover if blood flow is restored within 6 hours (although NIH that treatment should be earlier within a 3-hour window for tissue plasminogen activator tPA treatment)

Can gave secondary injury including brain herniation and death can occur if ICP is not managed following a hemorrhagic stroke. Vasospasms can result in additional infarctions, enhanced collateral circulation, swelling/edema can result in mass effect and herniation in the worse case

Downstream effects of stroke pathology with reduced blood flow and metabolism from the site (supply stolen distally) - cognitive deficits may arise in regions not associated with

Question 3

Risk factors for stroke

Answer 3

Common risk for perinatal ischemic stroke is maternal infertility, preeclampsia, prolonged rupture of membranes, and maternal infection

Childhood ischemic stroke: common risks are cardiac disease, cerebral arteriopathy (particularly sickle cell disease) and infection

Trauma is the most common cause of intracranial hemorrhage in children, AVMs, brain tumors

Question 4

Incidence

Answer 4

70% of survivors of childhood stroke have seizures or other neurological deficits

Recurrence rates of childhood stroke (ischemic or hemorrhagic) are 10-25%. Recurrence rates are considerably lower for perinatal stroke

Childhood stroke is higher in males than females - not accounted for by trauma

Question 5

Determinants of severity

Answer 5

Age of the patient
Size and location of infarct or hemorrhage
Acute treatment (e.g., tPA, neurosurgical intervention)
Medical comorbidities (previous stroke)
Secondary medical events (coma and its duration, infection, surgery)

Question 6

Acute presentation of stroke

Answer 6

Both ischemic and hemorrhagic stroke will have poorly controlled hypertension and loss or altered consciousness

Hemorrhage: more like to have LOC, with ICP will have vomiting and nausea, abrupt onset of several clinical signs followed by progressive neurological deterioration `

Question 7

Recovery of course of stroke

Answer 7

Can have comorbid issues that complicate recovery, such as difficulty swallowing, incontinence, feeding tube, mechanical ventilation, pneumonia, cardiac or metabolic abnormalities, increased risk of infection, and mechanical ventilation

Question 8

Neuropsychological profile of strokes

Answer 8

Can see focal deficits - such as Gertsman syndrome (deficits in writing, math, inability to distinguish rings on the hand, and left-right disorientation or when Acomm infarct is involved can see triad of impaired episodic memory (Korsakoff-like), confabulation, and personality changes)

Young children are less likely to have classic profile - more likely to show change as they get older and more diffuse pattern of impairment

Language skills can be lateralized to the right - in majority of cases, sensory and motor functions retain their usual lateralization although “pathological” left-handedness can occur (development of left-handedness after left hemispheric damage in the absent of family history of left-handlers)

Damage in left hemisphere causes language deficits or aphasia in 99% of right handlers but only 60-70% of left-handers

Question 9

Treatment for stroke

Answer 9

CT is sensitive to acute hemorrhage but not to ischemic damage, especially in the first 24 hours after stroke. MRI can detect infarcts within minutes of symptom onset. Magnetic resonance arteriography (MRA) can help identify aneurysms and AVMs

tPA within 3-4.5 hours (but safety and efficacy has not been established)

Antithrombotic medications such as aspirin
Angioplasty
Constraint-based therapies for hemiplegia (experimental)
Compensation strategies

Speech and language pathologist, especially if their is aphasia