TIAs, Strokes, Intracerebral AVM, Aneurysms Flashcards
how to differentiate stroke from TIA
- stroke: deficity > 24 hrs, infarction present on imaging
- TIA: deficity is only minutes to hrs; no infarction on imaging
what is RIND?
reversible ischemic neurologic deficit
what causes RIND
due to occlusion of blood supply to the brain leading to ischemia which recovers from 1d to a few wks
what 2 things keep the brain happy?
oxygen & glucose
what does the frontal lobe control?
7
- planning
- reasoning
- personality
- personality
- emotions
- motor functions
- motor speech area (Broca)
what does the parietal lobe control?
6
- sensory info/processing
- taste/temp/pain
- understanding language
- memory
- reading/writing
- spatial awareness
what does the temporal lobe control?
7
- memory functions
- speaking/understanding written/verbal material
- hearing
- facial recognition
- learning
- Wernicke’s area
- seizures
what does the occipital lobe control?
- primary visual cortex is at the rear of this lobe
- controls vision and visual processing
what is involved with anterior circulation
- anterior cerebral artery and middle cerebral artery
- they branch off of the internal carotid arteries
what is involved w/ posterior plumbing
- posterior cerebral artery branches from the vertebral/basilar arteries
how do pts w/ stroke or TIA usually present
6
- abrupt sx onset
- hemiparesis
- speech disturbance
- sensory loss
- visual field defect
- ataxia/coordination
ACA stroke sx
3
- usually occurs with MCA stroke
- contralateral motor and sensory
- leg more affected than the arm
MCA stroke sx
3
- contralateral weakness to the face and arm
- contralateral sensory loss
- aphasia if dominant hemisphere
PCA stroke sx
9
- contralateral visual field defect
- MILD contralateral motor/sensory deficit
- dysarthria
- diplopia
- dizziness
- dysphagia
- decreased LOC
- ataxia
- disturbed hearing
what is in the brainstem
midbrain, pons, medulla
what does the brainstem control?
7
- breathing
- heart rate
- temperature
- swallowing
- weakness
- paralysis
- consciousness
Brain Stem Events
non modifiable risk factors
4
- age
- male gender
- race
- family hx
Brain Stem Events
modifiable risk factors
5
- HTN
- dyslipidemia
- CAD
- hypercoagulability
- diabetes
Brain Stem Events
behavioral risk factors
6
- smoking
- alcohol
- obesity
- physical inactivity
- illicit drug use
- OCPs ONLY if also smoker
what should you always order first?
CT
What will CT show?
subtle indicators of infarction within 6 hrs of stroke onset
Ischemic Stroke
what % of strokes are this kind?
~85%
Ischemic Stroke
how did the stroke occur if it is thrombotic?
produces stroke by reduced blood flow or by fragment carotid arteries, plaque build up and rupture. Usually a unilateral pattern
Ischemic Stroke
what causes small vessel strokes?
- HTN
- DM
- atherosclerosis
Ischemic Stroke
how did the stroke occur if it is embolic?
- most likely a cardiac source (a. fib, PFO, valvular disease, artery to artery embolism)
- bilateral appearance
Ischemic Stroke
how did the stroke occur if it was in a large vessel?
atherothrombosis most common pathology
Hemorrhagic Strokes
what to order?
- CT without contrast
- Blood will “light up” on CT
Intracerebral Hemorrhage
Risk Factors
6
- HTN
- Arteriovenous Malformation
- Ruptured Aneurym
- Coagulopathy
- Eclampsia
- Trauma
Subarachnoid Hemorrhage
Sx
6
- thunder clap headache
- “worst headache of my life”
- nausea/vomiting
- decreased LOC
- nuchal ridigity
- seizures
Subarachnoid Hemorrhage
Primary Cause
arterial aneurysm
Subarachnoid Hemorrhage
Other Risk Factors
4
- AVM
- bleeding disorders
- trauma
- illicit drug use
Subarachnoid Hemorrhage
Risk factors for arterial aneurysm
5
- HTN
- EtOH
- Family Hx of SAH
- Family Hx of connective tissue disorder
- personal previous SAH
Subarachnoid Hemorrhage
FAST acronym
- F: facial drooping
- A: arm has pronator drift
- S: speech is slurred, abnormal, dysarthric, or absent
- T: time is “last known well”
Subarachnoid Hemorrhage
Immediate Management
- CT brain stroke protocol ASAP
- if bleeding: control BP, OACs, seizure prophylaxis, neurosurgery consult
- if no bleed: tPA? thrombectomy? ASA, VTE prophylaxis? further work up
Subarachnoid Hemorrhage
Monitoring
- closely monitor vitals
- monitor mental status, speech changes
- fundoscopic, cardiac, and neurologic exams
Subarachnoid Hemorrhage
imaging to consider?
6
- brain CT w/out contrast
- CTA of head/neck
- MRI of the brain (once admitted)
- EKG
- echo w/ bubble study
- carotid US
Subarachnoid Hemorrhage
lab testing to order
5
- cardiac enzymes
- CBC w/ diff
- coag studies
- blood type & screen
- metabolic panel
Subarachnoid Hemorrhage
inclusion criteria for IV tPA
3
- clinical dx w/ measureable deficit
- age > 18 y/o
- sx since < 4.5 hrs
Subarachnoid Hemorrhage
pmhx exclusion criteria for IV tPA
4
- stroke/head trauma in last 3 mo
- recent head/spine surgery
- prior IC hemorrhage, malignancy, AVM, aneurysm
- incompressible arterial puncture last 7d
Subarachnoid Hemorrhage
clinical exclusion criteria for IV tPA
- SAH
- BP > 185 / > 110
- blood glucose < 50
- active internal bleeding
Subarachnoid Hemorrhage
heme exclusion criteria for IV tPA
- Plt < 100 K
- current A/C (coumadin with INR > 1.7)
- therapetic heparin w/ in 48 hrs w/ elevated PTT
- DOACs within 48 hrs
what is a thrombectomy
a procedure to remove a blood clot from a blood vessel using a catheter and a clot retriever
how many brain cells die each minute a strok goes untreated?
2 million
Subarachnoid Hemorrhage
surgical options
- carotid endarterectomy
- carotid stents per vascular surgeon
Subarachnoid Hemorrhage
if embolic, when are warfarin or apixaban indicated?
- a. fib
- mitral stenosis
- prosthetic cardiac valve
- LV thrombi
- atrial myxoma
Subarachnoid Hemorrhage
what can you use as adjunct w/ warfarin? until what?
- heparin
- INR therapeutic (2.0 to 3.0)
Subarachnoid Hemorrhage
what meds don’t require bridging or monitoring?
NOACs
Subarachnoid Hemorrhage
if event was thrombotic or lacunar and the pt was not on anti-platelet meds at presentation what are they discharged on?
ASA 81mg PO QD
Subarachnoid Hemorrhage
if the pt was on ASA and had a stroke then what are they discharged on?
- overlap 21d with ASA 81 mg PO QD and Plavix 75 mg PO QD
- Plavix only after 21d
Subarachnoid Hemorrhage
how long to delay ASA if pt received tPA? what does CT need to confirm?
- hold ASA for 24 hr
- CT confirms no hemorrhagic transformation
Subarachnoid Hemorrhage
Hypertensive Tx- when to treat?
- all tPA candidates if BP > 185/110
- everyone if BP > 220/120
- HTN w/ end organ damage
Subarachnoid Hemorrhage
hypertensive in patient tx
- labetolol
- nicardipine
Subarachnoid Hemorrhage
Post stroke therapies
not meds….
- physical therapy
- occupational therapy
- speech therapy
Subarachnoid Hemorrhage
secondary prevention
6
- control risk factors
- comply w/ treatment
- lifestyle modifications
- statins
- DM control
- HTN control
Subarachnoid Hemorrhage
what lifestyle mods should be performed for secondary prevention?
- exercise
- mediterranean diet
- smoking cessation
- EtOH cessation
