Stroke Test 3

Question 1

Cerebrovascular disease and stroke

Answer 1

Stroke ( brain attack)
- sudden or rapid onset of neurologic deficit linked to vascular territory
-disruption of blood supply (oxygen) to part of the brain , in which turn disrupts the body function controlled by that brain area
aka CVA
( lack of oxygen /glucose that leads to disrupted function- very specific damage depending on region affected)

Question 2

Diff Dx

Answer 2

• seizure
• migraine (with sensory and motor impairments)
• tumor (putting pressure on location of brain)
• peripheral cause of motor impairment/sensory loss
  
  • nerve entrapment

Question 3

Incidence of Cerebrovascular disease and stroke

Answer 3

• 114 per 100,000 persons
• incidence doubles with every decade after 55 years of age across all ethnicities
• african american males and females have significantly higher incidence
  
  • occur at earlier ages-possible link to sickle cell anemia?
  • 50% higher chance of stroke in African american males than Caucasian males
  • 130-150% higher chance of stroke in African american males than Caucasian females
• recurrence rates in 1st year and in males
• 75% of strokes are first time-25% recurrent rate
• incidence is higher in spring
  
  • sedentary in winter and start moving again?

Question 4

Cerebrovascular disease and stroke Prevalance

Answer 4

4 million survivors in US

-3rd leading cause of death in 97

Question 5

modifable Risk factors

Answer 5

• HTN (>140/90): increased BP increases risk of hemorrhagic type stroke
• increased cholesterol: dyslipidemia, high LDL level
• adult onset diabetes(type 2 non insulin dependent)
• cigarette smoking: increases risk of stoke by 50%, risk increases w/ # of cigs smoked per day
• alcohol and cocaine use
• obesity
• MI: increases risk by 31% in 1st mo. post( due to clot forming in vessel)
• cardiac irregularities: atrial fibrillation-rapid continuous contraction of atrial w/out rest-> pooling/coagulation
• decreased activity
• carotid artery disease: increases risk by 30%

Question 6

non-modifiable risk factors

Answer 6

• age (greatest risk: 72% occur after 65y/o)
• race (African american)
• gender (males)

Question 7

early warning signs of stroke

Answer 7

• sudden weakness or numbness of face, arm,leg
• sudden dimness or loss of vision, particularly in on eye
• sudden difficulty speaking or understanding speech ( articulation/expression or receptive)
• sudden severe headache with no know cause ( diff dx -unexplained spike in BP, deprivation of caffeine, migraine)
• unexplained dizziness, unsteadiness or sudden falls ( medication side effect-infection)

Question 8

Pathophysiology of stroke

Answer 8

• loss of blood supply -> cell paralysis-> loss of function
• cell damage within core area-> cells die and spill contents (excitotoxity)-> increase release of NT-> additional cell death and increased cell swelling)
• result: area of damage-> ischemic prenumbra

Question 9

Causes of Ischemic stroke (thrombus or embolus)

Answer 9

• atherosclerosis-larger vessel disease
  
  • cerebral or peripheral vasculature
• thrombus : slow occlusion of blood vessel due to clot-coagulation of blood in one area
• embolus: thrombus or other material ( fat, blood clot, tumor) that breaks off and travels/ occludes a vessel

-atherosclerosic plaque may lead to tear in wall & bleed or the decreased lumen could lead to turbulence and increased viscosity pf blood leading to clotting

Question 10

causes of cerebrovascular disease: cerebral embolism

Answer 10

-emboli can travel from other areas of the body to the brain
-arterial source, fat emboli
-from the heart; most are from here, larger the size the more significant the problem
-atrial fibrillation-clot formation; may have meds or have surgery to increase heart function to decrease clotting
( DVT doesn’t increase risk of stroke bc goes to lungs 1st- PE)
-severity depends on location/distribution of vessel affected

Question 11

Hemorrhagic stroke

Answer 11

-more sudden onset
-rupture of elastic vessel wall &bleed into surrounding tissue putting pressure on brain through meninges or into parenchyma
Common causes:
-Berry Aneurysm:
-AV Malformation
-Charcot Bouchard Aneurysm
-subdural Hemorrhage

Question 12

Berry aneurysm

Answer 12

-abnormality in internal elastic lamina of vessel
-similar to a balloon enlarging over time(until point of rupture)
-related to defect in collagen or CT tissue of vessel wall
ruptured berry aneurysm at circle of willis
-major cause of subarchnoid hemorrhage
-may bleed directly into ventricles

Question 13

AV Malformation

Answer 13

• congenital defect, direct connection b/w veins and arteries w/out a capillary
  
  • high pressure goes directly into low pressure-may result in rupture
• high BP is major cause and increases risk

Question 14

Charcot Bouchard Aneurysm

Answer 14

clinical picture of events

• person engaged in activity which increases BP significantly: constipation, after sex
• present with extreme headache and change in level of consciousness (rapid)

Question 15

Subdural Hemorrhage

Answer 15

• TBI

- rupture of veins b/w surfaces of brain and dura-blood increases pressure on brain and deprives brain of blood

Question 16

Transient Ischemic Attack (TIA)

Answer 16

• resembles a stroke-focal symptoms
• damage to brain non-existent
• individual recovers rapidly w/out permanent deficit
• complete recovery within 24 hours
• majority of TIAs last 5-20 min
• present with sensory/ motor / speech deficits
• multiple TIAs increases risk of stroke
• can not differentiate b/w stroke and TIA until after( txt as stroke until ruled out)

Question 17

cerebrovascular disease and stroke clinical picture

Answer 17

• clinical picture is correlated with area of CNS damaged
• in general the pt may present with
  
  • Mvmt disorders; mm tone(hypo or hyper) and strength
  • Balance deficits
  • sensory disturbances
  • cognitive impairments; memory, emotion,sppech

Question 18

Middle Cerebral Artery Syndrome

Answer 18

• MCS supplies the lateral aspect of the frontal, temporal, and parietal lobes and subcortical structures
• most common site of stroke
• contralateral hemiplegia and hemianesthesia
• global aphasia( if dominant hemisphere)
  
  • loss of fluency, ability to name objects, comprehend auditory information or repeat language

Question 19

Anterior Cerebral Artery Syndrome

Answer 19

• ACA supplies medial aspect of frontal and parietal lobes and subcortical structures
• uncommon area
• collateral blood flow

Question 20

Posterior Cerebral Artery Syndrome

Answer 20

• PCA supplies occipital lobe, medial and inferior temporal lobe and upper brainstem
  
  • subthalamus, medial thalamus, ipsilateral cerebral peduncle and midbrain
  • contralateral ataxia
  • homonymous hemianopsia (can see only to one side)
  • cortical blindness
  • alexia (unable to read)
  • agnosia (inability to interpret sensations and recognize things)
  • memory deficits

Question 21

Cerebellar Infarcts

Answer 21

Cerebellum is supplied by 3 pairs of cerebellar arteries from the vertebrobasilar system

• Posterior Inferior Cerebellar A. (PICA)
• Superior Cerebellar A.
• Anterior Inferior Cerebellar A. (AICA)

Question 22

Lacunar Infacts

Answer 22

• hypertensive pts
• internal capsule: depending on location of infarct-variable presentations
• posterolateral thalamus

Question 23

diagnosis of stroke

Answer 23

• history of event (timing, pattern of onset, course)
• angiography( depends on pt presentation-done later so doesn’t increase fluid in system)
• CT (fastest to dx)
• MRI
• PET (done later , not acute)

Question 24

Angiography

Answer 24

• invasive procedure
• inject radio-opaque contrast agent or dye in a vein or artery
• series of x-rays taken
• can help dx obstruction or stenosis in vessels

Question 25

Clinical Picture: Mvmt problems associated with stroke

Answer 25

• decreased force production
• sensory impairments
• abnormal synergistic organization of movement
• altered sequencing (timing) of mm contractions
• impaired regulation of force control
• delayed responses
• abnormal mm tone (hypo or hyper)
• loss of ROM
• altered biomechanical alignment

Question 26

Left Stroke ( Right Hemiplegia)

Answer 26

(if in dominant hemisphere)

• speech and language problems: aphasia-receptive &/or expressive
• possible dysphagia
• profits from gestures and non-verbal instructions
• individual aware of problems, often responds w/ anxiety
• repetition is necessary due to impaired ability to retain info
• L/R discrimination may be impaired
• Problems with recognition of objects or word recall
• tends to be slow, cautious and disorganized when approaching unfamiliar tasks
• easily frustrated and angered w/ communication difficulties
• needs time to process information and time to respond either verbally or with gestures

Question 27

Right Stroke (Left Hemiplegia)

Answer 27

( if in dominant hemisphere)

• difficulty with spatial perceptual tasks
• profits from verbal instructions over gestures
• needs cues to take things one step at a time
• has difficulty assembling or completing tasks such as dressing and other self-care activities. Relearning ADL skills may take longer
• Left sided neglect
• Tends to move impulsively and not follow directions or cues( thinks they can do tasks independently =safety risk)
• overestimates own abilities to perform task
• has increased distractibility
• judgement and consistency are very important
• thinking is disjointed
• safety awareness is diminshed

Question 28

Medical Mgmt

Answer 28

• Fibrinolytic therapy: attempt to get repurfusion to area by dissolving the clot. may get hemorrhage in addition to thrombotic damage
  
  • tissue plasminogen activator-tPA
  • direct administration of anticoagulant at the site of the clot (

Question 29

Surgical mgmt

Answer 29

• carotid enarterectomy
  
  • if stenosis in carotid > 70% in internal carotid then surg. is warranted
  • could be an aboulsion? & destroy material
  • increases risk of stroke
  • balloon angioplasty-put in catheter and blow up in vessel to flatten plaque against wall
• Aneurysm clip (with wire)
• mechanical thrombolysis
  
  • thread in catheter to vessel and break up thrombus mechanically with vibration

Question 30

Prognosis

Answer 30

• loss of consciousness -> poorer prognosis
• ischemic stroke( thrombus type) typically has better outcome w/ respect to function vs embolic or hemorrhage
  
  • thrombus takes longer to form and gives more time to text before it becomes too late
• greatest amount of recovery of function occurs in first 3-4 mo.