Handler: Stroke Flashcards Preview

Setha: Neuro > Handler: Stroke > Flashcards

Flashcards in Handler: Stroke Deck (78)
1

the sudden or rapid onset of a neurologic deficit in distribution of a vascular territory lasting > 24 hours 

Stroke

"Brain attack"

2

the sudden or rapid onset of a neurologic deficit in the distributionof a vascular territory lasting < 24 houts.

Most last <30 mins 

TIA 

3

Reversible ischemicinsult to brain cells that recover but increases risk of subsequent stroke

TIA 

4

Worsening signs or symtpoms over time 

Stroke-in-evolution

(progressive stroke)

5

Ischemia/infart __%

hemorrhage __%

85%

15%

6

3rd leading cause of death in the US

>200,000 deaths/year

Perception of elderly

Men 1.3x > Women

Blacks 1.3x > whites

Stroke

7

Most common cause of death in patients with cerebrovascular disease is _________?

Myocardial infarction

8

What is the most powerful risk factor for a stroke?

HTN 

goal <140/90

9

Smoking (2-4x)

Atherosclerosis eslewhere (CHD, PAD)

Diabetes Mellitus (3x)

A fib (cardaic emboli)

Male gender, OCP, ETOH in excess, hyperlipidemia 

Risk factors for?

Stroke 

10

Large vessels (atheroscleorsis) often involved in ___% of all ischemic strokes (infarcts)

50%

11

Atherosclerosis: ______ vessels often involved 

Large 

12

___% of strokes are in anterior circulation of brain

80%

13

Why has incidence of stroke declined?

Development and treatment of HTN

14

Pathological outcomes depend on:

Adequacy of collateral circulation

Development of Circle of Willis

Duration of insult/restoration of blood flow 

Stroke

15

Carotid bifurcation, origin of internal carotid 

Base of aorta, external carotid, vertebral/basilar arteries

Effected in _____ strokes?

Ischemic 

16

Small vessel disease

deep penetrating arterioles occlude/thrombose

Lacunar infarcts 

17

20% of ischemic strokes are ____?

Lacunar infarcts 

18

Major risk factor for lacunar infarcts is ____

lipids, DM contribute 

HTN

19

Fibrous cap can erode and lead to an ______ placque?

ulcerative 

20

Very small strokes or TIA's defect < ____ cm (most are 5mm) on CT or MRI 

1.5 

21

May be without sx

detected by CT scan as incidental finding (small, punched out lesion) 

lacunar infarcts 

22

Embolism from heart or artery to brain 

Important role in pathology of strokes and TIA's 

Cerebral Emboli 

23

Blood clot breaks off, occludes more distant/distal vessel

 

Cerebral emboli

24

Often lodge in medium sized vessels (MCA,ACA)

If identified one, likely there are others 

Cardiac emboli

25

20% of ischemic strokes are ____?

Cardioembolism

26

What is a very common cause of cardioelmbolism?

A fib 

27

Abrupt onset of non-convulsive focal defect in a vascular territory 

Stroke 

28

___% of patients have no warning sx of stroke

___% have warning (TIA)

80-90%

10-20%

29

Contralateral hemiparesis or hemisensory loss

Hemianopsia (visual field defect)

If dominant hemisphere (left side of brain)-aphasia

If non-dominant- Speech and comprehension preserved; may develop anosognosia (denial/neglect of deficit) or a confusional state.

MCA 

30

less common

Sx more pronounced in leg, associated language, gait disturbance.

ACA

31

least common

Vertebral artery (Branch of subclavian artery)

Crossed contralateral dysfunction (motor/sensory) plus ipsilateral bulbar/cerebellar signs: vertigo, dizziness, gait disturbance, diplopia, facial palsy, dysarthria, etc.

Posterior circulation 

32

Clinical syndrome depending on where infarct is, may also present as TIA

Ex: contralateral motor/sensory deficit

Prognosis usually good

Lacunar strokes/infarcts

33

Carotid dx present

Transient monocular blindness

Embolism to opthalmic artery (off carotid)

Amaurosis fugax

34

What do you need to do to r/o hemorrhage associted with stroke?

MRI best in 1st 48 hours after intracranial hemorrhage

35

Detection of infarcts on CT is limited to what?

 

size and timing 

36

__% of infarcts visible on CT in 1st 12 hours

>__% visible at one week

5%

90%

37

Changes of infarct may be seen as early as 1 hour 

usually not available or needed emergently

Provides better detail than CT for small lesions and for imaging posterior fossa

MRI/MRA

38

Non-invasive with excellent resolution of large vessels

replaces need for arteriogramin some patients

May be difficult to differentiate complete vs. near complete occlusion

MRA 

39

Screening tool for evaluating common carotid and origin of internal carotid artery

May be difficult to differeniate complete vs. near complete occlusions

Non-invasive but limited capacity 

Carotid Doppler Ultrasound (Duplex)

40

MOST accurate

Invasive- "gold standard" for extra and intracranial disease

 

Arteriography

41

Complications: contrast reaction, kidney failiure, placque rupture, stroke

Use of non-ionic constrast has reduced complications

What type of imaging?

Arteriography

42

Risk factor modification: agressive control of BP, lipids, diabetes, smoking cessation, exercise, diet

Atrial fibrillation and emolization: full anticoagulation (Warfarin therapy long term)

Prevention for what?

CHD and stroke 

43

Abrupt onset of sx with transient focal neuro deficit dependent on involved anatomy 

Sx may vary during episodes

Exam between episodes normal 

Warning for subsequent stroke

TIA's 

44

Embolic from carotid stenosis/placque or 

Embolic from cardiac source

Severe carotid stenosis with transient HoTN

Small vessel occlusion: lacunar infarcts may minic

Etiology for ___?

TIA's

45

Important to listen for ___ with stethoscope with TIA's?

bruit

46

Carotid Endarterectomy and carotid angioplasty/stenting are surgical rx for?

Carotid TIA/Incomplete Stroke

47

Surgical rx to remove placque

Best results if symptomatic blockage and >70% stenosis 

Significantly recuces risk of subsequent ipsilateral stroke 

For selected patients with sx and 50-70% stenosis

Risks: stroke and complications of surgery 

Carotid endarterectomy 

48

Promising alternative to carotid endarterectomy but long term data is lacking

option in POOR surgical candidates

Carotid angioplasty/stenting 

49

For patients with poor operative risk 

<70% stenosis or asymptomatic carotid disease

Risk factor modification: HTN, smoking, lipids, DM

Medical rx for carotid TIA's

50

Indicated for ALL patients with <70% stenosis and TIA sx, diffuse cerebrovascular dx, poor operative candidates, and asx carotid dx

Prevent platelet aggregation and release of vasoactive substances like thromboxane A2

 

Anti-platelet agents 

51

Inhibits cyclooxygenase

Inhibits synthesis of thromboxane A2, decreasing both platelet aggregation and vasoconstriction

Decreases frequency of TIA's and risk of subsequent stroke and decreased recurrence of stroke 

325mg daily: GI side effects and bleeding 

Aspirin 

52

Inhibits platelet aggregation and prevents activation of glycoprotein ||b/|||a (a fibrinogen binder)

Decreases atherosclerotic events

Alternative to ASA for patients with recurrent TIA's or ASA intolerance/allergy

75 mg/day: Diarrhea, rash

Clopidogrel (Plavix)

53

Supportive measures plus ASA or Clopidogrel

Aggressive long term tx of BP and lipids

Usually good prognosis for recovery over 4-6 weeks 

Lacunar infarct tx

54

Hospitalize all  patients (most TIA-1st episode)

Supportive (IV fluids)

Consider thrombolytic therapy 

Tx for what?

Stroke

55

What do you want to avoid when treating a stroke?

Rapid BP reduction

decreases perfusion and brain will autoregular perfusion

Only tx if <200/100 --> wait 2 weeks for oral meds if possible 

56

Dependent on timing

1st obtain head CT to r/o hemorrhage 

if onset of sx <4.5 hours --> thrombolytic therapy with t-PA (bolus/infusion up to 90 mgs) over 1 hour

Tx for?

Cerebral infarct 

57

Requires team approach- best  done in large tx centers

neurologic outcome improved at 3 mon and 1 year with decrease in expected deficit and reduction of intial deficit 

increases chances of favorable outcome by ~50%

What type of stroke therapy?

Thrombolytic therapy

58

Risks: Cerebral hemorrhage (6-7% incidence adn half will die)

Contraindications: recent bleeding, prior stroke, BP >185/110, recent major surgery

For what type of stroke therapy?

 

thrombolytic therapy (t-PA)

59

loose mesh stent placed in thrombus obstructing cerebral vessels

removes thrombus and restores blood flow

Not yet FDA approved for all stroke patients 

Solitare  FR Revascularization Device

60

Indications:

Embolus from heart (stroke or TIA)

A fib > 72 hours

Risk is cerebral hemorrhage

What type if tx?

FULL anticoagulation

61

What must you do before starting full anticoagulation?

CT to r/o hemmorrhage

62

Used for immediate and short term anticoagulation

Inhibit action of clotting factors 

Heparin

63

Long term oral anticoagulation

Inhibits production of clotting factors in liver

Stroke or TIA from cardiac embolism (decrease subsequent stroke risk)

Chronic A fib (decrease stroke risk)

Monitored by INR and frequent follow up for dosing 

Warfarin

64

Physical therapy, occupation therapy, speech therapy

Avoid prolonged best rest (UTI's, skin infection/ulcers, PE)

Post stroke management 

65

What are the two types of Hemorrhagic stroke?

Intracerebral (HTN, AVM, Trauma)

Subarachnoid space (Aneurysm, AVM)

66

________ is diagnositic for hemorrhagic stroke

CT

67

What should you do if CT is negative for to rule out SAH?

Spinal tap

68

Rupture of small arteries or microaneurysms of perforating vessels

Risks: HTN, hematologic and bleeding disorders (leukemia, thrombocytopenia, hemophilia), trauma, anticoagulant therapy, liver dx

Intracerebral hemorrhage 

69

Rapid evolution of neuro deficit often progressing to hemiparesis, hemiplegia, or hemisensory loss

50% mortality

Loss of or impaired consciousness develops in 50%

Vomiting and HA are common

Intracerebral hemorrhage 

70

Cautious BP reduction where applicable

Conservative and supportive tx - some benefit from surgical evacuation of hematoma 

Surgery: decompression (limited usefulness)--> best in cerebellar bleeds and bleeding in AVM

Tx for?

Hemorrhagic stroke

71

Most due to bleeding from saccular aneurysms 

In 3-4% of population, usually w/o sx

2-3% risk of bleed per year

Highest risk if >6mm

Subarachnoid bleeds 

72

Sudden onset of severe HA followed by N and V, impaired or loss of consciousness +/- neuro deficits

Meningeal signs often present 

Subarachnoid bleeds 

73

What are the two meningeal signs?

Kernigs and Brudzinski signs 

74

What imaging is used to identify blood in subarachnoid space?

CT

75

If subarachnoid hemorrhage is suspected and CT is negative do _______ to look for blood or xanthochromia

CSF tap

76

If patient conscious: bed rest, sx and supportive care with cautious reduction of BP

Once patient stable: angiography

Surgery or coil placement to precent re-bleed when applicable 

Tx for?

Subarachnoid hemorrhage 

77

most common vascular malformation of CNS often involving MCA and branches

78