Week 2 - Early Recognition of Stroke

Question 1

what number is stroke in leading causes of death? what is it a leading cause of? what percentage is ischemic and hemorrhagic? where must emphasis lie?

Answer 1

4th leading cause of death
leading cause of disability
83% ischemic, 17% hemorrhagic
emphasis must be on prevention

Question 2

what are nonmodifiable risk factors for stroke?

Answer 2

increases with age and family history (hypercholesteremia); no real link for sex or race

Question 3

what are modifiable risk factors for stroke? how much do they increase risk?

Answer 3

hypertension: 2-4x
diabetes: 1.8-6x
smoking: 1.8x
hyperlipidemia: 1.8-2.6x
carotid stenosis: 2x
atrial fibrillation: 2.6-4.5x

Question 4

what are stroke symptoms?

Answer 4

SUDDEN:

• one-sided numbness or weakness of face, arm, leg
• confusion or trouble speaking/understanding speech (aphasia)
• trouble seeing in one/both eyes
• trouble walking, dizziness, or loss of balance/coordination
• headache w/o known cause

Question 5

what are the percentages of occurrence for stroke subtypes of ischemic and hemorrhagic stroke?

Answer 5

ischemic
-small vessel thrombosis: 20%
-large vessel thrombosis: 30%
-embolic stroke: 33%
hemorrhagic
-intracerebral: 10%
-subarachnoid: 7%

Question 6

what diseases can mimic stroke?

Answer 6

hypoglycemia
mass lesions
seizures and postictal states
migraine
psychogenic hemiparesis

Question 7

what do the areas that the middle cerebral artery perfuse do?

Answer 7

arm
eye fields
face
expressing and reception of language

Question 8

what do the areas that the anterior cerebral artery perfuse do?

Answer 8

leg

foot

Question 9

what are common stroke presentations for the left middle cerebral artery?

Answer 9

• right hemiparesis (face = hand > arm > leg)
• aphasia (mistaken as confusion)
• -expressive: difficulty producing language, or no language output
• -receptive: poor comprehension and/or incomprehensible speech
• anterior division: left head and eye division
• posterior division: visual field deficit, aphasia

Question 10

what are common stroke presentations for the right middle cerebral artery?

Answer 10

• left hemiparesis (face = hand > arm > leg)
• neglect: doesn’t acknowledge left visual space or denies own body parts
• anterior division: right head and eye deviation
• posterior division: visual field deficit, neglect

Question 11

what are common stroke presentations for the posterior cerebral artery?

Answer 11

• visual field deficit or cortical blindness if bilateral

- potential hemihypaesthesia (complete loss of sensation of contralateral face, arm, trunk, leg)

Question 12

what are common stroke presentations for the basilar artery?

Answer 12

• altered consciousness or coma
• often bilateral signs
• CN signs and “crossed” signs
• -right facial weakness and left arm/leg weakness
• -loss of pin sensation on left face and right arm/leg
• -oculomotor palsy, nystagmus, palate, or tongue weakness

Question 13

what are 4 types of lacunar syndromes?

Answer 13

• pure motor hemiplegia
• pure sensory hypaesthesia
• dysarthria clumsy hand syndrome
• ataxic hemiparesis

Question 14

what is pure motor hemiplasia caused by?

Answer 14

lacunar stroke in internal capsule (face = arm = leg)

Question 15

what is pure sensory hypaesthesia caused by?

Answer 15

lacunar stroke in thalamus (face = arm = leg)

Question 16

what is dysarthria clumsy hand syndrome caused by?

Answer 16

lacunar stroke in pons

Question 17

crossed signs indicate involvement in what area?

Answer 17

brainstem

Question 18

vertigo of central origin is associated with what?

Answer 18

cranial nerve deficits

Question 19

what is vertical nystagmus considered until proven otherwise?

Answer 19

brainstem ischemia

Question 20

what are early CT changes of stroke?

Answer 20

• early infarct signs
• hypodensity of gray/white matter
• obliteration of cortical sulci
• obscured basal ganglia
• loss of insular ribbon

Question 21

inclusion criteria for thrombolytic therapy

Answer 21

• acute ischemic stroke (not mimic)
• age < 80
• onset < 3 hours
• CT normal or early focal infarction
• NIHSS < 24
• informed consent (patient and/or family)

Question 22

exclusion criteria for thrombolytic therapy

Answer 22

• CT signs of hemorrhage or very large infarction (risk fatal intracerebral hemorrhage)
• undetermined time of onset
• uncontrollable HTN or diabetes
• recent trauma, major surgery, bleeding
• abnormal coagulation profile
• rapidly resolving deficit
• hemodynamic compromise from MI

Question 23

benefits and risks of thrombolytic therapy

Answer 23

treatment group had 30% more patients rated “good outcome”, but had 6% intracerebral hemorrhage, 50% of which were fatal (compared to 1% risk from placebo group)

Question 24

primary and secondary prevention of stroke

Answer 24

• control modifiable risk factors (HTN, DM, CAD, obesity)
• antihypertensive, cholesterol lowering medications
• antiplatelet medication
• anticoagulants
• carotid endarterectomy