Stroke / TIA / Syncope / Seizure Flashcards
Which is the most common stroke in the US?
A. SAH
B. Intracerebral Hemorrhage
C. Ischemic
Ischemic (87%)
Ischemic stroke is defined an acute neurological injury that occurs due to ischemia secondary to what THREE pathologies?
- Embolism / Thrombosis
- Systemic Hypoperfusion
- Hemorrhage
Where is the most common location of a extracranial thrombus?
Intracranial?
Extracranial: Internal Carotid (Common)
Intracranial: Circle of Willis
The presence of what in vessels increases the risk for embolization?
Stenosis
What is the most common mechanism of small vessel disease in the brain?
This is often secondary to what co-morbid condition?
Lipohyalinosis secondary to HTN
Where a common source (“starting point”) of emboli that travel to the brain?
Cardiac Origin (ie: Heart)
What cardiac conditions put patients at a HIGH risk for ischemic stroke?
Atrial Fibrillation
Mechanical Valves
CABG
Infectious Endocarditis
What blood disorders are commonly associated with ischemic stroke?
Factor V Leiden
Prothrombin Gene Mutation
“Man in a Barrel” effect is commonly associated with _________ ischemia
Watershed Ischemia
Following an ischemic stroke patients should receive neuro checks every __ hours.
2 hours
What is the goal BP in an acute ischemic stroke patient?
< 220/110 which should progress to normal range over time
T/F: DVT Prophylaxis is not need in ischemic stroke patients
False
It is needed by day 3 of admission and work up
A patient presents to the ED with symptoms concerning for stroke….
What is the most immediate imaging modality that should be obtained?
What is the more sensitive imaging modality in this case?
What is the ‘gold standard’?
Immediate: CT (Brain/Head) +/- CTA
Sensitive MRI / MRA
Gold Standard: DSA
Why would a TEE be ordered on a patient undergoing ischemic stroke work up?
To assess for thrombus, wall motion abnormalities, RA chamber size, EF, PFO, etc…..
What is the name of the ‘scoring system’ used to evaluate stroke patients?
NIHSS
What medication can be given in ischemic stroke patients to ‘dissolve’ any emboli HOWEVER needs to be given within 3 hours of onset and have to be older than 18 y.o.?
Tissue Plasminogen activator (tPA)
What ‘procedures’ can be often done in combination with tPA to help intervene in ischemic strokes?
Mechanical Thrombectomy
Intra-arterial Thrombolysis
Why may a hemicraniotomy be done in large territory ischemic strokes?
To help prevent or relieve swelling
It is important to start ischemic stroke patients on ________ therapy, such as 325 mg ASA, as well as a ______, to help control cholesterol.
Anti-platelet
Statin (Atorvastatin 40 mg)
_____ _______ _____ is defined as neurological dysfunction often do to ischemia but not infarction and symptoms often resolve within 1-24 hours
Transient Ischemic Attack (TIA)
What are two common causes of TIAs?
- Atherosclerosis (~70% Stenotic)
2. Emboli
Is there a difference in the work up of a TIA vs Ischemic Stroke in regards to diagnostics?
No
The work up is similar as TIAs can often be early signs of CVA
T/F: TIA and CVA patients should be evaluated for undiagnosed OSA (Obstructive Sleep Apnea)
True
A patient is diagnosed with a TIA is found to have 70-99% stenosis of their ipsilateral carotid artery…..
What procedure should be considered and likely beneficial?
Carotid Endarterectomy
A ________ hematoma is a collection of blood in the space between the dura and the bone
Epidural
Which vessel is commonly involved in epidural hematomas?
Middle Meningeal Artery
Epidural hematomas commonly occur in what setting?
Trauma
In a patient with an epidural hematoma…..
The period after initial loss of consciousness in which individual recovers partially prior to decompensating again usually secondary to expansion of hematoma is referred to as what?
Lucid Period
A ________ hematoma is defined as a collection of blood below the inner dura but external to the brain.
This is the most common type of traumatic intracranial lesion
Subdural Hematoma (SDH)
What percent of SDH patients present comatose?
~ 24%
SDH most often occurs due to injury to what vessels?
Bridging Veins
A ________ hemorrhage is defined as blood within the subarachnoid space.
Subarachnoid Hemorrhage (SAH)
SAH are most commonly due to what pathology?
Ruptured Aneurysm
What inherited renal disease puts patients most at risk for cerebral aneurysm?
Autosomal Dominant Poly-cystic Kidney Disease
Aneurysms greater than what diameter are most at risk for rupture?
> 7 mm
What is the unique presenting complaint in patients with SAH?
“This is the WORST headache of my life”
“Thunderclap”
What scale is helpful in evaluating patients with a SAH?
Fisher Scale
What two surgical procedures are used to treat SAH emergently?
Clipping
Endovascular Coiling
What is the goal systolic BP in a SAH patient?
< 150 mmHg
What electrolyte abnormality needs to be avoided in a patient with SAH?
Hyponatremia
What anti-hypertensive medication is used in patients with SAH as it is indicated to reduce brain damage as a result of ruptures aneurysm?
Nimodipine
Asymptomatic aneurysms only require surgical intervention if they are larger than what diameter?
> 10 mm
T/F: Non-traumatic intracerebral hemorrhage (ICH) is the THIRD most common cause of stroke
False
It is the SECOND most common cause
What is a common co-morbidity that ICH patients often have?
Uncontrolled HTN
Which scenario would favor surgical intervention in a patient with ICH…..
A. Onset <12 hours, younger patient, Non-dominant hemisphere, clinically deteriorating
B. Onset > 12 hours, older age, clinically stable, dominant hemisphere
A. Onset <12 hours, younger patient, Non-dominant hemisphere, clinically deteriorating
_________ is defined as a transient, self-limited, loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery
Syncope
Are cardiac causes of syncope more common in younger or older patients?
Older
What are examples of cardiac causes of syncope?
Valvular Disease Hypotension Arrhythmias MI PE
What are non-cardiac examples of syncope?
Vasovagal
Autonomic Insufficiency
Situational
Orthostatic
Fear, stress, and pain, are common causes of ________ syncope.
Sx Include……….
Nausea
Diaphoresis
Lightheadedness
Vasovagal Syncope
Micturition, defecation, tussive, and carotid sinus massage are all common causes of __________ syncope.
Situational
_________ syncope is secondary to orthostatic hypotension as a result of a disease process, hypovolemia, or medications.
Orthostatic Syncope
What are the THREE most common presenting symptoms in a syncopal patient?
Faintness
Dizziness
Lightheadedness
What are some precipitating factors to syncope?
Fatigue Sleep/Food Deprivation Warmth EtOH Consumption Pain Emotions (ie: fear) Positional Change Exertion
If a patient notices symptoms for a few seconds prior to a syncopal event, it is more likely related to what?
If these symptoms last for 2-3 minutes prior to the syncopal event, it is more likely to be what kind of syncope?
A few seconds = Arrhythmia-related
A few minutes = Vasovagal Syncope
When working up a patient for syncope……
It is important to obtain orthostatic vitals prior to administering what?
IVF Resuscitation
What may a syncopal patient be sent home with their syncopal episode is believe to be cardiac related?
Holter Monitor
Loop Monitor
A 46 y.o. patient presents with his 5th syncopal event this time with 20 seconds of documented asystole.
What cardiac device does he need to be evaluated for?
Pacemaker
Criteria:
> 40 yo
Recurrent Syncope
Documented Asystole
How can orthostatic hypotension be managed?
Recommend slow position changes Elevate head of bed TED stockings Fludrocortisone Midodrine Recommend PO fluid in take
_______ strokes typically involve frontal, parietal, temporal, or the occipital lobe.
Sx include…..
Agraphia Acalculia Neglect Gaze Prefernece Aphasia (if in the language center)
Cortical Stroke
________ stroke typically occurs in the Internal capsule, Basal Ganglia, or the Thalamus.
These are commonly lacunar infarcts.
Sx include……
Contralateral motor and sensory weakness
Subcortical Stroke
________ strokes often result due to trauma (ie: chiropractic manipulation), dissection, or artherosclerosis.
What portion of brain circulation do these often effect?
Sx include…..
CN deficits Headache Visual Changes Imbalance Comatose
Brainstem Stroke
These often involve POSTERIOR circulation in the brain…..
Basilar Artery
Verterbral Arteries
Cerebellar Arteries
A _________ _________ stroke often presents with cranial nerve abnormalities including EOM, facial paralysis, or bulbar symptoms.
Subcortical Brainstem Stroke
A ________ stroke is similar to a subcortical brainstem stroke, but these will predominantly present with imbalance, ataxia, tremor, and vomiting.
Cerebellar
What generalized seizure disorder is characterized by a starring spell?
Absence Seizure
What generalized seizure disorder is characterized by a sudden loss of tone, which ultimately results in falls and injuries?
Atonic
What generalized seizure disorder is characterized by whole body convulsions?
Tonic-Clonic
What generalized seizure disorder is characterized by quick, involuntary, twitching of the muscles?
Myoclonic
In which partial seizure disorder does consciousness remain intact…..
Simple or Complex?
Simple
There is LOC in complex partial seizures
Seizures lasting for longer than 5 minutes are considered what?
Status Epilepticus
Patients often have an _______ preceding the seizure which include smell, tastes, or visual changes.
Aura
The state after a seizure is referred to as what?
This includes symptoms like….
Somnolence
Fatigue
Confusion
Post-Ictal State
What are examples of causes of “acquired seizure disorder?”
FIVE
Tumor Stroke Trauma Alcohol Withdrawal Medications
Two unprovoked seizures more than 24 hours apart would be indicative of a diagnosis of what?
Epilepsy
When working up a patient for seizures it is important to obtain a metabolic and hepatic panel.
Why?
Renal Failure, Hepatic Failure, and dysglycemia can all result in generalized seizures
What “imaging” of the brain, similar to an EKG of the heart, is commonly used to evaluate seizure patients?
This involves 20 electrodes comparing simultaneously electrical activity in the brain
Electroencephalogram (EEG)
What medications are given to treat status epilepticus?
Lorazepam (Ativan) Phenytoin/Valproic Acid Midazolam (Versed) Phenobarbital Propofol
