Stroke/TIA/Syncope Flashcards

Question

# Stroke Thrombectomy

Answer 1

A procedure to remove a blood clot from a blood vessel using a catheter and clot retriever.

Answer 2

Close to 2 million brain cells die every minute a stroke goes untreated. For best possible outcome, ideally, a stroke patient needs to receive thrombectomy within 24 hours. If able, transfer for thrombectomy for large vessel occlusion Call to neurointerventionalist, or stroke team, as they can help determine if appropriate

Answer 3

Carotid endarterectomy- If stenosis on ultrasound- 70% -99% on affected side. If stenosis 50-70%- +/- medical therapy If less than 50% stenosis- medical therapy preferred Carotid stents per vascular surgeon

Answer 4

If embolic – atrial fibrillation, mitral stenosis, prosthetic cardiac valve, thrombus in left ventricle, atrial myxoma- **warfarin, apixaban** are used to prevent further strokes as secondary prevention. May be primary prevention if a fib caught first. If warfarin-can bridge with heparin until INR therapeutic (2-3) NOACs do not require bridging or monitoring Cost / transportation are barriers

Answer 5

If thrombotic/lacunar- on no antiplatelet medications at presentation = **aspirin** 81mg PO daily If on aspirin and have a stroke= overlap 21 days with aspirin 81mg PO daily and **Plavix** 75mg PO daily, then just continue Plavix thereafter Note: if received tPA, delay ASA for 24 hours until post tPA CT confirms no hemorrhagic transformation If have a stroke while on Plavix, dual antiplatelet therapy with Plavix AND aspirin. If someone has a fib and still has a stroke, they can be treated with anticoagulation AND antiplatelet, but with increased risk of bleeding.

Answer 6

All tPA candidates should be treated with BP >185/110 Everyone with BP > 220/120 Everyone “in between” with end organ damage (acute CHF, aortic dissection, hypertensive encephalopathy Treat inpatient with either labetolol or nicardipine via IV.

Answer 7

Labetolol causes vasodilation with onset of 5-10 minutes. Not a substantial reduction in heart rate or cardiac output- we need perfusion! Nicardipine- reduces vasospasm, rapid onset, decreased systemic vascular resistance

Answer 8

Ace/ARB/ARNI CCB Spironalactone Thiazide

Answer 9

Physical therapy Occupational therapy Speech therapy Discipline depends on symptoms but therapy is highly indicated for stroke patients The brain is not a muscle but you have to work it like one

Answer 10

Control risk factors Comply with treatment Lifestyle modification- exercise, Mediterranean diet, stop smoking, stop ETOH Statin DM control HTN control

Answer 11

Transient loss of consciousness and postural tone Vasodepressor or cardiogenic causes with prompt, spontaneous recovery without resuscitative measures Inadequate nutrient flow to the brain Usually leads to a fall Presyncope events are possible Prodromal symptoms

Answer 12

History of structural heart disease Abnormal EKG Age older than 60 years

Answer 13

30% of adults will experience ≥ 1 syncopal episode Incidence increases with age, esp older than 70 Results in ~3% of ED visits Can cause serious injury, esp in elderly Specific cause identified in ~50% of cases during initial evaluation Vasovagal most common History is key in order to identify the causation Prognosis favorable except with accompanying cardiac disease

Answer 14

May be due to excessive vagal tone or impaired reflex control of peripheral circulation Subtypes below: Vasovagal Carotid sinus situational

Answer 15

“common faint” Caused by a stressful, painful, or claustrophobic experience

Answer 16

Stimulation of abnormally sensitive carotid body, with subsequent abnormal vagal response Results in bradycardia and arterial relaxation/dilation

Answer 17

Enhanced vagal tone with resulting hypotension Coughing, sneezing, micturition, exercise

Answer 18

Patients bp drops upon standing Normal vasoconstrictive response to assuming upright posture usually compensates for abrupt decrease in venous return Commonly in elderly patients Symptoms more likely to occur in early morning, after heavy meals, with prolonged standing, when core body temperature rises

Answer 19

Mechanical or arrhythmic basis arising from heart Brady: Sinus brady, sinus pauses, AV block Tachy: Ventricular tachycardia Mechanical: Aortic stenosis, Pulmonary stenosis, hypertrophic cardiomyopathy, congenital lesions, massive PE Commonly exertional or post-exertional Usually no prodrome Injury secondary to falling is common

Answer 20

* Lightheadedness. ●Feeling unstable in the upright position. ●A feeling of being warm or cold/clammy. ●Sweating. ●Palpitations – The sudden onset of palpitations immediately followed by syncope suggests a cardiac arrhythmia, but palpitations due to sinus tachycardia may also precede reflex syncope. ●Nausea, vomiting, or nonspecific abdominal discomfort. ●Visual "blurring" occasionally proceeding to temporary darkening or "white-out" of vision. ●Diminution of hearing and/or occurrence of unusual sounds (particularly a "whooshing" noise). ●Pallor reported by onlookers

Answer 21

Anti-hypertensives (including diuretics) Βeta blockers Anti-dysrhythmics Antipsychotics Anti-parkinson drugs Antidepressants Phenothiazines Nitrates Alcohol Cocaine Etc.

Answer 22

Patients with normal initial evaluation: Unremarkable H&P, absence of cardiac disease, absence of significant comorbidities, normal baseline EKG Note – EKG should be obtained in all patients with suspected syncope May not need further testing Routine comprehensive lab testing is not useful Routine cardiac imaging is not useful in evaluation of patients with syncope unless cardiac etiology is suspected based on history, physical examination, or ECG Carotid artery imaging is not recommended in routine evaluation of patients with syncope in absence of focal neurologic findings

Answer 23

Prodrome typical of reflex syncope (lightheadedness, feeling of warmth, sweating, nausea, vomiting) After sudden unexpected sight, sound, smell, or pain After prolonged standing or crowded, hot places During a meal or postprandial Triggered by cough, defecation, or micturition With head rotation or pressure on carotid sinus Standing up from supine/sitting position

Answer 24

New onset of chest discomfort, breathlessness, abdominal pain, or headache Syncope during exertion or when supine Sudden onset palpitation immediately followed by syncope ECG changes consistent with ischemia, etc

Answer 25

Trigger avoidance Increase fluids and salt Compression stockings Counterpressure maneuvers –Reduce venous pooling and improve cardiac output to stop an episode or allow for patient to move to a supine position Leg-crossing with simultaneous tensing of leg, abdominal, and buttock muscles (very effective). Handgrip, which consists of maximum grip on a rubber ball or similar object Arm tensing, which involves gripping one hand with the other while simultaneously abducting both arms May move to pharm treatment or pacemaker therapy if recurrent and severe

Answer 26

* Avoiding physical deconditioning in the elderly which helps maintain muscle tone in lower extremities * External compression devices such as waist-high compression stockings, abdominal binders * Physical maneuvers such as lunges, calf-raise, squatting, leg crossing * Review of home medications and discontinue diuretics and vasodilators if possible * Increase water and fluid intake to about 2-3 liters per day, avoid dehydration * Increase salt in diet 6-10g/day, eating small frequent low carbohydrate meals a day in case of postprandial orthostatic hypotension, avoid alcohol intake * Raising the head of the bed to 10 degrees at night reduces nocturnal diuresis * Avoiding activities such as saunas, spas, hot tubes, prolonged hot showers and excessive high intensity exercise

Answer 27

Goal is to increase blood volume: Midodrine 2.5 to 15mg orally once to thrice daily Fludrocortisone 0.1 to 0.2mg daily in the morning titrated up to 1mg daily if needed Pyridostigmine 30 to 60 mg orally trice daily Yohimbine 5.4 to 10.8mg orally trice daily Octreotide 12.5 to 50 ug subcutaneously twice daily Cafergot such as caffeine 100mg and ergotamine 100mg

Answer 28

Depends on causation Ablation or device implantation may be required