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S4- Neuro 1 > Week 1- CVA Introduction and Pathophysiology > Flashcards

Week 1- CVA Introduction and Pathophysiology Flashcards

1
Q

PART 1: INTRO AND BACKGROUND

A

PART 1: INTRO AND BACKGROUND

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2
Q

What is a stroke?

A

Event unique to CNS when there is a stoppage of blood supply to vital neurons leading to loss of O2 and nutrients. This leads to irreversible neuronal death and subsequent neurological symptoms.

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3
Q

What are the 2 ways a stroke can happen?

A
  • blockage

- hemorrhage

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4
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5
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7
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8
Q

PART 2: RISK FACTORS

A

PART 2: RISK FACTORS

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9
Q

__-__% of strokes are preventable.

A

80-91%

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10
Q

What are the non-modifiable risk factors associated with strokes?

A
  • Women > Men (early menopause, pregnancy)
  • Age > 55 (x2 risk every decade after age 55)
  • Race (minorities higher risk)
  • Prior Stroke, TIA, and/or MI
  • Genetics
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11
Q

What is the most common modifiable risk factor for strokes?

A

HYPERTENSION (>140/90)

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12
Q
  • What is the primary intervention for BP?

- What else can be done?

A

-Medications

  • Diet (Na restriction)
  • Minimize alcohol
  • Minimize dairy
  • Aerobic activity
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13
Q

What are the (3) most common modifiable risk factors for stroke?

A
  • HTN
  • Diabetes
  • CV Disease
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14
Q

Is the association between diabetes and strokes higher in males or females?

A

Females

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15
Q

What are some other modifiable risk factors for stroke?

A
  • Obesity
  • Obstructive Sleep Apnea
  • Physical Inactivity
  • Diet
  • Blood Disorders
  • Arrhythmias
  • Hyperglycemia
  • Smoking
  • Alcohol
  • Recreational Drug Use
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16
Q

Obesity is defined as a BMI>__.

A

30

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17
Q

What is obstructive sleep apnea?

A
  • When going to bed, you don’t do as good a job at getting O2 through the body. People often enter state of hypoxia when asleep.
  • Severe obstructive sleep apnea is associated with a 2x risk of stroke.
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18
Q

Obstructive sleep apnea is associated with ____-__ strokes.

A

wake-up strokes due to shift in O2 utilization

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19
Q

Is malnutrition associated with increased risk of stroke?

A

Yes

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20
Q

What types of blood disorders are associated with increased risk of stroke?

A

Ones that increase risk of clotting.

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21
Q
  • What is the biggest Arrhythmia associated with stroke?

- It increases your risk for stroke _x.

A
  • Atrial fibrillation (a.fib)

- 5x

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22
Q

Current smokers have a _-_x increased risk compared with non-smokers or people who quit more than 10 years ago.

A

-2-4x

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23
Q

Can alcohol be preventative for strokes?

A

Yes, 2 drinks for men and 1 for women. After that the risk goes up with ischemic strokes.

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24
Q

PART 3: TYPES OF STROKE AND ISCHEMIC CASCADE

A

PART 3: TYPES OF STROKE AND ISCHEMIC CASCADE

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25
Q

Strokes are classified by what 2 things?

A
  • Mechanism (why)

- Location

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26
Q

What are the 2 mechanisms for strokes?

A
  • Ischemic- Clot blocks blood flow to an area of the brain.

- Hemorrhage- Bleeding occurs inside or around brain tissue.

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27
Q

What is the most common form of stroke?

A

Ischemic (70-80%)

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28
Q

What is the cause of ischemic strokes?

-What are 2 types of ischemic strokes?

A
  • Atherosclerosis- Gradual worsening of fatty deposits lining arterial walls.
  • Thrombotic and embolic
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29
Q

What is the difference between thrombotic and embolic strokes?

A
  • Thrombotic strokes are caused by a blood clot that develops in the blood vessels inside the brain.
  • Embolic strokes are caused by a blood clot or plaque debris that develops elsewhere in the body and then travels to one of the blood vessels in the brain through the bloodstream.
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30
Q

Is a thrombotic or embolic stroke more common?

A

Thrombotic are most common types of stroke.

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31
Q

What is the main cause of embolic strokes?

A

A-fib (known to cause clots in heart)

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32
Q

What percentage of strokes are Hemorrhagic strokes?

A

20-30%

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33
Q

What is the cause of Hemorrhagic strokes?

A

Rupture of artery due to weakening of vessel wall.

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34
Q
  • What are the 2 types of Hemorrhagic strokes?

- Which is more common?

A
  • Intracerebral Hemorrhage (ICH)
  • Subarachnoid Hemorrhage (SAH)

-ICH more common

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35
Q

What is the number 1 cause of ICH?

A

HTN

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36
Q

What is the number 1 cause of SAH and what is it?

A
  • Aneurysm- enlargement/ballooning of weakened vessel wall (typically asymptomatic until rupture)
  • Arteriovenous Malformation (AVM)- tangle of abnormal blood vessels connecting arteries and veins
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37
Q
  • AVMs are __________.

- What are the symptoms of AVM?

A
  • Congenital

- Seizures, HA, weakness, speech and vision, OR can be asymptomatic

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38
Q

What is a Transient Ischemic Attack (TIA)?

A
  • Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.
  • Known as “mini stroke” or “warning stroke”
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39
Q

Patients who have had a TIA are at a __x increased chance for eventual CVA. The highest risk for stroke is in the first ___ days post TIA.

A
  • 10x

- 90 days

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40
Q

What is the Ischemic Cascade?

A

After a stroke, a cascade of damaging cellular events triggered by ischemia begins to spread across brain tissue.

41
Q

What are the (5) steps in the Ischemic Cascade?

A

1.) Loss of ATP production.
2.) Stoppage of Na/K pump.
3.) Excess intracellular Na+ leads to influx of H2O, causing “cytotoxic edema”.
4.)Excess intracellular Ca2+ build up due to stoppage of Na/K pump.
-Leads to excess glutamate release at axon terminal
-Hyper-excitable cycle transpires throughout
nearby neurons
- =”Excitotoxicity”
-Activates enzymes that break down proteins in
neuron and cell membrane.
-Release of free radicals.
5.) Breakdown of mitochondria in response to toxins and unstable cell membrane.

42
Q

What happens with the loss of ATP production in the ischemic cascade?

A
  • Switch from aerobic to anaerobic.
  • Build up of lactic acid.
  • Causes step 2 (stoppage of Na/K pump)
43
Q
  • Steps 3 and 4 of the Ischemic Cascade causes neuronal death via ___________.
  • Step 5 of the Ischemic Cascade causes neuronal death via ___________.
A
  • NECROSIS

- APOPTOSIS

44
Q
  • What area of an ischemic stroke is unsalvageable?

- What area of an ischemic stroke is salvegeable?

A
  • Infarct Core

- Penumbra

45
Q

Neuronal death within the core occurs within ________. Surrounding tissue (penumbra) death occurs within _________.

A
  • MINUTES

- HOURS

46
Q

Every minute in which a large vessel ischemic stroke goes untreated:
___ million neurons lost
____ billion synapses lost
__ miles of myelinated axonal fibers lost

A
  • 1.9 million
  • 1.38 billion
  • 7 miles
47
Q

PART 4: DIAGNOSIS

A

PART 4: DIAGNOSIS

48
Q

What are the 3 components to a diagnosis of a stroke?

A
  • History of Present Illness (HPI)
  • Clinical Examination
  • Medical Workup
49
Q

What are the 2 parts of the HPI?

A
  • PMHx/Systems Review

- Description of Symptoms

50
Q

Onset of Symptoms:

  • Thrombotic = ?
  • Embolic = ?
  • Hemorrhagic = ?
    • Aneurysm = ?
    • AVM = ?
A

Thrombotic= gradual onset, days to weeks (most common in late PM or first thing AM, may see “wake-up” strokes”)

Embolic=more abrupt than thrombotic, minutes to hours

Hemorrhagic= immediate, severe

  • Aneurysm= asymptomatic until rupture
  • AVM= may have preceding symptoms (seizures, etc)
51
Q

Types of symptoms are largely dependent of what?

A

Location of insult

52
Q

What are some common complaints of stroke patients?

A
  • imbalance
  • paresthesias
  • weakness
  • blurry/double vision
  • “worst HA of my life” common with hemorrhages, particularly aneurysms
53
Q

Acutely a ___________ screen is done during the Clinical Examination to determine the need for further workup. Eventually a complete neurological evaluation will be completed.

A

neurological

54
Q

What is the (B.E.) F.A.S.T. pneumonic for spotting a stroke?

A
  • Balance (sudden loss?)
  • Eyes (lost vision?)
  • Face (face look uneven?)
  • Arms (weak or numb?)
  • Speech (slurred? confused?)
  • Time
55
Q

What is the NIHSS?

A

National Institutes of Health Stroke Scale

-Quantitative measure of symptoms associated with cerebral infarcts.

56
Q

The NIHSS is most commonly used in the _______ phases of CVA.

A

acute

57
Q

What are the NIHSS cut-off scores for identifying stroke severity?

A
  • > 25 = Very Severe
  • 15-24 = Severe
  • 5-14 = Mild-Moderately Severe
  • 1-5 = Mild
58
Q

NIHSS Scores:

  • Severe and Very Severe NIHSS scores frequently require what?
  • Mild-Moderately Severe NIHSS scores typically require what?
  • __% of Mild scores will be discharged home from acute hospital.
A
  • Frequently require long-term skilled care.
  • Typically require acute patient rehabilitation.
  • 80%
59
Q

What are the parts of a Medical Workup?

A
  • Diagnostic Imaging (head CT, later MRI)
  • EKG
  • Chest Radiography
  • CBC
  • 24h cardiac monitoring
60
Q

What are the most common imaging that we will do of brain/brainstem?

A

CT or MRI

61
Q

When is an MRI preferred over a CT?

A
  • subtle areas of tumor, infarct, demyelination
  • brainstem lesion
  • ischemia
  • subacute or chronic imaging
  • anatomy detail needed
62
Q

When is a CT preferred over an MRI?

A

1

63
Q

PART 5: ACUTE MANAGEMENT

A

PART 5: ACUTE MANAGEMENT

64
Q

What are the (3) main acute CVA complications?

A
  • Cerebral Edema
  • Vasospasms
  • Seizures
65
Q

What (3) things can cerebral edema lead to?

A
  • ↑ Intracranial Pressure (ICP)
  • Midline shift
  • Brain herniation
66
Q

What is ICP?

A

Pressure exerted by fluids in the brain (CSF, interstitial fluid) that if elevated, can lead to further damage to brain tissue.

67
Q

What are the PT considerations for ↑ICP?

A
  • Monitor for S/S
  • Avoid activity that may exacerbate
  • Mobility usually contraindicated if >20mmHg
68
Q

What is midline shift?

A
  • Shifting of structures into contralateral hemispheric space due to fluid buildup.
  • Poor indicator for functional recovery.
69
Q

What are the PT considerations for midline shift?

A
  • evaluate for bilateral symptoms

- monitor for neurological decline

70
Q

What is brain herniation?

A

Protrusion of brain tissue through intracranial barrier (ex. foramen magnum)
-Very poor prognostic indicator, typically leads to mortality.

71
Q

What are the PT considerations for brain herniation?

A

PT usually not indicated.

72
Q

What is Vasospasm?

A

Persistent vasoconstriction and dilation of the blood vessels. It is typically asymptomatic, but can be highly dangerous.

73
Q

Vasospasm is most commonly seen post ______ and has a greater risk ___ days post bleed.

A
  • SAH

- 7 days

74
Q
  • How are Vasospasms monitored?

- What is the treatment?

A
  • Transcranial Doppler (TCD)

- Permissive HTN

75
Q

What are the PT considerations for Vasospasms?

A

Mobility contraindicated with mod-severe vasospasm, consult MD prior to mobility

76
Q

What is a seizure?

A

burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness.

77
Q

Seizures are most commonly seen post _____ and has a greater risk in the first ____ hours post.

A
  • ICH

- 48 hours

78
Q
  • How are Seizures monitored?

- What is the treatment?

A
  • Electroencephalogram (EEG)

- Anti-seizure medication, surgery rare

79
Q

What are the PT considerations for Seizures?

A

Mobility usually deferred until >24hr after quiet EEG.

80
Q

What are some other Acute CVA complications in addition to the main 3?

A
  • HTN
  • Infection
  • Fever
  • Pneumonia
  • Pressure Ulcers
  • Hyperglycemia
81
Q

Ischemic Stroke:

  • What is the major goal when treating ischemic strokes?
  • What are some ways this is done?
A

-Revascularization

  • Tissue Plasminogen Activator (tPA) “clot buster” given within 3-8hr window.
  • Permissive HTN (<220/110) to force blood flow through.
  • Antiplatelets for first 24-48 hours.
82
Q

Hemorrhagic Stroke:

  • What is the major goal when treating hemorrhagic strokes?
  • What are some ways this is done?
A

-Reduce ICP

  • Sedation, hyperosmolar agents, hyperventilation.
  • Anti-hypertensives for BP control (<130/80)
  • Vasospasm prevention and management (SAH)
  • Antiseizure prophylaxis (ICH)
83
Q

What are the surgical interventions done for Ischemic Strokes?

A
  • Mechanical Embolectomy
  • Mechanical Thrombectomy
  • Carotid Endarterectomy

-ALL involve breaking up clots

84
Q

What are the surgical interventions done for Hemorrhagic Strokes?

A
  • Endovascular Coiling (Aneurysm) = Inserts tube and places wires/coils which mesh up into ball and causes a blood clot to form and block spot of aneurysm.
  • Surgical Clipping (Aneurysm) = Clip and mechanically close at neck of aneurysm.
  • Resection (AVM) = Removal of AVM
  • Embolization (AVM, Hemorrhage) = Surgical glue at area of rupture.
  • Endoscopic Evacuation (Hemorrhage) = Sucking out blood.
  • Craniotomy (Any) = Removal of flap of bone to allow access to area.
  • Craniectomy (Any) = More involved surgery where large piece of bone is removed and kept off to help manage swelling.
85
Q

PART 6: PROGNOSTIC CONSIDERATIONS

A

PART 6: PROGNOSTIC CONSIDERATIONS

86
Q

What type of information should we consider when predicting outcomes?

A
  • Type, stage, and location of diagnosis
  • Severity of impairments
  • Age
  • Comorbidities
  • Medical course
  • Prior level of function
  • Current level of function
87
Q

What are some questions the PT may ask when predicting patient outcomes?

A
  • Is the patient a good rehab candidate?
  • Will the patient be able to return home? Family supports?
  • What type of locomotion will this patient likely rely on long-term?
  • Prognosis for UE? ADL prognosis?
  • What can we expect from this patient in 6 months? 12 months?
88
Q

What are the major prognostic indicators for CVA?

A
  • Time to medical intervention
  • Type of medical intervention
  • Initial NIHSS score
  • Age
  • Education level
  • Family support
  • PLOF
  • Ambulatory on evaluation (IP rehab)
89
Q
  • ____________ Strokes have a higher mortality rate acutely, but a better prognosis for neuro-recovery long-term.
  • ____________ Strokes have a lower mortality rate, but tend to demonstrate slower and less recovery.
A
  • Hemorrhagic

- Ischemic

90
Q

The first ___ months is the crucial period for rehabilitation and neuro recovery. Evidence supports possibility of significant neuro recovery up to ___ months post injury.

A
  • 3 months

- 18 months

91
Q

List these areas of strokes from most disability to least disability:

  • ACA
  • PCA
  • MCA
  • Brainstem
  • Multiple vascular territories
  • Cerebellar
  • Small Vessel Stroke
A
  • Multiple vascular territories
  • MCA
  • ACA
  • PCA
  • Brainstem
  • Small Vessel Stroke
  • Cerebellar
92
Q

What are some common impairments seen with UE recovery?

A
  • paresis
  • loss of isolated movement
  • abnormal muscle tone
  • sensory changes
93
Q

Are the UE or LE usually more involved in strokes?

A

UE

94
Q

80% of patients experience acute paresis of the UE with only __% reported to achieve full functional recovery.

A

33%

95
Q

What are some positive prognostic indicators for UE recovery (4 weeks post injury)?

A
  • Early active finger extension, grasp release, shoulder shrug and shoulder abduction observed.
  • Absence of additional nonmotor impairments, such as somatosensory loss, visual field loss and/or neglect.
  • Presence of a measurable grip strength or active shoulder flexion.
96
Q

What are some positive prognostic indicators for return to ambulation?

A
  • Ambulation on evaluation (IRF)*
  • Balance scores on evaluation (BBS, Romberg, DGI)*
  • Minimal loss of LE strength* and somatosensory function
  • No evidence of perceptual, visual, or cognitive deficits
  • Healthy BMI
  • Younger age (<65)
97
Q

Gait Speed:

  • _______: household ambulation
  • _______: limited community ambulation
  • _______: unlimited community ambulation
A
  • <0.4m/s
  • 0.4-0.8m/s
  • 0.8-1.2m/s
98
Q

__-__% of stroke survivors regain functional independence.

-__% of survivors achieve a full recovery in physical function.

A
  • 50-70%

- 14%

99
Q

What are some additional prognostic considerations?

A
  • Cognitive deficits
  • Activity intolerance
  • Cardiac disease (75% of stroke survivors)
  • Depression
  • Fatigue

S4- Neuro 1 (12 decks)

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