WEEK 2: STROKE [Salonga] Flashcards by Amiel Lorenzo

Stroke is
uncommon in people under 40 years; when it does occur, the
main cause is

High BP

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Strokes are broadly categorized as

ischemic and hemorrhagic

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Difference between ischemia and infarction?

Ischemia – reduction of blood flow for few seconds

Infarction – cessation of blood flow for a minutes

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Neurologic sx resolve within 24hrs, No evidence of

brain infarct via imaging

TIA

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Generalized ↓ cerebral blood flow d/t systemic

hypotension

syncope

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widespread decrease in cerebral
blood flow that persists for longer duration + sx of brain
infarction

Global hypoxia-ischemia

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ischemia/infarction of a small
area of the brain; usually caused by thrombosis (cerebral
vessels) or emboli (distant vessels)

infarction / focal ischemia

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3 direct effects of hemorrhagic stroke that cause neuro sx?

Increased ICP
▪ mass effect on neural structures
▪ toxic effects of blood itself

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supplies the medial surface of the frontal and parietal lobes and the corpus callosum.

ACA

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supplies the Choroid plexus of the temporal horn of the lateral ventricle, hippocampus, amygdala, optic tract, lateral geniculate body, globus pallidus, and part of the posterior limb of the internal capsule

Anterior choroidal artery

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Connects MCA to PCA

PCoA

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supplies the:
o Lateral convexity of the cerebral hemisphere and insula.
o Trunk, arm, and face areas of the motor and sensory cortices
o Broca’s and Wernicke’s speech areas.

MCA

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Lenticulostriate arteries are clinically relevant for what type of stroke?

Lacunar Stroke

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what are the subdivisions of MCA?

M1 - horizontal segment
M2 - Sylvian segment
M3 - cortical segment

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Supplies anterior 2/3 of the spinal cord

Anterior spinal artery

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Formed by the confluence of the paired Vertebral arteries

Basilar artery

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what arises from basilar artery? (4)

Pontine, AICA, SCA, PCA

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supply corticospinal tracts and the intra-axial exiting fibers of the abducens nerve (CN VI).

pontine arteries

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Supplies inferior surface of the cerebellum

AICA

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supplies the superior surface of the cerebellum and the cerebellar nuclei.
o rostral and lateral pons, including the superior cerebellar peduncle and spinothalamic tract

Superior Cerebellar Artery

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provides the major blood supply to the midbrain, occipital lobe, visual cortex

PCA

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where does PICA arise?

PICA sa vertebral, pero AICA sa basilar

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Supply of brainstem

pontine - from basilar

Ant Spinal Artery - Vertebral

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Cerebrum, Cerebellum and Brainstem empty into

Dural venouis sinuses

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Spinal cord venous drains in?

Internal and External Vertebral Plexuses

3 blood supply of the cerebellum?

SCA, AICA, PICA

receives most arachnoid granulations.

superior sagittal sinus

drains the superior surface of the cerebellum

straight sinus

due to occlusion of a cerebral blood vessel and causes cerebral infarction.

ischemic stroke

2 types of hemorrhagic strokes:

intracerebral hemorrhage | Subarachnoid hemorrhage

3 causes of cerebral infarction

1. atherothrombotic cerebral infarction 2. lacunar infarction 3. cardiogenic cerebral embolism

etiology of ischemic stroke if large vessel, embolic

1. The Heart o Valve diseases, A. Fib, Dilated cardiomyopathy, Myxoma 2. Arterial Circulation (Artery to Artery Emboli) o Atherosclerosis of carotid, Arterial dissection, Vasculitis 3. The Venous Circulation o PFO w/R to L shunt, Emboli

etiology of ischemic stroke if large vessel, thrombotic

``` Virchow’s Triad 1. Blood vessel injury o HTN, Atherosclerosis, Vasculitis 2. Stasis/turbulent blood flow o Atherosclerosis, A. fib., Valve disorders 3. Hypercoagulable state o Increased number of platelets o Deficiency of anti-coagulation factors o Presence of pro-coagulation factors o Cancer ```

Risk factors for small vessels stroke

``` HPN – HLD – DM – Tobacco Use – Sleep apnea ```

lacunes are how many cm?

<1.5 cm

duration of transient neurologic symptoms | lasting less than 1 hour

TIA

Transient reduction of blood flow to a region in brain in the absence of evidence of infarction on brain imaging

TIA

T or F? Significance of TIAs is increased risk of stroke after a TIA specifically early on after a TIA

what are 2 cortical signs on (R) Brain?

Right gaze preference | Neglect

cortical left brain signs? (2)`

left gaze preference aphasia basta pag nasa cortex ang tingin ng mata nasa side ng lesion. pag infratentorial nasa opposite ng lesion

gyrus of brocas?

Left posterior inferior | frontal gyrus

gyrus of wernickes

Posterior part of the superior temporal gyrus | – Located on the dominant side

Small Vessel: – No cortical signs on exam t or F?

stroke syndrome that Rarely presents with an isolated symptom. Usually a combination of cranial nerve abnormalities, and crossed motor/sensory findings such as:

Brainstem stroke syndromes

Causes of hemorrhagic stroke?

Htn, aneurysm, trauma, tumor, AVM

“star shaped” lesion on CT

Sub arachnoid hemorrhage

Sudden onset, severe headache (worst headache of your life)

Sub arachnoid hemorrhage

From congenital aneurysms of the Circle of Willis, less commonly from AV Malformations

Sub arachnoid hemorrhage

Rupture of thin walled lenticulostriate arteries, commonly seen in hypertensives

intracerebral hemorrhage

typical sites of hypertensive ICH?

Basal Ganglia – Cerebellum – Pons

`Vomiting is more common in IntraCerebellar Hemorrhage, SAH or Ischemic CVA?

Intracerebellar

``` Pin-point but reactive pupils Abrupt onset of coma Decerebrate posturing or flaccidity Ataxic breathing pattern typical of? ```

Pontine hemorrhage

``` “Worst headache of my life” AMS Photophobia Nuchal rigidity Seizures Nausea and vomiting ``` typical of?

Subarachnoid hemorrhage

meaning of FAST in stroke eval?

Facial Drooping, Arm Weakness, Speech Difficulty, Time to call 911

give some diff dx to stroke?

``` Space occupying lesion (tumor, infection/ abscess, Epidural, Subdural Hematomas) • Subarachnoid hemorrhage • Seizures • Hypoglycemia • Migraine • Syncope • Labyrinthine disorders ```

what are some initial eval or diagnostics you can do in a stroke?

``` Cardiac monitoring, pulse-ox, ECG § Stat CT brain § c-xray § CBC, Platelet, PT, PTT § blood glucose, serum electrolytes § Cardiac markers, ABG’s § Blood alcohol level, Toxicology screen, Pregnancy test( as necessary) ```

remains the gold standard as it is superior for showing IVH and ICH

non contrast CTH

Superior for showing | underlying structural lesions

MRi

primary objective in the management of stroke?

The primary objective is to restore adequate cerebral perfusion to ensure adequate cerebral metabolism and function: 1) Airway for adequate oxygenation • 2) BP - maintain mean arterial pressure • 3) Normal glucose level • 4) Avoid hyperthermia

Goal in BP mx of stroke patients?

The goal is to maintain cerebral perfusion!!

formula of CPP?

CPP = MAP – ICP (needs to be at least 70)

difference in BP Goals in Ischemic vs Hemorrhagic

Higher BP goals with Ischemic stroke MAP 110-130 mm Hg – Lower BP goals with Hemorrhagic stroke (avoid hemorrhagic expansion, especially in AVMs and aneurysms) < 160 mmHg systolic

T or F? Failure to recanalize (w/ or w/o thrombolytic therapy) results in high BP and poor neuro outcomes

T or F? Infarction size and edema increase with acute and chronic hyperglycemia

Hyperglycemia is an independent risk factor for hemorrhage when stroke is treated with t-PA. T or F?

Seizures are common after hemorrhagic CVAs. T or F?

why is it important to treat fever in CVA?

because fever >24 hrs correlates with ventricular extension of the bleed

window when to give the IV tPA

3 to 4.5 hrs

Inclusion criteria for IV tPA?

``` § Ischemic Stroke clinically § Persistent neurologic deficit beyond an isolated sensory deficit / ataxia § CT brain: No Blood § Initiation of Rx within 3 hours ```

exclusion criteria IV tPA?

``` Onset to treatment >3 hr (NINDS) § Rapid improvement § Blood on CT § Oral anticoagulant & PT>15 sec, INR>1.7 § Heparin (last 48 hr) & increased PTT § Platelet<100,000 § SBP>185 or DBP>110 § Aggressive treatment of b.p. § Stroke or head trauma (3 months) § Major surgery (2 wks) Prior ICH § GI tract/ Urinary bleed (14 d) § Seizure at onset § Signs & Sx’s of SAH § Non-compressible site of arterial puncture (7d) ```

if umabot ng 3 to 4.5 hrs, any exclusion criteria?>

Age >/= 80 Any use of anticoagulant regardless of the PT/PTT • NIHSS≥25 • Coexistent history of stroke and diabetes mellitus

Management Post Thrombolysis

Admit to ICU § BP monitoring (Q 15 m x2 h, Q 30 m x6 h, Q 1 h x16 h) § Treat SBP≥185 and DBP≥110 § No anticoagulants, no anti-platelet for 1st 24 hr post t-PA Worsening of neurologic state---CT brain § ICH---Neurosurgery consult § Possible surgical intervention § Preferably: no foley or NG for 2 hr > t-PA (t1/2-t-PA = 8-12 min)

What test? Designed for acute stroke trials. § Quick (5-10 min) & reproducible. § Requires speech/language cards & safety pin. § Quantifies clinical stroke deficit:

NIH stroke scale

what NIH stroke scale has inc risk for ICH

>22

what NIH Scale has poor prognosis if no treatment?

>15

NIH stroke scale that is mild stroke?

NIH score that will have will have an 80% | good or excellent outcome

12 to 14 and below

NIH Score of what will have less than a 20% good or excellent outcome

20-26

meaning of CADASIL?

Cerebral autosomal dominant arterof iopathy with subcortical | infarcts and leukoencephalopathy

mutation on CADASIL?

NOTCH 3 gene mutation on Ch 19

ICH total score?

ICH components on exam?

``` GCS IVH ICH Volume Infratentorial origin of ICH Age ```

NIHSS grading?

``` 0 No stroke symptom 1 - 4 Mild 5 - 15 moderate 16 - 20 moderate to severe 21 - 42 severe stroke ```

triad of increased ICP:

headache, papilledema, vomiting

cushing's triad

hypertension, bradypnea, bradycardia