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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
Definition of TIA?
a transient episode of neuro dysfunc. caused by focal brain, spinal cord or retinal ischemia w/out acute infarction
26
What is the ABCD2 score use for? What does it include
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
27
Interpretation of ABCD2 score?
two day risk of stroke 0-3: 1% 4-5: 4 % 6-7: 8 %
28
Preferred dx test to eval for TIAs? What other tests should be done?
MRI, including DWI within 24 hrs of sxs vessel imaging, cardiac eval (CA US, +/- catheter angiography, prolonged cardiac monitoring, TEE), routine blood test
29
In a pts with suspected TIAs, TEE is useful in identifying...
PFO, aortic arch atherosclerosis, and valvular disease
30
When can you hospitalize pts with TIA?
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
What is the penumbra?
zone of reversible ischemia around core of irreversible infarction- salvageable in first few hrs after ischemic stroke onset
32
What damages the penumbra?
hypoperfusion, hyperglycemia, fever, seizure
33
Should you lower BP in a pt having an acute ischemic stroke?
NO, high BP is a response not a cause - BP increases due to arterial occlusion - lowering BP starves penumbra, worsens outcomes
34
What determines the extend of ischemic injury?
rate/duration of ischemic event collateral circulation in involved area of the brain systemic circulation & arterial BP coagulation abnormalities Temp Glucose
35
Brain tissue can be preserved if perfusion is restored within critical time period of...
2-4 hours
36
What can happen if you suddenly restore blood flow to ischemic tissue?
hemorrhage (red infarcts) result when the fragile "ischemic" or injured" vessels rupture
37
Pathophys of AIS & TIA?
usually thromboembolism (blood clot forms in vascular system, travels downstream, plugs cerebral a.)
38
Acute therapy for AIS & TIA?
thrombolysis (or thrombectomy) do NOT lower BP
39
How can we prevent AIS & TIA?
antithrombotic therapy vascular risk factor therapy possible carotid endartectomy or angioplasty
40
Window for tPA?
3-4.5 hours (but can give sooner than this) look up contraindications!
41
What are some contraindications for tPA?
>80 y/o, on warfarin, NIHSS >25, lots more!
42
timeline for a pt with AIS in the ED?
Triage -10 min Med Care- 25 min CT & labs- 45 min Tx - 60 min
43
What are some mechanical thrombolysis options?
can be used in adjunct with tPA MERCI- corkscrew like apparatus designed to remove clots from vessels PENUMBR system- aspirates clot
44
What are some predictors of hemorrhagic transformation?
size of the infarction Afib, NIHSS, hyperglycemia, thrombocytopenia
45
Causes of hemorrhagic stroke?
Primary (70-90%): HTN Secondary: vascular malformation
46
manifestation of hemorrhagic stroke?
rupture of blood vessels with surrounding tissue damage -sxs of increased ICP
47
How do you dx hemorrhagic stroke? Plan?
noncontrast CT + for bleed ICP monitoring, neurosurg intervention
48
What does an AVM do? Why is this concerning?
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
What is a cerebral aneurysm? Most common spots?
enlargement of blood vessel due to wall weakening anterior communicating artery posterior communicating artery middle cerebral artery
50
Tx of cerebral aneurysm?
endovascular -coil embolization surgery
51
Causes of SAH?
aneurysm is circle of willis AVM since birth (maybe familial)
52
Presentation of SAH?
may have had prior bleeds or HAs suddenly increases ICP maybe associated with valsalva
53
How do we dx SAH?
CT w/o contrast LP > Xanthochromia (hemolyzed blood in CSF)
54
How do we tx SAH?
decreased ICP with stool softeners, cough suppressants, anxiolytics, analgesics, antiemetics, keep HOB elevated Treat/monitor vasospasm (CCB)
55
Subdural hematomas are usually due to...
trauma causes generalized neuro changes
56
What does a epidural hematoma look like on CT? presentation?
a lemon trauma, LOC +/- lucid then unconscious
57
Which of the following is NOT associated with trauma? concussion, subdural hematoma, epidural hematoma, SAH?
SAH
58
Which of the following is NOT associated with LOC or focal deficits? concussion, subdural hematoma, epidural hematoma, SAH?
concussion
59
Which tests should be done for pt with suspected CVA?
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
For diabetes with acute stroke, what is the goal inpatient blood sugar?
<150 peri-stroke hyperglycemia is associated with worse outcomes
61
How do we prevent complications in CVA pts?
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
How many pts suffer from post stroke depression?
50% of stroke pts often resolves within 1 yr SSRIs generally effective, but if pt takes Warfarin: Escitalopram (Lexapro), Citalopram, Sertaline
63
When is carotid endarterectomy (CEA) beneficial for secondary stroke prevention?
if 70-99% stenosis some benefit if 50-69% stenosis benefits greatest in: men, older pts, recent cerebral ischemia, ulcerated plaque
64
Who should have carotid angioplasty/stenting?
only high risk pts
65
Risks of CEA v. stenting
CEA lower risk of: periprocedural stroke or death, less risk of restenosis stenting lower risk of: cranial nerve injury, MI
66
Who should get a statin for secondary stroke prevention?
EVERYONE, regardless of cholesterol
67
What drugs should pts avoid to prevent secondary stroke?
Estrogen Sympathomimetic agents (decongestants, diet pills) NSAIDS PPIs (if taking Plavix)
68
What are some stroke mimics?
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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