Stroke & hemorrhages Flashcards
def stroke
Sudden onset of neuro deficits of a vascular etiology that persists for >24h w/ infarction of CNS tissue (confirmed by neuroimaging)
def ischemic stroke
stroke dt insufficient blood supply
causes of ischemic stroke
- embolic ➔ afib
- thromboembolic
- HTN/DM ➔ lacunar
- global hypoperfusion
- arterial thrombosis ➔ atherosclerosis
RF for ischemic stroke
- increased age
- HTN
- DM
- increased lipids
- smoking
- increase alcohol
- drugs ➔ polypharm
- anticoags and antiplatelets
- sickle cell disease
def hemorrhagic stroke
cerebral infarction dt hemorrhage
types of hemorrhage that could cause a hemorrhagic stroke
intracerebral hemorrhage: bleeding within the brain parenchyma
subarachnoid hemorrhage: in the subarachnoid space
intraventricular hemorrhage: bleeding within the ventricles
subdural hematoma: crescent along the borders of the brain and skull
epidural hematoma: doming
RF for intracranial hemorrhage
- increased age
- htn
- cerebral amyloid angiopathy
- smoking
- alcohol
- drugs ➔ polypharm
- anticoags and antiplatelets
RF for subarachnoid hemorrhage
- smoking
- htn
- alcohol
- age
- personal hx of aneurysm or SAH
- fhx of intracranial aneurysm
stroke mimics
- drug intoxication
- Infections
- Migraines – complex migraines
- Metabolic
- Seizures
- Tumours
- Hypoglycemia
- Stroke spares the forehead vs bell’s palsy involved the forehead (can move the eyebrows)
causes of hemorrhagic stroke
- nontraumatic (spon) intracerebral hemorrhage ➔ commonly from HTN emergency
- nontraumatic (spon) ➔ ruptured aneurysm
- traumatic SAH
general patho of an ischemic stroke
Insufficient blood flow to focal area of brain → central core of tissue → irreversible damage (area of infarction) → surrounding area (penumbra) does not have immediate cell death (has potential for recovery if there is early re-perfusion)
general patho for hemorrhagic stroke
hematoma ➔ mass effect and perihematoma edema ➔ increase ICP ➔ decreases cerebral perfusion and causes ischemic injury
what does BE FAST stand for for stroke?
B - balance loss
E - eyesight changes
F - facial drooping
A - arm numbness
S - slurred speach
T - time
s/s to suspect stroke
BE FAST
- sudden numbness
- confusion
- trouble seeing
- severe headache
most common type of ischemic stroke and s/s
Middle cerebral artery
CHANGes
C - contralateral hemiparesis and sensory loss
H - homonymous hemianopia
A - aphasia
N - neglect
G - gaze preference towards the side of the lesion
how to tx an ischemic stroke?
within 4.5h ➔ TPA ➔ BP we want <180
otherwise permissive HTN ➔ only lower if >220/120 ➔ IV labetalol
consider endovascular thrombectomy (EVT) if it has been <24h and there is still salvageable tissue (penumbra) via CT w/ perfusion
if TPA not an option ➔ dual anti-platelet therapy w/ ASA + plavix
consider anticoagulation (DOAC or warfarin) if there is some level of afib
consider HTN control ➔ labetalol
how to tx a hemorrhagic stroke?
refer to neurosurgery ➔ hematoma evacuation of decompressive craniotomy
blood pressure control ➔ can use IV mannitol to decrease ICP or elevate the head of the bed
reverse any anticoags
how to ix a suspected stoke?
- non-contrast CT/MRI
- POC glucose
- wanna get a contrast CT or a CT angio
- NIH stroke scale
consider carotid dopplers
what general non-stroke specific things can you do when managing them?
manage the HTN ➔ permissive ➔ goal <220/120; labetalol
manage sugars ➔ ensure not hypoglycemic
refer to a stroke centre later for secondary prevention
refer to SLP, PT, OT for rehabilitation and decrease disablity
what can we do to prevent another stroke?
- antiplatelet therapy – ASA
- cardiovascular risk factor management ➔ wt loss, statins
- DM control ➔ metformin
- control HTN ➔ diuretics, ACEi, ARBi
- smoking cessations
- increase exercise
s/s of anterior cerebral artery ischemic stroke
lower limbs paralysis + sensory loss ➔ unable to perform coordinated leg movements
cognitive deficits ➔ apathy, confusion, slowed mental state
s/s of middle cerebral artery ischemic stroke
the classic stroke s/s
- upper limb weakness/numbness
- facial droop
- wernickes and brocas aphasia
- vision changes
s/s of posterior cerebral artery ischemic stroke
4 deadly D/s
- Diplopia/ocular
- dizziness
- dysphagia
- dysarthria
what is a TIA?
Transient ischemic attack: brief, reversible episode of focal neurologic dysfunction w/out acute infarction (normal imaging)
what should a TIA tell you about stroke risk?
Considered to be a warning of an impending ischemic stroke → highest risk of ischemic stroke within 24h
what is amaurosis fugax?
transient monocular vision loss ➔ retinal vein or artery occlusion
RF for TIA
HTN, DM, age, smoking, obesity, alcoholism, stress, prev hx of stroke/TIA
what ix do you do for a TIA?
CT angiogram – CTA
- can get a carotid doppler, but the CTA includes the carotids
- helps to assess the extent of blockage in arteries/chance for ischemic stroke
what tx can we offer for TIA?
could offer stenting or carotid endarterectomy – removal of the fatty deposits/plaques that result in the narrowing
what prevention meds do we go on for TIA to not become a stroke?
DAPT - asa and plavix
