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6a > Stroke management > Flashcards

Stroke management Flashcards

1
Q

Stroke causes

A 
85% ischemic
(20% large artery atherosclerosis
25% small vessel lacunar stroke
20% cardioembolism
30% cryptogenic
5% others)

15% hemorrhagic

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2
Q

Ischemic stroke mechanisms

A 
intracranial atherosclerosis
small artery disease
carotid plaque with emboli
carotid stenosis
aortic arch plaque
a fib
valve disease
ventricular thrombi
cardiogenic emboli
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3
Q

Cardioembolic sources

A 
atrial septal aneurysm
patent foramen ovale
a fib
mitral stenosis mechanical vegetation
cardiomyopathy MI
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4
Q

A fib and stroke

A

1% of population in NA and europe AF
5% of those over 65
2.5 mil Americans
1 of every 6 strokes due to AF

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5
Q

CHADS2

A 
1 point:
CHF
Hypertension
Age > 75
Diabetes

2 points:
stroke, TIA

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6
Q

ACA stroke symptoms

A

Leg > arm weakness
Leg > arm numbness
Abulia

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7
Q

MCA stroke symptoms

A 
Hemiplegia --> affect motor strip
Cortical features:
- aphasia
- neglect
- visual field deficit
- gaze deviation
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8
Q

Posterior circulation stroke symptoms

A 
brainstem --> more nucleus/tract defects
Visual field defects
vertigo
Diplopia
Ataxia
Dysphagia
Weakness
Numbness
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9
Q

Small vessel disease lacunar stroke syndrome

A 
pure motor
pure sensory
mixed sensorimotor
dysarthria - clumsy
ataxia hemiparesis
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10
Q

Hyperacute/acute stroke treatment

A 
iv-tPA
endovascular mechanical thrombectomy
aspirin
stroke unit
hemicranectomy
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11
Q

Secondary stroke prevention

A 
antiplatelets (aspirin, clopidogrel, ASA and dipyridimole)
anticoagulants (warfarin, NOACs)
carotid revascularization (carotid endarterectomy, carotid stent)
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12
Q

Tissue plasminogen activator

A

serine protease
converts plasminogen –> plasmin
fibrinolytic
only effective FDA approved treatment for acute ischemic stroke
10% bolus then infusion over 1 hour within 3 hours of symptom onset

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13
Q

Antiplatelets for 2ndary stroke prevention (non-cardioembolic)

A 
Aspirin
Clopidogrel slightly better than ASA
ASA + DP superior to ASA
Clopidogrel + ASA NOT indicated
ASA + DP NOT superior to clopidogrel
Do not combine anticoagulants + antiplatelets!!
Start tx as soon as possible
long-term treatment
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14
Q

Hypertension control for stroke prevention

A

absolute target uncertain
benefits associated with overall reduction of 10/5 mmHg
optimal drug regimen uncertain - diuretic + ACEi?

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15
Q

European guidelines for management of hypertension

A

General:

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16
Q

TIA

A

episode of neurological deficit where symptoms resolve fully, noe vidence of loss of blood flow

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17
Q

Infarction

A

injury permanent

18
Q

Penumbra

A

dysfunctional but salvageable tissue

19
Q

Carotid stenosis stroke risk

A

25% of disabling stroke within one year

20
Q

Carotid ischemic syndromes

A

unilateral weakness, numbness (contralateral)
Dysphasia if language dominant hemisphere
Amaurosis fugax: ophthalmic artery branch off carotid artery; transient monocular vision loss due to reduced blood flow to the retina

21
Q

Endarterectomy indications

A

symptomatic (strong indication)

asymptomatic - bruit detected (modest indication)

22
Q

Intra-arterial thrombolysis

A 
direct local delivery of thrombolytic
lower dose/decreased systemic effects
increased rate of clot lysis
expanded time window (6 hours for MCA)
requires infrastructure/expertise
23
Q

Mechanical clot removal

A

time sensitive -

24
Q

Intracerebral hemorrhage sources

A

epidural, subdural: trauma
Subarachnoid: ruptured aneurysm
intraparenchymal - HTN
intraventricular

25
Q

Amyloid angiopathy

A

deposition of beta amyloid in vessel wall
lobar hemorrhages
typically in elderly
Common in DOwn’s syndrome
characteristic histology - Congo Red (birefringent rings of amyloid deposition)

26
Q

Aneurysms

A 
Saccular (berry)
fusiform (sausage)
arterial weakening
typically at branch points: Circle of Willis
common cause of subarachnoid hemorrhage
27
Q

Aneurysm risk factors

A

thinner intima/media
lack external elastica
medial defects

28
Q

Location of aneurysms

A 
Ant communicating - 30%
Post communicating - 25%
MCA - 20%
Carotid bifurcation - 8%
Basilar bifurcation - 7%
29
Q

Clinical presentation of subarachnoid hemorrhage

A 
Sudden, severe headache
neck pain from increased ICP
nausea - chemical irritation
photophobia
loss/alteration of LOC
focal neurological deficits
sudden death
30
Q

Pathological features of SAH

A 
raised ICP, cerebral edema
CN injury
intracerebral hemorrhage
intraventricular hemorrhage
hydrocephalus
31
Q

Epidemiology of SAH

A

incidence of aneurysm in popn ~2%
10/100,000 per year
most commonly age 40-60
modest female preponderance

32
Q

Hunt & Hess scale

A

1: asymptomatic/mild headache
2: severe headache/meningismus
3: drowsy, confused, mild deficit
4: stuporous, severe deficits
5: deep coma, moribund

33
Q

SAH management

A 
neurosurgical ICU
airway, ventilation
BP control
ICP control - ventriculostomy
fluid/electrolyte monitoring
early aneurysm repair
34
Q

SAH complications

A

recurrent bleeding from aneurysm
- arterial pressure –> tamponade
- clot stops intial bleed, then recurrent bleed can happen
Vasospasm –> narrowing of blood vessels
hydrocephalus
seizures
electrolyte abnormalities (commonly hyponatremia)

35
Q

Unruptured aneurysm/incidental aneurysms

A

risk of bleeding 1-3%/year
risk increased with previous history of SAH, large size, HTN, smoking, posterior fossa location
repair if >5 mm

36
Q

Cerebral A-V malformation

A

congenital
3 components: feeding arteries, nidus, draining veins
High pressure from artery to vein with no arteriole or capillaries or venule in between
Distended vein –> rupture

37
Q

Cerebral A-V malformation clinical features

A

hemorrhage
seizures
headache
focal neurology

38
Q

Grading of cerebral A-V malformation

A

size
location
deep venous drainage

39
Q

Cerebral AV malformation treatment

A 
none
microsurgical removal
stereotactic radiosurgery
embolization
combination/multidisciplinary
40
Q

Stroke mimics

A 
DIIMMSSS
Drug intoxication
Infection
Insanity conversion disorder
Metabolic: hypoglycemia, renal failure, hepatic failure
Migraines
Syncope
Seizure
Structural: trauma, tumour, subdural hemorrhage

6a (26 decks)

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