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Foundations II-Neurology > Strokes- Vascular Disorders > Flashcards

Strokes- Vascular Disorders Flashcards

1
Q

A 64yo R. hand dominant female with a PMH including HTN and HLD awakes this morning with slurred speech and R. arm weakness. Her husband calls EMS and presents to your E.D. 30 minutes later. What is the next best step in the management of this pt?

A. CT scan of the head with contrast
B. CT scan of the head without contrast
C. Intravenous tPA administration stat
D. Echocardiogram for clot evaluation
E. MRI of the brain
A

B.CT of the head w/out contrast

we want to r/o ICH

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2
Q

What the protective layers of the brain? (Deep to SF)

A

PAD

Pia mater

Arachanoid mater

Dura Mater

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3
Q

Right side of your brain controls? Left side?

A

left side of your body

the right side of your body

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4
Q

Left brain functions?

A

usability/analytic

  • analytic thought
  • logic
  • language
  • science/math
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5
Q

Right brain functions?

A

design/creative

  • holistic though
  • intuition
  • creativity
  • art/music
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6
Q

What is a stroke?

A

sudden focal neuro deficit or acute neuro impairment caused by interruption of blood flow to a specific region of the brain

  • sudden brain damage
  • lack of blood flow
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7
Q

What are the two types of strokes?

A

Ischemic 85%

Hemorrhagic

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8
Q

What does FAST stand for?

A

Face drooping
Arm weakness
Speech difficulty
Time to call 911

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9
Q

What are some risk factors for stroke?

A

Modifiable: HTN, obesity, Afib, DM, cardiac disease, dyslipidemia, excess ETOH, smoking, stress, diet

Non-modifiable: age, gender, fam hx, ethnicity, vascular abn.

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10
Q

Who is more likely to have a stroke African Americans or caucasians? Hispanics?

A

African Americans twice as likely

Hispanics also more likely than caucasians and at younger age

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11
Q

Stroke =

A

brain attack!

time = tissue = brain

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12
Q

What is included in the Cincinnati pre-hospital stroke scale?

A
  • facial droop
  • arm drift
  • abn. speech (have pt say: you can’t teach an old dog new tricks

if 1/3 is +, chance of stroke is 72%

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13
Q

What should be included in pt hx?

A

incoordination, loss of vision (esp. unilateral), double vision, HA, last seen normal, sudden v. gradual onset

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14
Q

What is the National Institute of Health Stoke Scale (NIHSS)?

A

standard method to measure level of impairment caused by stoke

used to determine if disability is severe enough to use tPA

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15
Q

NIHSS interpretation

A

0: no stroke

1-4: minor stroke

5-15: moderate stroke

15-20: moderate/sever stroke

21-42: severe stroke

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16
Q

Which stroke pts have the best outcomes?

A

lacunar infarct pts

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17
Q

Describe ischemic stroke

A

clot occluding aa.

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18
Q

Describe intracerebral hemorrhage. Subarachnoid hemorrhage?

A

bleeding into brain

bleeding around the brain

both caused by a ruptured blood vessel in the brain

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19
Q

MC cause of thrombotic stroke? Other causes?

A

atherosclerosis

fibromuscular dysplasia, arteritis, dissection of vessel wall and hemorrhage into atheromatous plaque, hypercoagulability

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20
Q

What are the 2 main sources of emboli leading to embolic stroke?

A

left sided cardiac chambers

artery to artery stroke-detachment of thrombus from ICA at site of a plaque

many embolic strokes become hemorrhagic

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21
Q

Etiology of ischemic stroke?

A

large vessel disease
-atherosclerosis

small vessel disease
-lacunar infarction

cardioembolic
-most commonly afib

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22
Q

Describe acute ischemic stroke

A

sudden onset, focal neuro sxs, interruption in blood supply to a part of the brain

typically > 1 hr, permanent damage

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23
Q

Describe transient ischemic attack

A

sudden onset, focal neuro sxs, transient lack of blood supply and focal ischemia

<24 hrs
typically <1 hr, no permanent damage to the brain

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24
Q

% of pts who don’t report TIA?

A

50%

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25
Q

Definition of TIA?

A

a transient episode of neuro dysfunc. caused by focal brain, spinal cord or retinal ischemia w/out acute infarction

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26
Q

What is the ABCD2 score use for? What does it include

A

short term risk of stroke in pts after TIA

1-Age >60

1- BP >140/90 on first eval

2-focal weakness

1- speech impairment w/out weakness

2- > 60 mins

1- 10-59 mins

1- DM

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27
Q

Interpretation of ABCD2 score?

A

two day risk of stroke

0-3: 1%

4-5: 4 %

6-7: 8 %

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28
Q

Preferred dx test to eval for TIAs? What other tests should be done?

A

MRI, including DWI within 24 hrs of sxs

vessel imaging, cardiac eval (CA US, +/- catheter angiography, prolonged cardiac monitoring, TEE), routine blood test

29
Q

In a pts with suspected TIAs, TEE is useful in identifying…

A

PFO, aortic arch atherosclerosis, and valvular disease

30
Q

When can you hospitalize pts with TIA?

A

If present within 72 hours +

-ABCD score 3
or
-ABCD score 0-2 and uncertainty that dx work up can be done in the next 2 days
or
-ABCD sore 0-2 and there is other evidence that indicates pts event was caused by focal ischemia

31
Q

What is the penumbra?

A

zone of reversible ischemia around core of irreversible infarction- salvageable in first few hrs after ischemic stroke onset

32
Q

What damages the penumbra?

A

hypoperfusion, hyperglycemia, fever, seizure

33
Q

Should you lower BP in a pt having an acute ischemic stroke?

A

NO, high BP is a response not a cause

  • BP increases due to arterial occlusion
  • lowering BP starves penumbra, worsens outcomes
34
Q

What determines the extend of ischemic injury?

A

rate/duration of ischemic event

collateral circulation in involved area of the brain

systemic circulation & arterial BP

coagulation abnormalities

Temp

Glucose

35
Q

Brain tissue can be preserved if perfusion is restored within critical time period of…

A

2-4 hours

36
Q

What can happen if you suddenly restore blood flow to ischemic tissue?

A

hemorrhage (red infarcts) result when the fragile “ischemic” or injured” vessels rupture

37
Q

Pathophys of AIS & TIA?

A

usually thromboembolism (blood clot forms in vascular system, travels downstream, plugs cerebral a.)

38
Q

Acute therapy for AIS & TIA?

A

thrombolysis (or thrombectomy)

do NOT lower BP

39
Q

How can we prevent AIS & TIA?

A

antithrombotic therapy

vascular risk factor therapy

possible carotid endartectomy or angioplasty

40
Q

Window for tPA?

A

3-4.5 hours (but can give sooner than this)

look up contraindications!

41
Q

What are some contraindications for tPA?

A

> 80 y/o, on warfarin, NIHSS >25, lots more!

42
Q

timeline for a pt with AIS in the ED?

A

Triage -10 min

Med Care- 25 min

CT & labs- 45 min

Tx - 60 min

43
Q

What are some mechanical thrombolysis options?

A

can be used in adjunct with tPA

MERCI- corkscrew like apparatus designed to remove clots from vessels

PENUMBR system- aspirates clot

44
Q

What are some predictors of hemorrhagic transformation?

A

size of the infarction

Afib, NIHSS, hyperglycemia, thrombocytopenia

45
Q

Causes of hemorrhagic stroke?

A

Primary (70-90%): HTN

Secondary: vascular malformation

46
Q

manifestation of hemorrhagic stroke?

A

rupture of blood vessels with surrounding tissue damage

-sxs of increased ICP

47
Q

How do you dx hemorrhagic stroke? Plan?

A

noncontrast CT + for bleed

ICP monitoring, neurosurg intervention

48
Q

What does an AVM do? Why is this concerning?

A

directly diverts blood from the aa. to the vv. –> may bypass brain tissue and cause chronic ischemia

weakened wall –> dilation –> increased risk of rupture

49
Q

What is a cerebral aneurysm? Most common spots?

A

enlargement of blood vessel due to wall weakening

anterior communicating artery

posterior communicating artery

middle cerebral artery

50
Q

Tx of cerebral aneurysm?

A

endovascular
-coil embolization

surgery

51
Q

Causes of SAH?

A

aneurysm is circle of willis

AVM since birth (maybe familial)

52
Q

Presentation of SAH?

A

may have had prior bleeds or HAs

suddenly increases ICP

maybe associated with valsalva

53
Q

How do we dx SAH?

A

CT w/o contrast

LP > Xanthochromia (hemolyzed blood in CSF)

54
Q

How do we tx SAH?

A

decreased ICP with stool softeners, cough suppressants, anxiolytics, analgesics, antiemetics, keep HOB elevated
Treat/monitor vasospasm (CCB)

55
Q

Subdural hematomas are usually due to…

A

trauma

causes generalized neuro changes

56
Q

What does a epidural hematoma look like on CT? presentation?

A

a lemon

trauma, LOC +/- lucid then unconscious

57
Q

Which of the following is NOT associated with trauma?

concussion, subdural hematoma, epidural hematoma, SAH?

A

SAH

58
Q

Which of the following is NOT associated with LOC or focal deficits?

concussion, subdural hematoma, epidural hematoma, SAH?

A

concussion

59
Q

Which tests should be done for pt with suspected CVA?

A

1st tier: CBC, BMP, Glucose, PT/PTT, +/- ESR, EKG, non con CT head

2nd tier: CA dopper US, TTE/TEE, MRI/MRA, LP, cerebral angiogram

60
Q

For diabetes with acute stroke, what is the goal inpatient blood sugar?

A

<150

peri-stroke hyperglycemia is associated with worse outcomes

61
Q

How do we prevent complications in CVA pts?

A

Aspiration- NPO until swallowing eval

DVT- compression devices or Heparin

UTI- avoid foley caths

Consitipation- laxative- docusate for all

UGI bleeds- beta 2 receptor antagonist PPI

Fever- acetaminophen + abx PRN

62
Q

How many pts suffer from post stroke depression?

A

50% of stroke pts

often resolves within 1 yr

SSRIs generally effective, but if pt takes Warfarin: Escitalopram (Lexapro), Citalopram, Sertaline

63
Q

When is carotid endarterectomy (CEA) beneficial for secondary stroke prevention?

A

if 70-99% stenosis

some benefit if 50-69% stenosis

benefits greatest in: men, older pts, recent cerebral ischemia, ulcerated plaque

64
Q

Who should have carotid angioplasty/stenting?

A

only high risk pts

65
Q

Risks of CEA v. stenting

A

CEA lower risk of: periprocedural stroke or death, less risk of restenosis

stenting lower risk of: cranial nerve injury, MI

66
Q

Who should get a statin for secondary stroke prevention?

A

EVERYONE, regardless of cholesterol

67
Q

What drugs should pts avoid to prevent secondary stroke?

A

Estrogen

Sympathomimetic agents (decongestants, diet pills)

NSAIDS

PPIs (if taking Plavix)

68
Q

What are some stroke mimics?

A

encephalitis

HTN encephalopathy: HA, delirium, HTN, cerebral edema

Hypoglycemia: DM, low BG, decreased LOC

Migraine

Seizures

Stroke reactivation

TIA

Toxic/metabolic

tumor

Conversion disorder/psychogenic

Foundations II-Neurology (9 decks)

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