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Stroke_StepUp_Pre-Test Flashcards

1
Q

What is the MOST COMMON etiology of a TIA/CVA? Does the risk of stroke in a pt with TIA history increase?

A

EMBOLI

YES, risk of stroke in a preceding TIA pt is 10%, with 30% 5-year risk of stroke

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2
Q

What are the risk factors of an ISCHEMIC stroke?

A

MOST IMPORTANT - Age>40yo, HTN
Others - DM, HL, Obesity, Smoking
Afib, CAD, Carotid bruits, previous stroke/TIA

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3
Q

What are other rare causes/risk factors of an ISCHEMIC stroke in particularly younger pts?

A

VASCULAR - Vasospasm (amphetamines, cocaine), Vasculitis
METABOLIC - Sickle cell disease, Hypercoagulable states (Protein C, S deficiency, Factor V leiden mutation, Anti-Thrombin III Def, Prothrombin mutation, anti-phospholipid syndrome, OTC use), PCV, CNS

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4
Q

Which two systems can a TIA affect? How do they present?

A

1) CAROTID - Temporary hemiparesis, clumsiness of one limb, dysarthria
2) VERTEBROBASILAR SYSTEM - Decreased perfusion of the posterior fossa (medulla and pons - dysarthria, horseness, dysphagia, numbness of ipsilateral face, projectile vomiting, double vision, vertigo, headaches, drop attacks

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5
Q

What is AMAUROSIS FUGAX? How do they classically present?

A

Example of TIA that presents with TRANSIENT, CURTAIN-like loss of eyesight in IPSILATERAL EYE due to MICROEMBOLI to retina

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6
Q

What is the first imaging study that should be obtained in the evaluation of an acute stroke? Why?

A

CT Head WITHOUT CONTRAST - To distinguish between ischemic and hemorrhagic infarct

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7
Q

How do you tell the difference between ISCHEMIC and HEMORRHAGIC stroke on CT scan without contrast?

A 
ISCHEMIC = DARK 
HEMORRHAGIC = WHITE
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8
Q

Why might you miss an ISCHEMIC STROKE on CT head w/o contrast? (2 reasons)

A
  1. Timespan - Ischemic strokes usually take 24-48hrs to visualize the infarct on CT
  2. Small size - <1cm may be missed
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9
Q

What is the MOST SENSITIVE imaging test for stroke eval? Why is this one not preferred in an emergency setting?

A

MRI - Identifies ALL infarcts + detects earlier than CT (95% infarcts detected within 24hrs)

NOT preferred in emergency because it takes LONGER to perform + Not suitable for potentially UNSTABLE pts

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10
Q

What is the MOST DEFINITIVE test for identifying etiology of stroke?

A

MRA - Magnetic resonance arteriogram
Identifies stenotic vessels of the head and neck
Evaluates carotids, vertebrobasilar circulation, circle of willis, anterior, middle, and posterior cerebral arteries

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11
Q

If pt has carotid bruit, peripheral vascular disease, and CAD, what SCREENING TEST should be ordered?

A

CAROTID DUPLEX US - Estimates degree of carotid stenosis

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12
Q

If a pt is young (<50) and presents with stroke, what states should you look out for? (3)

A
  1. CNS VASCULITIS
  2. HYPERCOAGULABLE STATES
  3. THROMBOPHILIA
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13
Q

What tests should be ordered in a young pt (<50) presenting with stroke?

A
  1. Test hypercoagulable states - PROTEIN C, PROTEIN S, anti-phospholipid Abs, Factor V Leiden mutation
  2. Test autoimmune conditions - ANA, ESR, RF
  3. Test infectious causes - VDRL/RPR, Lyme serology
  4. Test cardiac embolic sources - TEE
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14
Q

Which type of stroke classically presents in a SLOWLY PROGRESSIVE in which pt AWAKES from sleep with neuro deficits?

A

THROMBOTIC STROKE

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15
Q

Which type of stroke classically presents with MAX DEFICITS AT ONSET (VERY RAPID WIHTIN SEC)?

A

EMBOLIC STROKE

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16
Q

What are the 3 possible complications of a stroke?

A
  1. CEREBRAL EDEMA - Occurs within 1-2 days -> Cause MASS EFFECTS for up to 10days
  2. HEMORRHAGE INTO INFARCTION Rare
  3. SEIZURES <5%
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17
Q

What is the TREATMENT for CEREBRAL EDEMA-RELATED MASS EFFECT as a complication of stroke?

A

HYPERVENTILATION + MANNITOL(osmotic diuretic) - to lower ICP

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18
Q

What are the 3 categories of STROKE TREATMENT?

A
  1. ACUTE Treatment
  2. BP Control
  3. Prevention Recurrence
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19
Q

ACUTE TREATMENT: What must be secured most initially?

A

ABC - Airway, Breathing, Circulation (O2, IVF)

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20
Q

ACUTE TREATMENT: What is the window of tPA?

A

3hours - Improves clinical outcome in 3mo

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21
Q

ACUTE TREATMENT: What are the exclusion criteria of tPA due to increased risk of HEMORRHAGIC TRANSFORMATION?

A
  1. UNCONTROLLED HTN (BP>185/110)
  2. WARFARIN USE with INR>1.7
  3. HEP USE with PTT>15
  4. PLT<100K
  5. Disorders that INCREASE risk of bleeding (AVM, ANEURYSM, NEOPLASM)
  6. <3mo of INTRACRANIAL or INTRASPINAL SURGERY
  7. <3wks of ACTIVE INTERNAL BLEEDING
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22
Q

ACUTE TREATMENT: If tPA is given, what must you NOT give for the first 24hrs?

A

ASA - due to 3% risk of intrancranial hemorrhage

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23
Q

ACUTE TREATMENT: If tPA window is past (>3hrs since stroke onset), which medication can be given to pt?

A

1) ASA
2) If pt cannot take ASA, give CLOPIDOGREL
3) If pt cannot take ASA or PLAVIX, then TICLOPIDINE

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24
Q

ACUTE TREATMENT: What is the efficacy of ANTICOAGULANT USAGE in stroke?

A

HEP or WARFARIN - NOT Shown to have efficacy in acute stroke
Generally NOT given in acute setting

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25
ACUTE TREATMENT: What are the measures of preventing aspiration?
1) HEAD OF BED ELEVATION 30deg | 2) Assess pt's ability to protect his/her airway -> NPO
26
BP CONTROL: Do NOT give anti-hypertensives unless which conditions?
1) VERY HIGH BP - Systolic >220, Diastolic >120, MAP >139 2) Significant medical indication for anti-hypertensive - MI, aortic dissection, HF, HTN encephalopathy 3) RECEIVED TPA - aggressive BP control necessary to reduce bleeding likelihood
27
PREVENTION: What are the recommended preventative measures of LARGE VESSEL ATHEROSCLEROSIS-mediated STROKE?
1) Control RISK FACTORS - HTN, DM, HL, HL, OBESITY 2) ASA 3) SURGERY - carotid endarterectomy
28
PREVENTION: What is the indication of CAROTID ENDARTERECTOMY?
``` LARGE VESSEL (>70% carotid artery stenosis) in SYMPTOMATIC pts with ACUTE THROMBOTIC STROKE **NASCET TRIAL ```
29
PREVENTION: What is the recommended preventative measure for ASYMPTOMATIC LARGE VESSEL ACUTE THROMBOTIC STROKE?
REDUCTION of atherosclerotic factors and ASA only NO CAROTID ENDARTERECTOMY **4 major studies - 3 showed no benefit of CE, 1 (ACAS) showed very small benefit with Asx CA stenosis >60^% pts
30
PREVENTION: What are the recommended preventative measures of ACUTE STROKE of EMBOLIC etiology?
1) ANTI-COAG (ASA) | 2) Reduce risk factors - HTN, HL, DM, Smoking, obesity
31
PREVENTION: What are the recommended preventative measures of ACUTE THROMBOTIC LACUNAR STROKE?
1) Control HTN!!
32
What is the MOST COMMON cause of INTRA-CEREBRAL HEMORRHAGIC STROKE?
HTN
33
What are some other less common causes of INTRA-CEREBRAL HEMORRHAGIC STROKE other than HTN?
1) ISCHEMIC STROKE conversion to hemorrhagic stroke 2) CEREBRAL AMYLOID ANGIOPATHY - Complication of Alzheimer's 3) Hypo-coagulable state - Liver disease, anti-coag/anti-thrombolytic use 4) Neoplasm 5) AVM 6) Drugs - Cocaine 7) Trauma
34
What is the classic presentation of a INTRA-CEREBRAL HEMORRHAGIC STROKE?
Sudden onset of focal neuro deficits that worsen steadily over 30-90min -> INCREASED ICP (Headache, vomiting, bradycardia, decreased alertness/consciousness/stupor/coma)
35
What types of stroke are associated with COCAINE USE?
1) ISCHEMIC - Vasospasm 2) HEMORRHAGIC - INTRACEREBRAL (ICH) 3) SAH ALL TYPES OF STROKE
36
Which physical exam finding is particularly useful in localizing the lesion of the ICH?
PUPILLARY FINDINGS
37
Pupillary finding of ICH in PONS? in THALAMUS? in PUTAMEN?
1) PONS = PINPOINT PUPILS (Lesion of SYMPATHETIC fibers = Unopposed PARASYMPATHETIC-mediated constriction) 2) THALAMUS = POORLY REACTIVE PUPIL 3) PUTAMEN = DILATED PUPILS
38
What are the possible complications of ICH?
1-3) INCREASED ICP, REBLEEDING, HYDROCEPHALUS 4-5) SEIZURES, VASOSPASM 6) SIADH
39
What are the 3 steps of Treatment of HEMORRHAGIC STROKE? (Same as ISCHEMIC)
1) ACUTE TREATMENT - Secure ABC, MICU admission 2) BP CONTROL 3) PREVENTION of recurrence
40
ACUTE TREATMENT: Why is airway management particularly important in HEMORRHAGIC STROKE pts?
Altered mental status + Decreased respiratory drive -> Often require INTUBATION
41
BP CONTROL: Why must BP reduction be GRADUAL?
* ELEVATED BP -> INCREASES ICP -> Causes FURTHER RE-BLEEDING * HYPOTENSION -> Lowers cerebral blood flow -> WORSENS neuro deficits RESULT - BP Control must be gradual so as to NOT induce HYPOTENSION
42
BP CONTROL: What are the measures for treating HTN in ICH?
SBP>160-180 | DBP>105
43
What is often the TREATMENT of choice for lowering BP in a HEMORRHAGIC STROKE PT?
NITROPRUSSIDE
44
HEMORRHAGIC STROKE: Which other treatment scan be given to reduce ICP? Can this be given PPX?
MANNITOL (Osmotic agent) + DIURETICS NO, DO NOT give them prophylactically
45
HEMORRHAGIC STROKE: Is the use of steroids recommended?
NO - actually harmful
46
HEMORRHAGIC STROKE: Rapid surgical evaluation of ___ HEMATOMAS can be lifesaving particularly if hemorrhage >3cm
CEREBELLAR HEMATOMA evacuation (SURGICAL DECOMPRESSION) can be lifesaving Often times, surgical intervention is NOT helpful in most ICH cases
47
What is the most common cause of SAH?
Ruptured saccular (berry) aneurysm at BIFURCATIONS OF ARTERIES of CIRCLE OF WILLIS - 1) Anterior communicating Artery w/ ACA 2) PCommArtery w/ ICA 3) MCA Bifurcation
48
What are other causes of SAH?
TRAUMA AVM VENOUS INFARCT
49
What is the classic description of a SAH?
1) WORST HEADACHE of my life in the ABSENCE of focal neuro deficits 2) Sudden transient LOC 3) Vomiting 4) Meningeal signs - Nuchal rigidity + Photophobia (Takes several hrs to develop) 5) Retinal hemorrhages - 30% pts
50
Which pathologies are associated with BERRY ANEURYSMS?
1) POLYCYSTIC KIDNEY DISEASE 2) AORTA COARCATION 3) MARFAN DISEASE
51
Which exam is absolutely mandatory for SAH candidate? Why?
OPTHALMOLOGIC EXAM! - R/o papilledema If + Papilledema - Do NOT perform LP (May cause herniation)
52
If papilledema is present in a SAH candidate, what test do you NOT perform? What diagnostic test do you do instead?
Do NOT do an LP - possible herniation | INSTEAD do CT scan
53
What is the initial SCREENING test for SAH?
CT Scan WITHOUT CONTRAST - Identifies 90% of SAHs
54
What is the DIAGNOSTIC TEST for SAH?
LP - Perform this if CT is unremarkable or negative + high clinical suspicious BLOOD in CSF (not from traumatic spinal tap) = XANTHOCHROMIA (YELLOW CSF) from RBC lysis Yellow indicates that the blood has been in CSF for several hours
55
After diagnosis of SAH is made, what is the DEFINITIVE study for detecting site of bleeding?
CEREBRAL ANGIOGRAM - Detect site of bleeding for surgical clipping
56
What are possible complications (5) of an SAH? Hint: Think vascular (2), too much blood (2), endocrine
1-2) Vascular - RERUPTURE + VASOSPASM (More often with ANEURYSMAL SAH) resulting in ISCHEMIA/INFARCTION -> ISCHEMIC STROKE 3-4) Too much blood - COMMUNICATING HYDROCEPHALUS 2/2 blood within subarahcnoid space hindering normal CSF flow + SEIZURE (blood acts as irritant) 5) SIADH
57
What are two possible avenues of treatment of an SAH?
1) SURGICAL - Consult neurosurg: Surgically treat berry aneurysms (ANEURYSM CLIPPING) 2) MEDICAL
58
MEDICAL TX SAH: What are the main goals of medical treatment for SAH?
Prevent risk of REBLEEDING + VASOSPASM 1. Rebleeding - STOOL SOFTENERS -> Avoid straining/sex (which would INCREASE ICP -> Risk of re-rupture) 2. Vasospasm - Ca CHANNEL BLOCKER (NIFEDIPINE/NIMODIPINE) generally peaks 7-10d OTHER 3. BP Control - Lower BP gradually bec ELEVATED BP could be COMPENSATION for decrease in cerebral perfusion pressure 2/2 INCREASED ICP OR CEREBRAL ARTERY STENOSIS 4. Headache control - ACETAMINOPHEN 5. Hydration - IVF 6. BED REST in quite, dark room
59
What is the most common cause of ICH (LOBAR) in elderly pts (>70yo) without HTN + MULTIPLE CORTICAL HEMORRHAGES (often seen on gradient Echo MRI) +/- dementia?
CAA - CEREBRAL AMYLOID ANGIOPATHY
60
What type of lesions can be clarified with NERVE CONDUCTION STUDIES?
PERIPHERAL NERVOUS SYSTEM
61
What does it mean when a lesion appears largely the same on UNENHANCED + ENHANCED CT scans?
Means that it is a HEMATOMA
62
What is the most common cause of a SAH? What is this pathology most likely 2/2?
Ruptured SACCULAR BERRY, MYCOTIC ANEURYSM - 2/2 Gm+ or Gm- infections (relatively low virulence) that form over cerebral convexities with SUBACUTE BACTERIAL ENDOCARDITIS -> Bleed directed into subarachnoid space
63
What is the most appropriate choice of therapy for FOCAL SEIZURE as a complication of ICH?
LEVETIRACETAM (KEPPRA)
64
Why is LAMOTRIGINE (LAMICTAL) generally NOT given for a FOCAL SEIZURE as a complicaiton of ICH?
Bec LAMOTRIGINE needs to be SLOWLY TITRATED over many weeks when first started due to risk of SEVERE RASH
65
What is the most common AE of LAMOTRIGINE?
SEVERE RASH
66
FOCAL WEAKNESS lasting for 24hrs AFTER MOTOR SEIZURE is evidence of __? What diagnostic test must be ordered to r/o something more serious?
POSTICTAL PARALYSIS - TODD PARALYSIS CT imaging - necessary to r/o bleeding or new areas of cerebrocrotical damage
67
What is the pathophysiology of TODD PARALYSIS?
TODD PARALYSIS = Post-ictal paralysis - Neuronal exhaustion (Epileptic focus neuronal Glc depletion) after frequent repetitive discharges
68
FACIAL CUTANEOUS ANGIOMAS (Port-wine nevus) + INTRACRANIAL LEPTOMENINGEAL ANGIOMAS + MENTAL RETARDATION = __?
STURGE-WEBER SYNDROME (ENCEPHALOFACIAL ANGIOMATAOSIS)
69
For STURGE-WEBER SYNDROME pts, what motor deficits are generally seen?
HEMIPARESIS/ HEMIATROPHY on side CONTRALATERAL to port-wine nevus
70
Where is the nevus associated with STURGE-WEBER SYNDROME generally located?
SENSORY DISTRIBUTION of first division of trigeminal nerve (usually on ONE SIDE of face) + ANGIOMA of the CHOROID OF EYE Intracranial angioma UNLIKELY if UPPER FACE is not involved
71
What are associations of HEMANGIOBLASTOMAS? (Hint: VHL SYNDROME)
CEREBELLAR HEMANGIOBLASTOMAS + RENAL CELL CARCINOMA + PHEOCHROMOCYTOMA + POLYCYSTIC KIDNEY DISEASE + RETINAL TELANGIECTASIAS
72
Where is the most common site for hematoma formation 2/2 CHARCOT-BOUCHARD MICROANEURYSMS (Due to chronic HTN-mediated hyaline arteriosclerosis of the arteries)?
PUTAMEN
73
What is the difference between CHARCOT-BOUCHARD and FUSIFORM aneurysms?
CHARCOT BOUCHARD - SMALL aneurysms 2/2 chronic HTN, most commonly appears in PERFORATING ARTERIES FUSIFORM - DIFFUSELY WIDENED aneurysms 2/2 atherosclerotic damage to arterial wall + Evaginations along walls (BERRY-SHAPED/SACCULAR structures WITHOUT stalks)
74
What are some example CLASSICAL Sx of EXTRACRANIAL INTERNAL CAROTID ARTERY DISEASE? What diagnostic test should be done to confirm this?
IPSILATERAL TRANSIENT MONOCULAR CLINDNESS (AMAOUROSIS FUGAX) + CONTRALATERAL ischemic attacks consisting of motor weakness CAROTID DOPPLER OR MRI/MRA
75
What type of infarct is generally mostly associated with MIXED TRANSCORTICAL APHASIA (-F,-C,-R)?
WATERSHED INFARCTS - 2/2 protracted hypotension and limits of supply of principal cerebral arteries is LIMITED/ HYPOPERFUSED -> Isolated infarcts in speech areas of FRONTAL (broca) and TEMPORAL (wernicke) areas
76
What type of infarct is generally mostly associated with ANOMIC APHASIA (+F,+C,+R)?
DIFFUSE BRAIN DYSFN - isolated word finding deficit
77
What are the typical features of CEREBELLAR INTRAPARENCHYMAL HEMORRHAGE?
OCCIPITAL HEADACHE (radiates to neck/shoulders) + NECK STIFFNESS (blood extends into 4th ventricle) + N/V over long duration of hours + NYSTAGMUS + IPSILATERAL HEMIATAXIA of trunk (vermis) and/or limbs (cerebellar hemispheres)

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