Stroke Lecture Powerpoint Flashcards
Cerebrovascular disease
A collective term for a range of conditions that affect and decrease blood flow to brain such as carotid stenosis, aneurysms, vascular malformations, stroke, etc.
Risk factors for CVD (also which is MOST important?) (8)
- HTN (MOST important)
- atherosclerosis
- hyperlipidemia
- diabetes
- smoking
- diet
- obesity
- increasing age/male/african americans
Carotid stenosis definition, when is it symptomatic, diagnostic studies (3), treatment options
- A type of cerebral vascular disease caused by atherosclerosis plaque in the arteries that are main supply to brain
- Often asymptomatic until a TIA
- PE might find carotid bruit, doppler ultrasound, or cerebral angiography
- In less than 50% occlusion treated conservatively with antihypertensives, statins, anticoags while >50% require stenting but NOT endarterectomy (too risky)
Cerebral aneurysm causes (4), epidemiology, types, signs/symptoms, diagnosis
- Caused by hypertension, atherosclerosis, trauma, congenital defect
- most prevalent in ages 50-60 and more common in women
- 2 types: saccular (rounded outpouching containing blood also called berry) and fusiform (balloons or bulges out on all sides of artery)
- Signs and symptoms unruptured are asymptomatic but occasionally have cranial nerve palsy, dilated pupils, double vision, or pain - ruptured have localized headache, nausea and vomiting, stiff neck
- Diagnosed via MRA and carotid angiogram, rupture can also be detected by CT or lumbar puncture then cerebral angiography
Vertebrobasilar insufficiency cause, signs/symptoms, diagnosis (2), treatment options (3)
- Caused by decreased blood flow to vertebral and basilar arteries, affects the brainstem, occipital lobes, and cerebellum
- vision loss, diplopia, vertigo, dysarthria, ataxia, confusion
- MRA or angiography
- lifestyle modifications, meds, surgery
Arteriovenous malformations definition, cause, signs/symptoms (2), diagnosis (2), treatment (1)
- Groups of abnormal/poorly formed blood vessels resulting in increased rate of bleeding
- typically congenital found incidentally
- seizure and headache (4/100 people will hemorrhage per year)
- MRI and angiography
- Treated by neurosurgery
Stroke definition, how does it clinically present?
- Abrupt onset of neurological deficit attributable to focal vascular disease, acute brain injury caused by decreased blood supply (ischemia) or hemorrhage
- clinical manifestations are variable because of the complex anatomy of the brain and its vasculature
Stroke is a ____ diagnosis
clinical
Stroke pathophysiology
- Brain is 2% of body weight but takes 17% of cardiac output and 20% o2
- ischemia is caused by decrease in blood flow that lasts longer than a few seconds
- neurons lack glycogen so energy failure is rapid and necrosis occurs faster than in other tissue
Stroke epidemiology
Stroke is the leading cause of what?
- 5th leading cause of death, 87% are ischemic rather than hemorrhagic,
- leading cause of serious long term disability
2 types of stroke based on dysfunction and their subclasses
- focal brain dysfunction (ischemic and intracerebral hemorrhage)
- diffusion brain dysfunction (subarachnoid hemorrhage)
80% of ischemic strokes occur from occlusion of ____ caused by _____.
Majority of strokes are ____ rather than ____
- large or small vessels
- thrombosis (clot), embolism (dislodged flowing object), or systemic hypoperfusion (circulatory problem of whole brain)
- ischemic, hemorrhagic
Ischemic stroke vs TIA
Ischemic stroke is infarction with sequelae (symptoms don’t completely go away while body tries to compensate) vs TIA has no infarction and no sequelae but is a transient “mini stroke”
Transient ischemic attack (TIA)
Transient episode of focal ischemic cerebral neurologic deficits without infarction, symptoms typically less than 1 hour but varies, risk of stroke rises if not treated early enough
Transient ischemic attack clinical presentation (3) and which set of symptoms does carotid TIA belong to and which does vertibrobasilar ischemic belong to?
- abrupt and rapid recovery
- weakness and heaviness of contralateral arm, leg, or face with possible numbness (carotid)
- vertigo, ataxia, diplopia, dysarthria, changes in vision (vertebrobasilar ischemic)
TIA diagnostic studies (5)
- CT of head
- echo
- EKG (afib)
- CBC (infection)
- blood glucose (hypoglycemia)
TIA treatment options (4)
- carotid endarterectomy if surgery accessible stenosis
- anticoagulants
- aspirin 325mg po daily
- clopidogrel (plavix)
Penumbra
Zone of reversible ischemia around core of irreversible infarct, salvageable in first few hours after ischemic stroke onset and goal to save with treatment to reverse and minimize permanent damage
Lacunar infarct ischemic stroke definition and presentation (3)
- A common type of ischemic stroke usually caused by small lesions often in patients with no memory of CVA found incidentally, usually progress over 24 hours then stabilize
- Present with contralateral motor and sensory deficits, ipsalateral ataxia, and dysarthria
Carotid circulation ischemic stroke definition and presentation (1)
-A common type of ischemic stroke that is usually asymptomatic but can present with amaurosis fugax (collateral circulation brings vision back)
LEFT sided MCA ischemic stroke should raise worry for….
….broca’s or wernicke’s aphasia
anterior cerebral artery ischemic stroke key points (2)
- emotional symptoms
- unilateral occlusion well tolerated because of collateral blood flow
middle cerebral artery ischemic stroke key point (1)
-wernicke and broca’s aphasia if on left side of brain
posterior cerebral artery ischemic stroke key points (2)
- thalamic syndrome: contralateral hemisensory disturbance followed by spontaneous pain and increased sensation
- memory loss
Older infarcts often appear ____ while fresh appear ____ on a CT
Darker, lighter
Anterior portion of pons locked in syndrome
An absence of movement except for eyelids despite sensation and consciousness preservation associated with incomplete occlusion of the vertebral or basilar arteries
Patients having a stroke are generally not in….
….pain, they don’t seek assistance on their own (time is tissue)
ED stroke care timeline
-Triage (10 min)
-medical care (25 min)
-CT and labs (45 min)
Treatment (60 min)
NIH stroke scale (NIHSS)
Standardized method used to measure the level of impairment caused by a stroke, scored from 0-42 to determine the severity, includes CN, motor, sensory, cerebellar, inattention, language, etc.
Differential diagnosis of stroke (5)
- seizure
- syncope
- migraine
- hypo/hyperglycemia
- drug toxicity
Stroke diagnostic studies (which is the most important) (6)
- CT without contrast (most important)
- Standard MRI
- MRA
- Angiography
- EKG
- CXR
Labs to order in a suspected stroke patient (7)
- Blood glucose
- Troponin I
- Pt/PTT
- CBC with diff
- Chem 7
- lipid panel
- urinalysis (looking for elicit drugs)
Contraindications to treating ischemic stroke with tPA (3)
- Recent surgery
- GI bleed
- High blood pressure even after treatment
Ischemic stroke treatment options (2)
- IV tPA
- mechanical thrombectomy
Many ischemic strokes present with ___ blood pressure. This is because….
high,
….it is a response, not a cause (don’t lower it unless its super high! (>185/110))
Ischemic stroke supportive therapy (5)
- fluids
- glucose management
- swallowing eval to prevent aspiration
- treat fevers
- seizure prophylaxis
If a patient comes in with a stroke that is not a stroke center, best course of action is to…
….stabilize best as possible (prob give tPA) and then transfer to a stroke center
CT/MRI appearance cannot determine the etiology of ____
Small cerebral infarcts
Prescriptions post ischemic stroke as secondary prevention (4)
- antithrombotic agent based on cause
- ACEI or ARB regardless of BP
- Statin regardless of cholesterol
- lower BMI, alcohol intake, cigarrete smoking, estrogen
Intracerebral hemorrhage definition
A type of hemorrhagic stroke from bleeding into the brain that spreads along white matter, occurs over minutes to hours and is progressive with gradual onset, not abrupt
Subarachnoid hemorrhage definition
Type of hemorrhagic stroke that is most often caused by aneurysm rupture with bleeding into CSF, abrupt and severe thunderclap “worst headache of life” with no focal neuro symptoms but generalized vomiting and progressive impairment alongside nuchal rigidity
One of the reasons important to get immediate CT in evaluation of stroke is to determine if patient has….
….hemorrhage which would contraindicate tPA and indicate immediate need for neurosurgery
Biggest risk factor for intracerebral hemorrhage and 2 other ones(3)
- Hypertension
- aneurysm
- cocaine or amphetamine use
Lumbar puncture is contraindicated in a ___ hemorrhage but useful in a ____ hemorrhage
intracerebral, subarachnoid
If CT is ___ on a subarachnoid hemorrhagic patient, then must perform ___ looking for ____
negative, lumbar puncture, xanthrochromia (yellowish appearance of CSF after bleeding)
subarachonid hemorrhage treatment
uhhh
TIA’s should be treated as though they are….
….strokes
Ischemic strokes of the vertebral or basilar arteries characteristics (4)
- consciousness changes
- vision deficits
- coordination issues
- lack of balance
Ischemic strokes of the cerebellar arteries characteristics (3)
- vertigo
- nystagmus
- ataxia
Ischemic strokes of anterior spinal artery characteristics (2)
- Flaccid paralysis below level of lesion
- loss of sensation below level of lesion
Ischemic strokes of posterior spinal artery characteristics (1)
-sensory loss
In the initial assessment of the suspected stroke patient, provider should establish a…
….time of symptom onset (last known normal) as this will dictate the treatment
MRI vs MRA
MRA is used specifically to examine blood vessels
There are more consequences for doing what regarding tPA?
Not giving, compared to giving in case of acute treatment for ischemic stroke
Intracerebral hemorrhage treatment options (3)
- supportive care
- intracranial pressure monitoring
- potential neurosurgical consult
Subarachnoid hemorrhage treatment options (4)
- operative treatment
- pain medication
- gradual BP treatment but maintenance of DBP >100
- prophylactic anti seizure medication such as pheyntoin
