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Wahba Notes > Wahba Part 3 - Seizure and Stroke > Flashcards

Wahba Part 3 - Seizure and Stroke Flashcards

1
Q

TPA inclusion criteria based on time

A

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

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2
Q

If don’t meet TPA criteria

A

Give ASA (don’t give w/ TPA)

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3
Q

TPA inclusion criteria “SCANT

A 
SEVERAL TIAs
CLINICAL dx of stroke
AGE > 18
NON-contrast CT
TIME of onset
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4
Q

Exclusion criteria for TPA

A

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

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5
Q

TPA inclusion criteria based on NIH Stroke Scale

A

Score 4-28, give TPA; if

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6
Q

When to intubate

A

GCS

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7
Q

HOT VINTAGES (see chart)

A

Hereditary, Occupational, Trauma, Vascular, Infectious, Neoplastic, Toxic-Metabolic, Autoimmune, Gender-related, Electrical events, Secondary effects

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8
Q

VITAMINS

A

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

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9
Q

First step in management of status epilepticus

A

Ensure ABCs+give thiamine+dextrose, naloxone (stimulate respiratory centers); DON’T GIVE FLUMAZENIL unless you’re sure cause is BZD

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10
Q

Management of status epilepticus by stage

A

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

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11
Q

Causes in pts w/ seizure d/o history

A

Non-compliance w/ meds, alcohol

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12
Q

Causes in pts w/ NO seizure d/o history

A

“TITS MD” = Trauma, Infection, Tumor, Stroke, Metabolic/hypoxic, Drug OD/alcohol; check AED levels!

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13
Q

Dx of status epilepticus

A

EEG (pseudo-status has no EEG findings); titrate anesthesia in tx until burst suppression pattern achieved

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14
Q

Patient who do not need medical tx for epilepsy

A

Seizure after alcohol, stopped baclofen, TBI w/ no SAH or cracked skull, AED for 2 weeks and then off

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15
Q

Pts who need lifetime epilepsy tx

A

Brain tumor resected w/ radiation, HIV w/ low CD4 (first seizure)

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16
Q

Seizures that don’t need LP

A

Stops baclofen, alcohol overdose

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17
Q

Seizures that do need LP

A

Homeless man w/ DTs, new onset seizures

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18
Q

Etiology of epidural hematoma

A

Tear in meningeal artery, esp MCA, 15% injuries in dural sinus; posterior fossa = venous sinus torn

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19
Q

Progression of epidural hematoma

A

Immediate LOC, lucid interval, then relapse into coma

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20
Q

Diagnosis of epidural hematoma

A

Bulging convex pattern on CT

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21
Q

S+S of epidural hematoma

A

CL hemiparesis, dilated then nonresponsive ipsilateral pupil, CNS III compression+impending transtentorial herniation

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22
Q

Signs of hematoma in posterior fossa

A

Fracture of occipital bone, cerebellar signs, nuchal rigidity, drowsiness

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23
Q

Management of epidural hematoma

A

Stabilize+intubate and move to surgical interventions; cannot just do cerebral dehydration like elevation of head

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24
Q

Etiology of subdural hematoma

A

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

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25
Q

S+S of ACUTE subdural hematoma

A

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)

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26
Q

S+S of CHRONIC subdural hematoma

A

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

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27
Q

Etiologies of SAH

A

Rupture of aneurysm, AVM, trauma, vessel weakness (2/2 infection), coagulopathies

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28
Q

S+S of SAH

A

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

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29
Q

Dx of SAH

A

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

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30
Q

Tx of SAH

A

Bed rest+analgesia+nimodipine

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31
Q

Prognosis of SAH

A

30-40% mortality in first few days, risk of re-bleed in first 6 weeks; complications - hydrocephalus

32
Q

Etiology of ICH

A

HTN w/ microaneurysm (Charcot-Bouchard), bleeding tumors, AVM, vasculitis, amyloid, trauma

33
Q

S+S of ICH

A

Focal neurological signs+Sz+increased ICP

34
Q

Diagnosis of ICH

A

CT

35
Q

Complications of ICH

A

Hydrocephalus and coning

36
Q

Tx of ICH

A

anti-HTN drugs, anticonvulsants, correct coagulopathy, mannitol for increased ICP, surgical intervention for evacuation of hematoma and ventricular drainage

37
Q

Etiology of cerebellar hemorrhage

A

HTN, AVMs, tumors

38
Q

S+S of cerebellar hemorrhage

A

Sudden onset HA, inability to stand or walk independently; vomiting, meningismus, nystagmus, dysarthria, occasional ipsilateral facial+gaze palsy, ipsilateral appendicular incoordination

39
Q

Prognosis of cerebellar hemorrhage

A

Depends on level of consciousness - higher the better

40
Q

Surgical criteria for cerebellar hemorrhage

A

Hemorrhage > 3 cm = emergency surgery

41
Q

Dx of cerebellar hemorrhage

A

CT, MRI, cerebral angiogram, coagulation studies

42
Q

First part of MCA stem

A

First part supplies internal capsule+basal ganglia

43
Q

S+S of MCA stem stroke

A

CL hemiparesis+sensory loss, hemonymous hemianopia, conjugate gaze paresis (eyes look toward lesion); dominant infarct = global aphasia, nondominant = impaired spatial perception+CL neglect

44
Q

Superior division of MCA

A

Lateral frontal lobe+anterior lateral parietal lobe+insula

45
Q

S+S of MCA superior division stroke

A

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

46
Q

Inferior division of MCA

A

Posterior lateral parietal lobe+lateral temporal lobe

47
Q

S+S of MCA inferior division stroke

A

CL homonymous hemianopia/quadrantanopia, little or NO weakness/sensory loss/gaze paresis; dominant = WERNICKE aphasia, nondominant = CL neglect+impaired spatial perception+behavioral changes

48
Q

ACA supplies what location?

A

Medial portion of frontal lobe

49
Q

S+S of ACA stroke

A 
Unilateral infarct = CL leg weakness+sensory loss (dist>prox),  trouble initiating speech, urinary incontinence;
BL infarct (incomplete circle of Willis);
50
Q

Severe behavioral abnormalities in ACA stroke

A

AMPII = Akinetic muteness, Motor inertia, Psychomotor retardation, Incontinence, Increased muscle tone

51
Q

ICA strokes

A

Can cause MCA, ACA syndromes; embolization to central retinal branch of opthalmic artery causes ipsilateral blindness (

52
Q

S+S of ICA strokes

A

Varying degrees of CL weakness+sensory loss, homonymous hemianopia, aphasia or hemineglect; MCA-ACA borderzone - proximal arm/leg weakness+face sparing, stereotyped TIA

53
Q

PCA supplies what location?

A

Prox part branches to midbrain+thalamus, cross tentorium, occipital lobe+inf medial temporal lobe

54
Q

S+S of PCA strokes

A

Memory problems (BL stroke), CL homonymous hemianopia, macular sparing (w/ collaterals); dominant = inability to read; bilateral = complete cortical blindness/tunnel vision

55
Q

Proximal occlusion of PCA

A

Thalamic infarction = CL sensory loss; Webber syndrome - midbrain infraction = CL hemiparesis+IPSI CN3 palsy

56
Q

Basilar and vertebral arteries supply what?

A

Posterior fossa (brainstem + cerebellum)

57
Q

S+S of vertebrobasilar syndromes

A

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

58
Q

S+S of SCA infarct

A

Prominent dysarthria + IPSI limb+truncal ataxia + nystagmus (fast phase towards lesion)

59
Q

S+S of AICA infarct

A

Affects lateral pons + anterolateral cerebellum

60
Q

S+S of PICA infarct

A

Truncal ataxia + IPSI limb ataxia + acute vertigo + nystagmus, edema+hydrocephalus, brainstem compression+tonsillar herniation

61
Q

S+S of basilar infarct

A

“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)

62
Q

Labs to get in cerebellar infarct

A

CBC, PT, PTT, BMP, cardiac enzymes, CT, MRI, US

63
Q

Midbrain infarcts

A

CN 3, PCA (central)

64
Q

Mid pons infarct

A

CN V, SCA (lateral)

65
Q

Lower pons infarct

A

CN 6; paravertebral (central)

CN VII, AICA (lateral)

66
Q

Upper medulla infarct

A 
CN XII, spinal artery (central)
Nucleus ambiguus (CN IX, X), PICA (lateral)
67
Q

Etiology of lacunar stroke

A
68
Q

Lenticulostriate branches of MCA supplies what?

A

Internal capsule + basal ganglia + corona radiata

69
Q

S+S of pure motor hemiparesis

A

Affects CL internal capsule, face/arm/leg equally affected, no sensory loss/homonymous hemianopia/aphasia/hemineglect

70
Q

Thalamoperforate branches of PCA supplies what?

A

Thalamus

71
Q

S+S of pure sensory stroke

A

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)

72
Q

Paramedian penetrating branches of basilar artery supplies what?

A

Pons

73
Q

S+S of sensorimotor stroke

A

Affects internal capsule+adjacent thalamus, CL weakness+sensory loss, absence of visual/language/cognitive disturbance

74
Q

Ataxic hemiparesis

A

CL weakness+more severe limb ataxia; infarction of pons, internal capsule, or corona radiata

75
Q

Dysarthria Clumsy Hand syndrome

A

Prominent dysarthria + ataxia of upper limb, facial weakness, dysphagia, varying degrees of weakness; infarct of internal capsule or pons

Wahba Notes (4 decks)

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