Stroke/TIA Flashcards
Describe the kind of strokes and their prevalence
- Ischemic (87%)- from thrombosis, emboli hypoperfusion
2. Hemorrhagic (13%) from intracranial hemorrhage or SAH (MC younger populations)
What are modifiable risk factors for stroke?
- Hypertension: most important modifiable risk factor
- Cardiovascular disease - congestive heart failure, previous MI, aortic valve disease and atrial fibrillation.
- Cigarette smoking: inc. risk of 2-3 times
- Carotid Artery Disease: can limit blood flow to the brain, act as a potential source for cerebral emboli
- Diabetes: doubles stroke risk
- Dyslipidemia: high LDL, low HDL
- Obesity: can double risk of ischemic stroke
- Lack of Exercise and Physical Activity
- Use of Birth Control and Hormone Therapy: birth control pills (esp. if they smoke and are over the age of 35)
What are non-modifiable risk factors for stroke?
- Family History: stroke or CAD
- Age: risk doubles every 10 yrs after age 55
- Gender: <55 (men more likely to have stroke); >55 risk same for males and females
- History of Prior Stroke, TIA or Heart Attack
- Race: African Americans - higher incidence and risk of death from stroke; Asian Americans – high risk of hemorrhagic stroke
S/S of stroke (focal Sx)
- Sudden onset
- max. severity at or w/in minutes of onset
- Sensory sx: altered feeling, vision loss on 1 side, bilateral blindness, double vision, vertigo
- Loss of focal cerberal fxn (neg. sx/loss of fxn)
- Speech disturbance: understanding, expressing, reading, writing, slurred, calculations
- Motor sx: weakness, clumsiness on 1 side, difficulty swallowing*, ataxia
- Consciousness is normal or only slightly impaired
*evolution of new neuro sx or reduced LOC is uncommon w/in first few hours
What quick screening guide should you educate pts and pts familys on for stroke signs
FAST Facial droop Arm weakness Slurred speech Time is critical--> call 911
*80% sensitive and specific
Compare and contrast the def. of TIA and CVA
TIA: neurodysfunction caused by focal brain ischemia
- s/s last <1hr
- NO evidence of ischemia on imaging
CVA: neurodysfunction caused by cerebrovascular dz
-s/s last >24 hrs or until death
Non-focal Sx (NOT likely to be TIA/CVA)
- Generalized weakness or numbness BILATERALLY
- faintness or syncope
- Incontinence
- Isolated sx
- Vertigo or loss of balance
- Double vision
- Slurred speech or difficulty walking
- Confusion/disorientation
- Impaired attention/concentration
- Diminution of all mental activity
Isolated language or visual-spatial perception problems (may be ___)
Isolated memory problems (may be ____)
TIA
transient global amnesia
Identify and differentiate between the differential diagnosis for CVA
- Hypoglycemia
- Migraine with aura (positive symptoms)
- Partial/focal seizure (positive symptoms)
- Transient global amnesia (no other sx/findings)
- Intracranial lesion (mass, AVM)
- Multiple sclerosis (signs more pronounced than symptoms)
- Labyrinthine disorders
- Peripheral nerve lesions (often painful)
- Subdural Hematoma
- Metabolic Disturbance (hypoxia, drug overdose)
- TIA (negative symptoms)
Stroke Symptoms vary depending on which ____ the ischemia or hemorrhage occur
region and side of the brain
If you suspect stroke by symptoms or physical exam, emergent imaging by ___ is essential for diagnosis and treatment.
CT or MRI
Note: ___ is the most important predictor of non-stroke pathology
reduced conscious level
- Stroke rarely causes reduction of conscious level in the first few hours
- Reduced consciousness in ischemic stroke occurs 2-5 days after onset (large infarcts due to brain swelling)
TIAs have a high risk of leading to stroke (esp w/in ___) – use __, __, and __ to assist with disposition (admit v. send home)
first 48 hrs
- clinical features,
- imaging to eliminate other causes, and
- ABCD2 score
A 73-year-old man presents with his son, who reports that the patient had a brief episode (around 30 minutes) of difficulty speaking and weakness in his right arm earlier today. The patient reports that he feels fine now and would like to go home.
TIA
-brief episode <1hr
Describe the ABCDD assessement for CVA risk after TIA
-Age [A]: >60 (1 pt)
-Blood pressure [B]: >140/90 (1 pt)
-Clinical features [C]
•Unilateral weakness (2 pts)
•Dysphasia w/out weakness (1 pt)
-Duration of symptoms [D]
•>60 min (2 pts)
•10-59 min (1 pt)
-Diabetes [D]: 1 pt
0-3= low risk: 1% in 48hrs 4-5= med risk 4% in 48hrs 6-7= high risk 8% in 48hrs
Hospital admit recommendations after TIA
- first TIA w/in past 24-48 hrs AND…
- Crescendo symptoms
- Symptom duration > 1 hour
- Internal carotid stenosis > 50%
- Known Afib or other cardiac source
- Known hypercoagulable state
- ABCD2 Score >3
Important HX for the w/u of CVA
- Determine exact time of stroke (if possible) – affects tx options
- Characteristics of the attack
- Associated symptoms - trauma, seizure activity, headache
- RF: Vascular Disease, Cardiac Disease, Hematologic Disorders, Smoking
- Prior stroke or TIA
Important PE for w/u of CVA
- Vitals- HTN, pulse irregularity
- HEENT: trauma, carotid bruits
- Cardiac dysrhythmias
- Neurologic Exam
- Carotid Bruits: may suggest carotid stenosis (signal a need for doppler US evaluation)
- Cardiac Exam
- Peripheral Pulses
Labs/imaging for the w/u of CVA
- Labs on a case-by-case basis
1. blood glucose
2. CBC
3. PT and PTT
4. BMP- r/o hypoNa+
5. EKG/cardiac monitoring for at least first 24hrs
6. Echo in 1st hr if suspect endocarditis
7. TEE in days after r/o cardioembolism
8. CTA, MRA,
9. Carotid US
acute stroke outcome is predicted by
NIHSS
- severity of initial stroke
- age
- blood glucose
- hx of previous stroke
___ is needed to differentiate cerebral infarction from intracerebral hemorrhage
Imaging (CT noncontrast or MRI)
*noncontrast (more widely available, faster, less susceptible to motion artifact, cheaper)
CT or MRI of the brain is required to
- Differentiate between ischemic or hemorrhagic stroke (both detect bleeds; MRI has higher sensitivity for ischemia)
- Verify a cerebrovascular cause of the clinical neurologic deficit and initiate appropriate tx to attempt to reperfuse ischemic penumbra (area of dysfunction caused by metabolic and ionic disturbances, but structural integrity is still preserved)
- Show any abnormal findings that may contraindicate use of thrombolytics
what imaging is best used to detect ischemic changes
MRI
Goal door to CT completion (___) and interpretation (___)
25 min
45 min
Acute management of ischemic stroke
- Stroke care units (SCUs): effective and appropriate for all types of stroke (physical location best)
- Thrombolysis: recombinant tPA
- Aspirin 300 mg QD for 14 days (initiate after 24 hrs if using thrombolytics)
- Decompressive hemicraniectomy
Benefits of SCUs (stroke care units)
- Most substantial advancement - reduces mortality and improves outcome by about 20%
- Improved BP control,
- early mobilization,
- adherence to best practices
Thrombolysis (IV alteplase) improves odds of recovery when given up to ___ hrs after onset of ischaemic stroke
3 hrs
Acute tx of TIA
management in SCU
Acute tx for cerebral hemorrhage (aka hemorrhagic CVA)
- Management in SCU
- Regulate BP (not yet found to improve outcome)
- Control of brain edema (not yet found to improve outcome)
- Neurosurgical consultation: pts at risk for obstructive hydrocephalus
benefits of ASA in CVA
- improves functional outcome and likely reduced chance of recurrent ischemic stroke
- Benefit is small, but ASA is cheap, safe, and effective across wide range of pts
Contraindications for reperfusion therapy (alteplase) for Acute ischemic stroke
- Onset of sx >3 hr before start of tx
- Intracranial hemorrhage on CT or MRI
- Head trauma or stroke in previous 3 mo
- MI in previous 3 mo
- GI or urinary tract hemorrhage in previous 21 days
- Major surgery in previous 14 days
- HX of intracranial hemorrhage
- SBP pressure ≥185 mm Hg or DBP ≥110 mm Hg
- Evidence of active bleeding or acute trauma on PE
- Use of oral anticoagulants and an INR ≥1.7
- Use of heparin in previous 48 hr and a currently prolonged aPTT
- Platelet count <100,000 per mm3
- BG level <50 mg/dl (2.7 mmol/liter)
- Seizure with postictal residual neurologic impairments
Identify and implement the Methods of Stroke Prevention for patients who
Have Never Had A Previous Stroke or TIA (Primary Prevention):
- Anti-coagulation (Warfarin): for patients with atrial fibrillation (CHA2DS2-VASc score)
- antihypertensives
- statin for pts w/ pre-existing ischaemic heart disease
- Aspirin in women 45 years or older (but not men)
- Modification of risk factors such as diabetes, moderation of EtOH, reduction in smoking
the benefit of rt-PA is greater ____
the risk of symptomatic intracranial hemorrhage after thrombolysis is higher in patients with ___ and __
the sooner treatment is started.
more severe strokes and with increased age.
Secondary Prevention of Recurrent Stroke (some who has already had a TIA/CVA)
- Anticoagulants/warfarin
- Antiplatelet (when const cosiderations are paramount) – ASA or plavix when ASA allergy or concurrent sx CAD
* *DONT TAKE WARFARIN AND ASA TOGETHER-bleed risk - Carotid Endarterectomy when 70%+ stenosis
___ remains one of the most biologically effective secondary prevention strategies for patients with atrial fibrillation and reduces RR of recurrent stroke in patients with TIA or minor stroke by about __
Warfarin
70%
Endarterectomy must be undertaken within __ of a Stroke or TIA for maximum benefit.
2 weeks
___: aids in the decision of whether to anti-coagulate with Atrial Fibrillation to prevent thromboembolism
-Score of __ or greater should warrant strong consideration for full oral anticoagulation
CHA2DS2-VASc Score
1 or greater
O = low risk: possibly DO NOT use Warfarin / Coumadin
1 or greater = moderate to high risk: recommended to use Warfarin / Coumadin
What is included in the CHAD2VASC score
- age
- Sex
- CHF
- HTN
- CVA/TIA HX
- Vascular hx
- DM
