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PT 10111 MedSurg 2 > Stroke Syndrome > Flashcards

Stroke Syndrome Flashcards

1
Q

First Stroke Neurologist
Correlated brain lesions with clinical findings

A

Charles Foix

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2
Q

Neurological deficit of sudden onset accompanied by focal dysfunction and symptoms lasting more than 24 hrs that are presumed to be of non-traumatic vascular origin

A

Stroke

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3
Q

2nd most common cause of death (next to heart disease)
Viewed as a pandemic

A

Stroke

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4
Q

Prevalence of stroke in the PH

A

0.9-1.1%

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5
Q

Has the highest stroke DALY, mortality rate

A

China

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6
Q

Highest percentage of global DALYs for neurological disorder

A

Cerebrovascular disease - Stroke
(followed by Alzheimers and dementia)

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7
Q

Stroke accounts for how much percent in CVD deaths?

A

30%

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8
Q

Gender with more strokes

A

Slightly more females have stroke than males
(Women who live longer have a higher chance of developing stroke)

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9
Q

Direct medical cost

A

Hospitalization, rehabilitation,
nursing home (very few in PH), home health care services (growing business sector in PH)

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10
Q

Indirect medical cost

A

Home medications, appliances, transportation,
domestic aid, rehabilitation aid, loss of production (work) due to the stroke

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11
Q

T/F: Stroke is a vascular disease of the heart

A

False: Stroke is a vascular diseases of the BRAIN

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12
Q

Prevalence of stroke: _ in 6 people will have a stroke

A

1

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13
Q

Rapidly developing clinical signs of FOCAL (at times GLOBAL) disturbance of brain function

Lasting more that 24 hours or leading to death

No apparent cause other than of vascular origin

A

Stroke (WHO definition)

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14
Q

Abrupt onset of a neurologic deficit is attributable to

A

Focal vascular cause

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15
Q

Is an acute neurologic event having foundation in pathology of the blood vessels supplying the brain

A

Stroke (WHO definition)

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16
Q

T/F: Vessel pathology is both acquired or congenital

A

True: Vessel pathology can be congenital or acquired, but mostly acquired

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17
Q

T/F: Strokes are ischemic or hemorrhagic

A

True

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18
Q

Non-modifiable risk factors (6)

A

Age, gender, hereditary factors, race, prior stroke, existing heart disease

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19
Q

Elderly at greater risk

A

Age

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20
Q

T/F: Males more susceptible

A

True: Gender (NMRF)

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21
Q

Family history indicates greater risk

A

Hereditary factors

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22
Q

T/F: Non-white groups at lesser risk for stroke

A

False: The darker your color is, the higher the risk (Africans, African-Americans, African-Europeans; Non-caucasians)

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23
Q

Modifiable Risk Factors (2)

A

Lifestyle and Pharmacotherapy

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24
Q

Factors under lifestyle (5)

A

Smoking, low physical exercise, morbid obesity, excess alcohol consumption, diet (high salt and fat)

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25
Q

Factors under pharmacotherapy (5)

A

Hypertension, arterial disease, heart disease or failure, risk of thrombotic or embolic phenomena, certain blood disorders (cholesterol, DM)

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26
Q

Risk factors identified to increase chances for stroke among Filipinos (9)

A

● Hypertension
● Diabetes
● Atrial fibrillation
● Stress
● Smoking
● Habitual snoring - higher risk for stroke
● Myocardial infarction
● Frequent alcohol
● Rheumatic heart disease

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27
Q

Types of Stroke

A

Ischemic and hemorrhagic

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28
Q

Types under ischemic (4)

A

Thrombotic, embolic, lacunar, venous

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29
Q

Types under hemorrhagic (5)

A

subdural, epidural, subarachnoid, intraparenchymal, hemorrhagic transformation

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30
Q

Causes occlusions or diminished blood flow

A

Ischemic

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31
Q

Most of the time d/t trauma but can also be d/t
anti-coagulation

A

Subdural

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32
Q

d/t trauma but most are seen secondary to ruptured aneurysms

A

Epidural

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33
Q

d/t uncontrolled HTN

A

Intraparenchymal

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34
Q

Causes of stroke (4)

A

Thrombotic occlusion of arteries or veins
Embolic disease from the great vessels or heart
Occlusion of the small penetrating vessels
Hypoperfusion

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35
Q

Occurs in the venous sinuses
(superior/inferior sagittal sinus, sigmoid sinuses)

A

Venous infarction

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36
Q

T/F: Most strokes are arterial

A

True: ischemic stroke

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37
Q

Dislodged to the system and goes to the circle of Willis & the brain circulation

A

Embolism

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38
Q

Lack of oxygenation (e.g. when you snore a lot -
may lead to sleep apnea & reduction of oxygenation)

A

Hypoperfusion

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39
Q

Causes of Hemorrhage (2)

A

Can be breakage of the blood vessel d/t hypertension or aneurysm

Trauma penetrating injury → leads to fragile vessels from infarction

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40
Q

Clinical findings: Acute Onset of focal deficit (most common) (5)

A

○ Weakness (most common)
○ Sensory loss
○ Ataxia
○ Speech deficit
○ Visual loss

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41
Q

Arises from the heart, aorta, or the carotid or vertebral arteries

A

Embolic disease

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42
Q

Can be from valvular disease, akinetic myocardium with thrombus formation, or from the venous system via a right-to-left shunt from septal defect

A

Cardiac emboli

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43
Q

pts w/ mitral stenosis, traumatic heart disease, endocarditis

A

Valvular disease

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44
Q

Heart muscle is not pumping anymore (dilated cardiomyopathy)

A

Akinetic myocardium

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45
Q

Foramen ovale does not close at
the age of 1; atrioseptal defect or atrioseptal aneurysm

A

Septal defects

46
Q

Occlusion of the vessel by propagation of thrombus

Atherosclerosis and lipid/fat deposits are
already present → clots and forms over time

A

Thrombotic disease

47
Q

T/F: The occlusion over time, and the extent of the symptoms depend not only on the size and location of the vessel, but on collateral flow

A

True: Thrombotic infarct

48
Q

T/F: These collateral have more time to expand if the occlusion occurs over time

A

True: Collateral circulation is a very important
determinant of how bad the stroke will be

49
Q

Much less common than arterial infarction
Appear in the sinuses
Poses more risk to pregnant, hypercoagulable
Patients present any combination of focal weakness, headache, cognitive di fficulty, and seizures

A

Venous infarct

50
Q

T/F: Seizures are common in arterial infarcts except in embolic strokes

A

False: Seizures are not common in arterial infarcts except in embolic strokes

51
Q

Usually due to rupture of an intracranial aneurysm

There is acute onset of headache and sometimes neurologic deficit

A

Subarachnoid hemorrhage

52
Q

Very prominent symptom of subarachnoid hemorrhage

A

headache

53
Q

Due to hypertension, although amyloid angiopathy and trauma

A

Intraparenchymal hemorrhage

54
Q

Main cause of intraparenchymal hemorrhage

A

Hypertension (poorly controlled BP)

55
Q

Another important cause of
intraparenchymal bleeding d/t a large infarct that bleeds into the infarct

A

Hemorrhagic infarction

56
Q

Presentation of intraparenchymal hemorrhage

A

Weakness, and may have
seizures and decreased level of consciousness

57
Q

d/t trauma wherein the middle meningeal artery is ruptured

A

Epidural

58
Q

d/t trauma wherein venous channels will tear and venous blood accumulate in the brain

A

Subdural

59
Q

Epidural or Subdural: Takes a longer time to present itself w/ neurological deficits

A

Subdural

60
Q

Temporary interruption of focal brain circulation, which results in neurologic deficit

A

Transient ischemic attack

61
Q

Most common cause of TIA

A

Embolic disease from the heart or cerebral arteries

62
Q

T/F: The embolus can then break up and go downstream, resulting in return of flow to the region

A

True

63
Q

T/F: After the Sx occur, they will NOT recover immediately and these are dangerous signs that the pt is at risk of developing a more severe type of neurologic disease or stroke if risk factors are not addressed

A

False: They will recover immediately but these are dangerous signs

64
Q

How long does a temporary neurologic deficit last (TIA)

A

<24 hours (definition); commonly <1 hour for 15 mins

65
Q

Most common deficits for TIA are:

A

○ Hemiparesis
○ Hemisensory loss
○ Aphasia
○ Confusion
○ Hemianopia
○ Ataxia
○ Vertigo
○ Monocular blindness

66
Q

T/F: The onset of the deficit is abrupt, which helps di fferentiation from the neurologic deficit of migraine, and which has a progressive onset and migration of symptoms

A

True

67
Q

T/F: Migraine can present with hemiplegia & has classical symptoms

A

True

68
Q

Prognosis of TIA

A

Gradual recovery

69
Q

T/F: Usual routine labs are normal for TIA patients

A

True

70
Q

Abrupt onset of deficit, with recovery usually lasting less than an hour

Imaging shows no abnormality or signs of previous strokes

A

Diagnosis of TIA

71
Q

Differential diagnosis of TIA

A

Migrane and seizure

72
Q

Focal weakness or sensory loss can occur as a part of this, either during the aura or during the this → in hemiplegic ____

A

Migraine

73
Q

T/F: Focal seizures usually are recurrent whereas TIAs are single, although they can occur

A

True

74
Q

General features of infarction: Symptoms (2)

A

Acute onset of neurologic deficit suggests infraction
Persistence of neurologic deficits

75
Q

Difference between TIA and infarction

A

TIA: transient occurrence of Sx w/ immediate
resolution

Infarcts: persistence of neurologic deficits

76
Q

Signs of infarction (8)

A

○Hemiparesis
○ Hemisensory loss
○ Hemianopia
○ Gait/Lim Ataxia
○ Aphasia
○ Neglect
○ Ocular Motor Abnormality
○ Doubling of vision

77
Q

Commonly affected vessels in ischemic stroke (4)

A

MCA
ACA
Posterior circulation
Vertebrobasilar artery

78
Q

Contralateral hemiparesis and hemisensory loss, aff ecting arms more than legs

With left hemisphere infarct: aphasia

With right hemisphere infarct: neglect and
constructional di fficulty

Contralateral hemianopia is common although not invariable

Occlusion can occur in its entirety (main stem) or partially → can occlude the penetrating arteries

A

MCA

79
Q

Patterns of occlusion: Entire MCA

A

Contralateral gaze palsy, hemiplegia, hemisensory loss, spatial neglect, hemianopia

Global aphasia (if on left or dominant side)

May lead to coma secondary to edema

80
Q

Patterns of occlusion: Deep branch

A

Contralateral hemiplegia, hemisensory loss

Transcortical motor and/or sensory aphasia (if on left or dominant side)

81
Q

Patterns of occlusion: Parasylvian branch

A

Contralateral weakness and sensory loss of face and hand

Conduction aphasia, apraxia, and Gerstmann syndrome (if on left side)

Constructional dyspraxia (if on right side)

82
Q

Patterns of occlusion: Superior branch

A

Contralateral hemiplegia, hemisensory loss, gaze palsy, spatial neglect

Broca’s aphasia (if on left or
dominant side)

83
Q

Patterns of occlusion: Inferior branch

A

Contralateral hemianopia or upper quadrant
anopsia

Wernicke’s aphasia (if on left side)

Constructional dyspraxia (if on right side)

84
Q

Contralateral hemiparesis mainly a ffecting the leg

If the arm is a ffected, the proximal arm is most
prominent.

Bilateral infarction may produce bilateral leg
weakness, which can be mistaken for myelopathy or spinal cord diseases

Frontal lobe signs can develop with bilateral
infarction - apathy, disinhibition (changes in mood)

A

ACA

85
Q

If the entire ACA is a ffected, they can develop: (5)

A

○ Incontinence
○ Contralateral hemiplegia
○ Abulia
○ Transcortical motor aphasia or motor & sensory aphasia
○ Left limb dyspraxia

86
Q

If the distal part of the ACA is a ffected, they can
develop: (4)

A

○ Contralateral weakness of the leg, hip, foot and shoulder
○ Sensory loss of the foot
○ Transcortical motor aphasia or motor and
sensory aphasia
○ Left limb dyspraxia

87
Q

Contralateral hemiplegia

Ipsilateral oculomotor deficits

Contralateral hemisensory deficits

Contralateral homonymous hemianopsia

Contralateral hemianopia, which may spare the
macula

Confusion with memory loss can occur acutely

A

PCA

88
Q

Right homonymous hemianopia

Extension to the splenium of the corpus callosum can cause alexia without agraphia

Larger infarcts, including the thalamus and internal capsule, may cause aphasia, right hemisensory loss, and right hemiparesis

A

Left PCA

89
Q

Vertigo and ataxia are common - dizziness & imbalance

Ataxia can be of gait and/or limbs – artery supplies the cerebellum

Ocular abnormalities can include
○ Diplopia
○ Nystagmus
○ Anisocoria - pupillary changes

Dysarthria and dysphagia with medullary involvement

Hemiparesis or quadriparesis with corticospinal tract involvement at any level.

A

Vertebrobasilar artery

90
Q

A ffects the proximal part of the PCA

Cranial Nerve III Palsy → weak medial rectus,
dilated pupils

Caused by the involvement of the fascicles of the 3rd nerve within the midbrain

Contralateral hemiparesis

Parasympathetic involvement

A

Weber’s syndrome

91
Q

Cranial Nerve III Palsy

Larger involvement

Caused by the involvement of the fascicles of the 3rd nerve within the midbrain, cerebral peduncle, & red nucleus

Contralateral hemiparesis

Contralateral ataxia, tremor, involuntary
movements
○ Ataxia – d/t involvement of the red nucleus
○ Rubral tremor

A

Benedikt’s syndrome

92
Q

● A.K.A. Lateral Medullary Syndrome
● Involves the vertebral artery & posterior inferior cerebellar artery
● Presents with:
○ Ipsilateral ataxia, vertigo, nystagmus, nausea
○ Ipsilateral facial numbness
○ Contralateral body hermo-analgesia
○ Ipsilateral Horner’s Syndrome
● Trigeminal nerve is involved

A

Wallenberg syndrome

93
Q

● Medial Medullary Syndrome
● Presents with more motor symptoms
● Contralateral hemiparesis
● Contralateral decrease in vibration and position
sense – d/t involvement of the medial lemniscus
● Ipsilateral tongue weakness – d/t involvement of the hypoglossal nucleus

A

Medial medullary syndrome

94
Q

● Internal capsule or basal ganglia: contralateral hemiparesis and/or incoordination
● Brainstem: Contralateral hemiparesis, may have ipsilateral appendicular ataxia depending on the location of the lesion, ocular signs are also common
○ Medial rectus palsy, nystagmus
● Pure motor or pure sensory symptoms suggest penetrating vessel occlusion

A

Penetrating arteries

95
Q

Focal deficit, often with headache and or seizures, can suggest venous infarction

Occurrence in postpartum women, or in young people generally at lower risk of arterial infarctions, suggests venous infarction
○ Higher venous infarction in stroke-like
presentations of young women

A

Veins and venous sinuses

96
Q

Transient blindness in one eye from temporary occlusion by platelet-fibrin or cholesterol emboli (on side of involved artery)

Aka Amaurosis fugax

A

Territory: ocular manifestations

97
Q

Occasional headache (usually supraorbital or temporal)

Homonymous (partial) visual field defects

Language defect – involvement of dominant
hemisphere

Contralateral hemiparesis or hemiplegia
with/without sensory deficits

Patients may awaken from sleep unable to move the a ffected side. → a.k.a. wake-up strokes

A

Territory: cerebral hemisphere manifestations

98
Q

Steps in emergency management (7)

A

ABC (airway, breathing, circulation)
Vitals signs
ECG, insert IV line, BP
Initial medical and neurologic assessment
History
Perform detailed neurologic and medical exam
Determine candidacy for immediate stroke intervention

99
Q

Tests performed in the Emergency Department
(immediate)

A

○ Blood exams: CMP, CBC, PT, aPTT
○ Imaging: Chest X-ray, Plain cranial CT/MRI
○ Urine: Urinalysis
○ Physiologic: ECG
○ Metabolic parameters should be done in the ER

100
Q

Patients with signs and symptoms of acute CNS bleed should have the CT performed as soon as possible

If the CT confirmed bleed, then neurosurgery should be emergently consulted

Whether they are good candidates for
evacuation of hemorrhage or not – either
minimal invasive or invasive surgery

The only exception to this would be a patient who would clearly not be a candidate for surgery e.g., patient who are unstable for any procedure or a patient who refuses consideration of any procedure

A

Considerations of surgery

101
Q

Performed on selected patients and at institutions where the staff is trained and experienced in the intervention (e.g. USTH)

Specialists at these institutions will determine when these are appropriate

Just because a procedure can be done does not mean that it should always be done

A

Warning on neurointervention

102
Q

Stroke warning signs: Main symptoms (5)

A

Weakness
Trouble speaking
Vision problems
Headache
Dizziness

103
Q

Stroke warning signs: BEFAST

A

Balance loss
Eyes: vision loss
Facial weakness
Arm weakness, sensory problem
Speech problem
Time: address immediately if possible

104
Q

Embolic infarction, most likely
Thrombotic infarction

A

Abrupt Onset of Focal Deficit

105
Q

Thrombotic infarction
Lacunar infarction

A

Awaken with Focal Deficit

106
Q

Thrombotic infarction
Lacunar infarction
Venous infarction
Intraparenchymal hemorrhage

A

Rapid but not Abrupt Onset of Focal Deficit

107
Q

Subarachnoid hemorrhage (SAH)
Intraparenchymal hemorrhage (less likely)

A

Acute Onset of Severe Headache without deficit

108
Q

Subdural hemorrhage
Epidural hemorrhage

A

Headache and Focal Deficit after Injury

109
Q

Intraparenchymal hemorrhage
Hemorrhagic transformation of ischemic stroke

A

Subacute Onset of Neurologic deficit

110
Q

Epidural hemorrhage (this is a classic history)

A

Coma after head injury, with or without a lucid interval

PT 10111 MedSurg 2 (3 decks)

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