Stroking Flashcards
Stroke Demo age race sex comorbid conditions
old
AA
male
HTN, Smoking, DM, CAD/CHF, Afib, carotid stenosis
Embolic stroke
clot dislodges, sudden onset (usually afib) usually at MCA
Thrombotic stroke
systemic vascular dz
gradual onset, narrowing
most common ischemic
wake up with symptoms
Lacunar stroke
small vessels- putamen, thalamus (pure sensory stroke) internal capsule (pure motor stroke)
associated with HTN
Hemorrahagic
burst vessel HTN or berry aneurysm
Subarachnoid hemorrhage
common cause
common location
description
deep hemorrhage
berry aneurysm
AComm (ant communicating), 2nd PComm (CN3 compression, parasympathetic blown pupil before motor changes)
“worst headache of my life”
Hunt and Hess Scale
for SAH
- nl
- HA + stiff neck
- HA + stiff neck + confusion
- drunk / hemiparesis
- coma
Intracranial hemorrhage ICH
HTN => vessel burst
sudden onset at rest n/v/ seizures
usually at putamen
contralateral hemiplegia
Acute stroke management
ABCs CTH w/o contrast (r/o hemorrhagic) ASA 325mg BP control if seizure IV lorazepam or phenytoin/ fosphenytoin Keel ICP <20mmg Hg CPP > 60mmHg CCP = MAP-ICP hypervent, IV mannitol, elecate HOB, hypthermia, Burr hole
BP control
Ischemic
Hemorrhagic
SBP<220
SBP>180
When tPA?
criteria
<3hrs adult neg CTH SBP<185 plt >100k Stroke <1/3 MCA
Acute stroke special consideration for SAH/ICH
Reduce strain keep SBP<180 Stool softener ICP <20 Nimodipine x21 days (decrease intracranial vasospasms due to blood irritation) clip/coil aneurysm or remove AVM
Imaging studies for stroke.
Initial?
Work up?
last resort?
CTH w/o contrast
MRI/MRA T2 (H2O- white)
TTE/TEE, carotid a. US
Lumbar - xanthochromia
Chronic stroke management 2ndary prevention AC and AP cardiac embolism thrombotic thrombotic from carotid carotid >70%
Afib: Warfarin INR 2-3 or riveroxaban, apixaban, dabigatran.
Thrombotic stroke: ASA 81mg
Thromboembolism from carotid stenosis ASA and dipyridamole
Carotid stenosis>70% and symptomatic: carotid enarterectomy CEA
Territories
anterior cerebral artery (ACA)
frontal= executive function, personality
LEs (distal> proximal)
bowel and bladder incontinence
Territories
meddle cerebral artery (MCA)
Face and UEs
L MCA = parietal dominant language
R MCA = parietal spatial perceptions (L hemi neglect with intact language)
Superior MCA = Broca’s- expressive aphasia and UE weakness
Inferior MCA= Wernicke’s- receptive aphasia or hemineglect
usually due to cardiac emboli- afib
Territories
posterior cerebral artery (PCA)
occiput: visual cortices
cerebellar
CSF flow
choroid plexus (lat ventricle) - down foramen of menro to 3rd ventricle- down cerebral aqueduct to 4th ventricle- divides to lateral foramen Luschka or medial foramen Magendie- down spinal cord, loops back up
Rule of 4 for brain stem
- 4 CN nuclei per structure: Midbrain, Pons, Medulla
- 4 Ms medial
1. Motor (corticospinal tract)
2. medial lemniscus (touch, vibration, proprioception)
3. Medial longitudinal fasciculus (MLF)- common in MS pt
4. Motor CN 3, 4, 6, 12 - 4 S= Side (lateral)
1. Spinothalamic tract (pain and temp) contralateral loss in body
2. Spinocerebellar: ipsilateral cerebellar ataxia
3. sensory nucleus of CN 5 (loss of pain and temp in face ipsi)
4. Sympathetic pathway (ipsi Horner’s syndrome)
3 components of aphasia
fluency, comprehension, repeating
Broca- expressive aphasia
location
definition
L inf frontal gyrus
nonfluent, comprehends, cannot repeat
transcortical motor aphsia
nonfluent, comprehend an repeat
broca’s but you can repeat
Wernicke aphasia
word salad
fluent, no comprehension, cannot repeat
Transcortical sensory
fluent, no comprehension, can repeat
conduction aphasia
Damage to arcuate faciculus
fluent, can comprehend, cannot repeat
anomia
cannot repeat
Anton syndrome
PCA lesion
b/l visual cortex stroke/ blindness and denial of blindness
lacunar stroke post limb of internal capsule/ corona radiata thalamus basal ganglia pontine
pure stroke (motor or sensory)
corona radiata= contralateral hemiplesia (pure motor)
thal= contralateral numbness (pure sensory) w/ neuropathic pain hard to tx
basal ganglia- contralateral hemiballismus (subthalamic nucleus) or contralateral hemichoria (caudate nucleus)
pontine: contralateral dysarthia/ clumsy hand syndrome
Brainstem stroke does not have…
no aphasia
no cog deficit
no personally d/o
Wallenberg syndrome
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