Stroke - Reynolds Flashcards
Strokes:
- affects > ____ persons per year
- causes ____ deaths per year
- ____th leading cause of death
- leading cause of long-term ____
- costs > $70 billion per year
- affects > 800,000 persons per year
- causes 200,000 deaths per year
•5th leading cause of death
- leading cause of long-term disability
- costs > $70 billion per year
Stroke Syndrome:
- Sudden acute neurological deficit
- Stroke have ___ etiologies. They can be: ___ or ____ infarcts.
- Infarction is death of ___, ___ and ___ due to ischemia
- Hemorrhage occurs when there is bleeding into the brain ____ or potential ___ space.
- ___ ____ occurs when there is bleeding into an area of ischemic infarction
Stroke Syndrome:
- Sudden acute neurological deficit
- Stroke have vascular etiologies. They can be: hemorrhagic or ischemic infarcts.
- Infarction is death of glial, neuronal and endothelium due to ischemia
- Hemorrhage occurs when there is bleeding into the brain parenchymal or potential intracranial space
- Hemmorhagic infarct occurs when there is bleeding into an area of ischemic infarction
As blood flow goes down, you can progress to ___ ____ and then neuronal cell death.
As blood flow goes down, you can progress to electrical failure and then neuronal cell death.
Types of strokes:
- ____ stroke - where you have an occluded artery and braincells will die (___%) downstream from that occlusion.
- ___ stroke:
- ____ (intraparenchymal - __%) - bleeding into the brain
- ____ - __% - bleeding around the brain
Types of strokes:
- Ischemic stroke - where you have an occluded artery and braincells will die (85%) downstream from that occlusion.
-
Hemmorhagic stroke:
- Intracerebral (intraparenchymal - 10%) - bleeding into the brain
- Subarachnoid - 5% - bleeding around the brain
Acute infarct (blocked blood vessel) on MRI and Pathology
Intracerebral Hemorrhage
Burst blood vessel
Subarachnoid hemorrhage
Bleeding around the brain, usually from an aneurysm rupture
TIA:
- ____ (low-blood-flow) stroke without ___ ___
- “___” of the brain
- <___ h by definition, but usually ___-___ min
- important warning of impending stroke. ___% of people who have TIA’s will have a full-blown stroke within __ months. Another 5% of people who have TIA’s will have a full-blown stroke within ___ hours.
- prompt evaluation urgent to prevent future stroke–find out the cause!
TIA:
- ischemic (low-blood-flow) stroke without permanent damage
- “angina” of the brain
- <24 h by definition, but usually 2-20 min
- important warning of impending stroke. 5% of people who have TIA’s will have a full-blown stroke within 3 months. Another 5% of people who have TIA’s will have a full-blown stroke within 48 hours.
- prompt evaluation urgent to prevent future stroke–find out the cause!
Stroke Symptoms: All symptoms occur suddenly
- ___ess or __ess, esp. 1 side of body
- difficulty speaking or understanding speech
- ____ loss in one or both eyes
- severe, unusual ____
- dizziness, if associated with another symptom
Stroke Symptoms: All symptoms occur suddenly
•weakness or numbness, esp. 1 side of body
- difficulty speaking or understanding speech
- visual loss in one or both eyes
- severe, unusual headache
- dizziness, if associated with another symptom
And Now, I VILL PLAY “D SHWVN
Hemmorhage vs. Ischemic Stroke
- Both present with ___, ___ deficit
- Supporting evidence for hemorrhage
- Severe ____ at onset (especially worst H/A of patient’s life with ___ ___ ____)
- younger age with h/o of ___
- Greater than expected ____ (mental dullness) with hemispheric stroke than usually seen in patients with ischemic infarcts
- CANNOT make definitive dx clinically
- *** Non-contrast head CT ***
Hemmorhage vs. Ischemic Stroke
- Both present with sudden, acute deficit
- Supporting evidence for hemorrhage
- severe H/A at onset (especially worst H/A of patient’s life with subarachnoid hemmorhage)
- younger age with history of of hypertension.
- Greater than expected obtundation with hemispheric stroke than usually seen in patients with ischemic infarcts
- CANNOT make definitive dx clinically
- *** Non-contrast head CT ***
What is this?
right thalamic hemmorrhage
Subarachnoid -aneurysm ruptured
Stroke Risk Factors
•Medical
HHH. T. DOS
•Lifestyle
MS. DD. AS
Stroke Risk Factors
•Medical
- Hypertension
- Heart disease, especially a-fib
- Hyperlipidemia,
- Prior stroke or TIA
- Diabetes
- Obesity
- Sickle cell disease
•Lifestyle
- Marijuana use
- Smoking
- Diet
- Drugs (legal and illegal)
- Alcohol use - heavy
- Sedentary lifestyle
Ischemic Stroke Causes:
- _____ 45%
- _____ 20%
- ____embolism 20% (from a-fib)
- _____ - often iatrogenic (relating to illness caused by medical examination or treatment)
- _____ states - Due to protein __ and __ antibodies that float around (remember, these proteins are anti-coagulants, so if you haev anti-bodies against them, then you will not be able to get rid of clots), as well as anti____ antibodies (a-PL)
Artery diseases other than atherosclerosis:
- •Dissections, ___ (usually in younger people)
Ischemic Stroke Causes:
- Atherocleoris 45%
- SAD (small artery disease) 20%
•Cardioembolism 20% (a-fib)
- hypoperfusion - often iatrogenic (relating to illness caused by medical examination or treatment)
- hypercoagulation states - Protein C, S, antiphospholipid antibodies (a-PL)
Artery diseases other than atherosclerosis:-
•Dissections, vasculitis (usually in younger people)
_Major Causes of
Hemorrhagic (Bleeding) Strokes:_
•Non-traumatic intracerebral hemorrhage
- bleeding into the brain itself
- usually due to longstanding high __ __ and small artery ___
•Non-traumatic subarachnoid hemorrhage
- bleeding into __ space
- usually due to a ruptured __ __
Major Causes of
Hemorrhagic (Bleeding) Strokes
•Non-traumatic intracerebral hemorrhage
- bleeding into the brain itself
- usually due to longstanding high blood pressure and small artery rupture
•Non-traumatic subarachnoid hemorrhage
- bleeding into subarachnoid space
- usually due to a ruptured berry aneurysm
Defending Against Brain Attack
Primary prevention
- identify and control/treat risk factors
- emergency action
- know warning signs (symptoms), call 911
- HTN, DM, hyper___, smoking, __ __ disease, carotid stenosis, obesity
Patient education for life-style changes:
- ____ cessation
- Medication adherence
- Diet/exercise
- Stop excessive ___ use and sympathomimetic drug use
Secondary prevention
- identify ___ of stroke
- take appropriate action (medicine, surgery, etc.) and initiate appropriate anti-thrombotic therapy
- Identify and treat all risk factors
Defending Against Brain Attack
Primary prevention
- identify and control/treat risk factors
- emergency action
- know warning signs (symptoms), call 911
- HTN, DM, hyperlipidemia, smoking, sickle cell disease, carotid stenosis, obesity
Patient education for life-style changes:
- smoking cessation
- Medication adherence
- Diet/exercise
- Stop excessive drug use and sympathomimetic drug use
Secondary prevention
- identify cause of stroke
- take appropriate action (medicine, surgery, etc.) and initiate appropriate anti-thrombotic therapy
- Identify and treat all risk factors
T-Pa Emergency Stroke Treatment
- _____ using t-PA available for patients with ___ stroke
- tPA does NOT save ____
- t-PA decreases risk of ____ if given within ___ hours of ___ onset
- Only FDA approved for < 3 but standard of care + < 4.5 with some additional exclusions
- t-PA may cause dangerous ___ if given after the time window to a person with a very large ___
T-Pa Emergency Stroke Treatment
•Thrombolysis using t-PA available for patients with ischemic stroke
- tPA does NOT save lives
- t-PA decreases risk of disability if given within 4.5 hours of stroke onset
- Only FDA approved for < 3 but standard of care + < 4.5 with some additional exclusions
- t-PA may cause dangerous bleeding if given after the time window to a person with a very large stroke
How does t-Pa work?
_____ is zone of ____ ischemia around the core of an irreversible infarction
The ____ is salvageable within the first few hours after ischemic stroke onset
Penumbra is damaged by:
- ____ perfusion
- Hyper____
- Fever
- Seizure
How does t-pa work?
Penumbra is zone of reversible ischemia around the core of an irreversible infarction
Penumbra is salvageable within first few hours after ischemic stroke onset
Penumbra is damaged by:
• Hypoperfusion
• Hyperglycemia
- Fever
- Seizure
TREATMENT OF INFARCTION
Hyperacute Therapy
- The rationale for hyperacute therapy is preservation of viable but nonfunctional tissue in the ___
- Therapeutic approaches include restoration of blood __, decreased metabolic demands or prevention of 2º ischemic changes (neuroprotective agents) and inhibitors of the post-ischemic inflammatory response
- ____ therapy has been shown to be effective in humans in Phase 3 trials
- ___ is the only FDA approved acute stroke drug therapy
- ____ therapy with thrombectomy and clot removal/disruption has also been proven effective
TREATMENT OF INFARCTION
Hyperacute Therapy
- The rationale for hyperacute therapy is preservation of viable but nonfunctional tissue in the penumbra
- Therapeutic approaches include restoration of blood flow, decreased metabolic demands or prevention of 2º ischemic changes (neuroprotective agents) and inhibitors of the post-ischemic inflammatory response
•Thrombolytic therapy has been shown to be effective in humans in Phase 3 trials
•T-Pa is the only FDA approved acute stroke drug therapy
•Endovascular therapy with thrombectomy and clot removal/disruption has also been proven effective
Thrombus Formation and how T-Pa works
- Fibrinogen, in the presence of ____, creates Fibrin Strands. Fibrinogen is a soluble protein present in blood plasma, from which fibrin is produced by the action of the enzyme ___
- __ __ and ___ adhere to the fibrin strands
- Activated factor ___ stabilizes the clot
To break up the clot:
- ____, in the presence of plasminogen activators, form plasmin
- Plasminogen activators are upregulated by binding to ____, making their activity ‘___-specific’
- Plasmin degrades ___. This is how __ works…*
Thrombus Formation
•Fibrinogen, in the presence of THROMBIN, creates Fibrin Strands. Fibrinogen is a soluble protein present in blood plasma, from which fibrin is produced by the action of the enzyme thrombin.
•Red cells and platelets adhere to the fibrin strands
•Activated Factor XII stabilizes the clot
To break up the clot
Plasminogen in the presence of plasminogen activators, form plasmin
- Plasminogen activators are upregulated by binding to fibrin, making their activity ‘clot-specific’
- Plasmin degrades fibrin. This is how tPA works…*
Only give T-pa:
Within less than ___ hours (when the last time the person was acting normal)
Pressure must be less than ___/___
•Don’t give T-Pa to people who are:
- Already _____
- Have bleeding contraindications
- Seizures or trauma (T-Pa can enhance the N-methyl-D-aspartate receptor also known as the NMDA receptor, a glutamate receptor, which can induce seizures).
- Blood sugar is ___. Hypoglycemia can cause focal neurologic deficits and thereby masquerade as a true ischemic stroke. It would be a shame to subject someone to the risk of intracranial hemorrhage from tPA if all they needed was dextrose.
- Recent ____ or arterial stick in non-compressible site
- T Time < 4.5 hours
- P Pressure < 185/110
•Don’t give T-Pa to people who are:
- Already anticoagulated
- Bleeding contraindications
- Seizure or trauma
- Blood sugar low. Blood sugar is ___. Hypoglycemia can cause focal neurologic deficits and thereby masquerade as a true ischemic stroke. It would be a shame to subject someone to the risk of intracranial hemorrhage from tPA if all they needed was dextrose.
- Recent surgery or arterial stick in non-compressible site
Endovascular Therapy:
Good for ___, ___ artery occlusions
- Usually within ___ hours of onset to start procedure
- Clot ___ or mechanical ____ works best
- Stent retriever devices work the best
Endovascular Therapy:
- Good for proximal, large artery occlusions
- Usually within 6 hours of onset to start procedure
- Clot retrieval or mechanical disruption works best
- Stent retriever devices work the best
Acute Stroke Treatment:
- The ONLY acute stroke treatments are ___ and ___ ___
- There is NO role for ____ in the treatment of acute ischemic stroke from an arterial lesion
- Remember that heparin is an ___ and not a ___
- Heparin will not ___ a clot that is already there
- Heparin will increase ____ complications
Heparin is ___ the answer on a test if the question is referring to treatment of an ischemic stroke of arterial origin. We sometimes use heparin to try to ____ another stroke in an acute setting.
Heparin is often used acutely to treat a stroke due to a venous thrombosis such as a clot in a brain sinus. This is a “deep” clot analogous to a DVT anywhere else in the body and the treatment is anticoagulation to allow the body to deal with the clot and prevent clot propagation.
Acute Stroke Treatment:
- The ONLY acute stroke treatments are tPA and endovascular therapy
- There is NO role for heparin (an anticoagulant. It is used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels). in the treatment of acute ischemic stroke from an arterial lesion
- Remember that heparin is an anticoagulant and not a thrombolytic.
- Heparin will not dissolve a clot that is already there
- Heparin will increase bleeding complications
Heparin is NEVER the answer on a test if the question is referring to treatment of an ischemic stroke of arterial origin. We sometimes use heparin to try to PREVENT another stroke in an acute setting.
Heparin is often used acutely to treat a stroke due to a venous thrombosis such as a clot in a brain sinus. This is a “deep” clot analogous to a DVT anywhere else in the body and the treatment is anticoagulation to allow the body to deal with the clot and prevent clot propagation.
All ischemic stroke patients likely benefit from ___ therapy regardless of their cholesterol profile
All ischemic stroke patients likely benefit from statin therapy regardless of their cholesterol profile
