Wahba Part 3 - Seizure and Stroke Flashcards
TPA inclusion criteria based on time
0-4.5 hrs = IV TPA 0.9 mg/kg; 4.5-6 hrs = IA TPA; 3-8 hrs = mechanical embolectomy (8 in basilar artery, pt will be posturing need to go after with IA TPA?); >8 hrs = antiplatelets
If don’t meet TPA criteria
Give ASA (don’t give w/ TPA)
TPA inclusion criteria “SCANT
SEVERAL TIAs CLINICAL dx of stroke AGE > 18 NON-contrast CT TIME of onset
Exclusion criteria for TPA
NIH Score 185/110 post-tx, GI bleed/urinary hemorrhage w/in 3 weeks, heparin w/in 48 hrs, coumadin w/ INR1/3 of MCA, suspect SAH, arterial puncture w/in 7 days, LP w/in 7 days, plts 400, coma
TPA inclusion criteria based on NIH Stroke Scale
Score 4-28, give TPA; if
When to intubate
GCS
HOT VINTAGES (see chart)
Hereditary, Occupational, Trauma, Vascular, Infectious, Neoplastic, Toxic-Metabolic, Autoimmune, Gender-related, Electrical events, Secondary effects
VITAMINS
Vascular (Basilar artery, ICH, SAH, extradural hematoma, PE, MI, dissection), Infectious, Trauma, Autoimmune, Metabolic (DKA, myxedema coma), Inflammatory/Iatrogenic/Intoxication (intermittent recurrent stupor), Neoplastic, Sz/Stroke/Sychogenic
First step in management of status epilepticus
Ensure ABCs+give thiamine+dextrose, naloxone (stimulate respiratory centers); DON’T GIVE FLUMAZENIL unless you’re sure cause is BZD
Management of status epilepticus by stage
Premonitory phase = dizepam IV or rectal, repeat once 15 min later; Early status = IV lorazepam, repeat once after 10 min; Established status = phenobarbital bolus +/- phenytoin infusion, BZD for early control; Refractory SE = general anesthesia w/ thiopentone+artificial ventilation, don’t taper for 12 hrs
Causes in pts w/ seizure d/o history
Non-compliance w/ meds, alcohol
Causes in pts w/ NO seizure d/o history
“TITS MD” = Trauma, Infection, Tumor, Stroke, Metabolic/hypoxic, Drug OD/alcohol; check AED levels!
Dx of status epilepticus
EEG (pseudo-status has no EEG findings); titrate anesthesia in tx until burst suppression pattern achieved
Patient who do not need medical tx for epilepsy
Seizure after alcohol, stopped baclofen, TBI w/ no SAH or cracked skull, AED for 2 weeks and then off
Pts who need lifetime epilepsy tx
Brain tumor resected w/ radiation, HIV w/ low CD4 (first seizure)
Seizures that don’t need LP
Stops baclofen, alcohol overdose
Seizures that do need LP
Homeless man w/ DTs, new onset seizures
Etiology of epidural hematoma
Tear in meningeal artery, esp MCA, 15% injuries in dural sinus; posterior fossa = venous sinus torn
Progression of epidural hematoma
Immediate LOC, lucid interval, then relapse into coma
Diagnosis of epidural hematoma
Bulging convex pattern on CT
S+S of epidural hematoma
CL hemiparesis, dilated then nonresponsive ipsilateral pupil, CNS III compression+impending transtentorial herniation
Signs of hematoma in posterior fossa
Fracture of occipital bone, cerebellar signs, nuchal rigidity, drowsiness
Management of epidural hematoma
Stabilize+intubate and move to surgical interventions; cannot just do cerebral dehydration like elevation of head
Etiology of subdural hematoma
Stretching or tearing of veins that drain brain surfaces, blood w/in dural and arachnoid membranes, mostly located over lateral cerebral convexities; seen in elderly and alcoholics w/ cerebral atrophy and “hanging” veins
S+S of ACUTE subdural hematoma
Symptomatic w/in 72 hrs of injury, falls/assaults>MVA, ipsilateral pupillary dilatation, CL hemiparesis, false localizing signs (2/2 herniation and midbrain compression - Kernohan’s notch phenomenon)
S+S of CHRONIC subdural hematoma
Symptomatic 21 days after injury or later, pt>50, no trauma, 50% have hx of alcoholism or epilepsy and trauma; risk factors are overdrainage of VP shunt+coagulopathies
Etiologies of SAH
Rupture of aneurysm, AVM, trauma, vessel weakness (2/2 infection), coagulopathies
S+S of SAH
Sudden severe HA+photophobia, N/V, meningismus, severe hemorrhages, increased ICP (false localizing signs), decreased consciousness, papilledema, retinal hemorrhages, coexistent ICH, vasospasm; systemic – increase in HR, BP, and Temp, pulmonary edema, cardiac arrhythmias; AVM may presents w/ epilepsy
Dx of SAH
Get CT - can be negative w/ small bleeds; confirm with LP; spin down blood in CSF, exclude coagulopathies; do cerebral angio to find source of bleeding
Tx of SAH
Bed rest+analgesia+nimodipine
Prognosis of SAH
30-40% mortality in first few days, risk of re-bleed in first 6 weeks; complications - hydrocephalus
Etiology of ICH
HTN w/ microaneurysm (Charcot-Bouchard), bleeding tumors, AVM, vasculitis, amyloid, trauma
S+S of ICH
Focal neurological signs+Sz+increased ICP
Diagnosis of ICH
CT
Complications of ICH
Hydrocephalus and coning
Tx of ICH
anti-HTN drugs, anticonvulsants, correct coagulopathy, mannitol for increased ICP, surgical intervention for evacuation of hematoma and ventricular drainage
Etiology of cerebellar hemorrhage
HTN, AVMs, tumors
S+S of cerebellar hemorrhage
Sudden onset HA, inability to stand or walk independently; vomiting, meningismus, nystagmus, dysarthria, occasional ipsilateral facial+gaze palsy, ipsilateral appendicular incoordination
Prognosis of cerebellar hemorrhage
Depends on level of consciousness - higher the better
Surgical criteria for cerebellar hemorrhage
Hemorrhage > 3 cm = emergency surgery
Dx of cerebellar hemorrhage
CT, MRI, cerebral angiogram, coagulation studies
First part of MCA stem
First part supplies internal capsule+basal ganglia
S+S of MCA stem stroke
CL hemiparesis+sensory loss, hemonymous hemianopia, conjugate gaze paresis (eyes look toward lesion); dominant infarct = global aphasia, nondominant = impaired spatial perception+CL neglect
Superior division of MCA
Lateral frontal lobe+anterior lateral parietal lobe+insula
S+S of MCA superior division stroke
CL hemiparesis+sensory loss; face/arm>leg; spare internal capsule+topographic arrangement; weakness+sensory worse distally; paresis of CL gaze, NO homonymous hemianopia; dominant infarct = BROCA aphasia, nondominant = impaired spatial perception+CL neglect
Inferior division of MCA
Posterior lateral parietal lobe+lateral temporal lobe
S+S of MCA inferior division stroke
CL homonymous hemianopia/quadrantanopia, little or NO weakness/sensory loss/gaze paresis; dominant = WERNICKE aphasia, nondominant = CL neglect+impaired spatial perception+behavioral changes
ACA supplies what location?
Medial portion of frontal lobe
S+S of ACA stroke
Unilateral infarct = CL leg weakness+sensory loss (dist>prox), trouble initiating speech, urinary incontinence; BL infarct (incomplete circle of Willis);
Severe behavioral abnormalities in ACA stroke
AMPII = Akinetic muteness, Motor inertia, Psychomotor retardation, Incontinence, Increased muscle tone
ICA strokes
Can cause MCA, ACA syndromes; embolization to central retinal branch of opthalmic artery causes ipsilateral blindness (
S+S of ICA strokes
Varying degrees of CL weakness+sensory loss, homonymous hemianopia, aphasia or hemineglect; MCA-ACA borderzone - proximal arm/leg weakness+face sparing, stereotyped TIA
PCA supplies what location?
Prox part branches to midbrain+thalamus, cross tentorium, occipital lobe+inf medial temporal lobe
S+S of PCA strokes
Memory problems (BL stroke), CL homonymous hemianopia, macular sparing (w/ collaterals); dominant = inability to read; bilateral = complete cortical blindness/tunnel vision
Proximal occlusion of PCA
Thalamic infarction = CL sensory loss; Webber syndrome - midbrain infraction = CL hemiparesis+IPSI CN3 palsy
Basilar and vertebral arteries supply what?
Posterior fossa (brainstem + cerebellum)
S+S of vertebrobasilar syndromes
Diplopia+vertigo+HL+circumoral numbness+dysphagia+hiccups, N/V, LOC, bilateral symptoms, dysconjugate gaze, Horner’s syndrome, nystagmus, unilateral pharyngeal weakness, prominent ataxia, IPSI face+CL body weakness/sensory deficit
S+S of SCA infarct
Prominent dysarthria + IPSI limb+truncal ataxia + nystagmus (fast phase towards lesion)
S+S of AICA infarct
Affects lateral pons + anterolateral cerebellum
S+S of PICA infarct
Truncal ataxia + IPSI limb ataxia + acute vertigo + nystagmus, edema+hydrocephalus, brainstem compression+tonsillar herniation
S+S of basilar infarct
“Top of the basilar syndrome” = MB+thal+occipital+med temp lobes; impaired consciousness, perinaud syndrome = midsized+unreactive pupil, abnormal vertical gaze w/ convergence nystagmus (CN 6 spared), proximal basilar = locked in syndrome (pons infarct, spares midbrain)
Labs to get in cerebellar infarct
CBC, PT, PTT, BMP, cardiac enzymes, CT, MRI, US
Midbrain infarcts
CN 3, PCA (central)
Mid pons infarct
CN V, SCA (lateral)
Lower pons infarct
CN 6; paravertebral (central)
CN VII, AICA (lateral)
Upper medulla infarct
CN XII, spinal artery (central) Nucleus ambiguus (CN IX, X), PICA (lateral)
Etiology of lacunar stroke
Lenticulostriate branches of MCA supplies what?
Internal capsule + basal ganglia + corona radiata
S+S of pure motor hemiparesis
Affects CL internal capsule, face/arm/leg equally affected, no sensory loss/homonymous hemianopia/aphasia/hemineglect
Thalamoperforate branches of PCA supplies what?
Thalamus
S+S of pure sensory stroke
Affects thalamus, sensory loss on CL side, partial hemisensory defects possible, “pins and needles”, skin tightness; Dejerine-Roussy syndrome =severe intractable pain+allodynia (tx w/ gabapentin or TCA)
Paramedian penetrating branches of basilar artery supplies what?
Pons
S+S of sensorimotor stroke
Affects internal capsule+adjacent thalamus, CL weakness+sensory loss, absence of visual/language/cognitive disturbance
Ataxic hemiparesis
CL weakness+more severe limb ataxia; infarction of pons, internal capsule, or corona radiata
Dysarthria Clumsy Hand syndrome
Prominent dysarthria + ataxia of upper limb, facial weakness, dysphagia, varying degrees of weakness; infarct of internal capsule or pons
