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Flashcards in Stroke, HA, HTN Deck (112):
1

Stokre sxs

• Symptoms vary – location dependent
• Weakness/numbness face/limbs, one side
• Confusion, difficulty speaking/understanding
• Agitation, seizure
• Vision changes – one/both eyes, visual field cut
• Difficulty walking, ataxia, loss of coordination

• Dizziness, vertigo, loss of balance

• Atraumatic loss of consciousness (did they have a seizure? Did they faint? Did they have a stroke?)

• Sudden, severe headache

2

VA changes associated with stroke

visual periphery changes
difficulty seeing out of one eye

3

Sudden, severe headache would be associated with what type of stroke

hemorrhagic

4

RF for stroke (11) starting with number 1

• TIA or previous CVA (#1)
• HTN
• DM
• Atrial Fibrillation
• EtOH, IVDU, stimulants
• Atherosclerosis
• High cholesterol
• Sickle Cell
• Obesity/inactivity
• Tobacco
• Increasing age

5

hx that would contribute to RF

• Heredity
Family Hx of CVA
• Ethnicity
African Americans
Hispanic Americans
• Gender
Men > Women

6

women are at greater risk for

Women > for SAH

7

critical timing hx for stroke pt

1. When did symptoms begin?
Treatment is time dependent
When were you/they last normal?
2. Sudden or gradual onset?

3. What are the symptoms, exactly?

4. Symptoms persistent or transient?

5 are you on anticoagulants?

6. PMHx, meds, risk factors

7 . Trauma? Syncope? N/V?


8 . Headache??

what are out CI for TPA

8

what % of strokes are ischemic

1. ~85% of all strokes

9

gradual vessel occlusion is known as a

2. Thrombotic


Atherosclerosis, gradual vessel occlusion
b. Sx onset may be gradual, stuttering
c. May have hx TIA

no blood distal

10

Sudden occlusion; sudden, fixed deficit

embolic stoke

11

who has embolic strokes

A fib, atrial clot, endocarditis (

12

pts with a thrombotic strokes may have has

TIA

13

Types of hemorrhagic CVA

2. Intracerebral Hemorrhage
3. Subarachnoid Hemorrhage


THESE ARE 15% OF ALL STROKES

14

evens that made lead to hemorrhagic stroke

a. HTN --> really uncontrolled
b. Cocaine, Meth, stimulants
c. Aneurysm bursts open
d. Arteriovenous Malformation (AVM)

15

Tx for hemorrhagic stroke

a. ABCDE’s
b. Control BP carefully
c. Neurosurgical consult
d. Multi-detector CT angiography
e. NIHS will be greater than 20

16

Left is dominant hemisphere in what pts

a. All right-handed

b. 80% left-handed

17

what % of people are right hemisphere dominant

3. Right is dominant in 20% lefties

18

how to tell where a stroke is- two major possibilities

2. Anterior circulation CVA
3. Posterior circulation CVA

19

Anterior circulation CVA comes off of and includes

CC

i. Anterior Cerebral Artery
ii. Middle Cerebral Artery

20

Posterior circulation CVA is where in origin and includes what

a. Vertebral artery origin


i. Posterior Cerebral Artery
ii. Vertebrobasilar stroke
iii. Cerebellar stroke

21

motor differences seen with
anterior Circulation CVA

: Contralateral weakness (If R sided symptoms, then your bleed is on the left)
• Leg, foot symptoms> arm symptoms

22

Sensory differences seen with
anterior Circulation CVA

Contralateral deficit
• Leg sx’s > arm sx’s

23

Loss of frontal lobe control seen with anterior cerebral artery

• Personality change
• Perseveration
• Incontinence
• Gait disturbances
• Apraxia (you know you want to move the muscle but you cannot)


this is seen in anterior cerebral artery strokes

24

apraxia is

can’t perform tasks or follow commands even though they know the task and wish to follow the command. Several specific types

seen with loss of anterior cerebral artery

25

Most common area to get a stroke – bad if big/central

Middle Cerebral Artery

often in the corners of the middle cerebral artery

26

Motor deficits with middle cerebral CVA

Contralateral weakness
• Face/arms > legs
• Facial droop

27

sensory deficits with middle cerebral CVA



Contralateral deficit
• Arms > legs

28

if a pt has a CVA in the middle cerebral of dominant hemisphere

If affecting the dominant hemisphere: aphasia (either receptive or expressive

29

if a pt has a CVA in the middle cerebral of non dominant

Non-dominant: neglect (neglect that part of the body that is affected completely)

30

Middle Cerebral Artery see the eyes doing this

Eyes turned toward side of stroke --> common in MCA strokes that are large

31

Homonymous hemianopsia

seen with posterior circulation CVA AND middle cerebral
s hemianopic visual field loss on the same side of both eyes.

32

Posterior Circulation CVA is seen with

Visual disturbances

1. Posterior Cerebral Artery
2. Occipital cortex affected

(cortical blindness)
• Homonymous hemianopsia

33

cortical blindness

** (normally functioning pupils and normal eye reflexes but they can’t see. Visual loss can be profound)

seen with posterior circulation

34

what type of motor findings do we see with posterior circulation CVA

4. Ipsilateral CN 3 palsy
5. Minimal motor findings

35

Vertebrobasilar CVA seen with

• IPSIlateral eye, cranial nerve defects

• CONTRAalateral motor defects

• Vertigo/ataxia, nausea/vomiting

• Tinnitus/deafness, nystagmus

• LOC or ALOC, coma

36

central vertigo think

vertebral basilar issue

diplopia with CNIII palsy is experienced with both horizontal and vertical eye movement

37

“Locked-in” syndrome associated with CVA in what artery

Basilar artery/Pontine

38

Basilar artery/Pontine sxs

• “Locked-in” syndrome
• Extensive motor deficit (you do not move, you are awake)
• Consciousness, eye movements spared

39

Cerebellar strokes classically seen with these sxs

• Central vertigo, vertical nystagmus

• Cranial nerve deficits

• Abnormal finger->nose, RRAM, etc

• Ataxia

40

Small vessels that perforate the deep, subcortical areas

Lacunar Infarcts

41

Lacunar Infarcts RF

HTN, DM = 2 big risks

42

sxs of lacunar infarct

Pure” motor or sensory sx’s
4. “Clumsy hand” syndrome

43

tx of lacunar strokes

Usually don’t require treatment unless there are persistent symptoms

44

difference between a TIA and lacunar stroke

location

lacunar is deep

45

NIHSS when is a initial score good

a. Initial score <15 better

46

NIHH when is a score not so good

b. Initial score >20 not so good

location
prognosis
severeity

47

ED work up of a stroke need a

Recognition first, ABCDE’s, D-stick (glucose)

48

D-stick

dextrose stick

or

POC glucose

49

what tests do you need to order for a suspected stroke

FIRST- D-stick

IV
EKG
monitor
O2
basic labs (CBC -need to know platelets)ƒ
PT/INR
troponin (high risk of stroke also puts you at a high risk of CV event as well),
utox
upreg

THEN CT of the brain NON-contrast

50

if you have a negative CT for blood and the sxs are significant

CTA of brain and neck

51

if you have an ischemic event on CT it will look like ....
what do you do

a. Ischemic? No gross blood, +/- edema?
i. Call Neurology/Stroke Team

52

if you have a hemorrhagic stroke on CT it will look like

b. Hemorrhagic? Gross blood on CT?
i. Call Neurosurgery

53

the Penumbra is...

the area that is affected past the blockage)!

54

how do you preserve the Penumbra

don't let the BP drop!

ASA (not in hemorrhagic!)

thrombolytics

thrombectomy

55

BP control for ischemic ot

Avoid acute drop in BP. Raise BP if very low to perfuse
b. -Tx BP if >220/120, MAP goal
c. -Labetolol, Nicardipine - easy to titrate IV
d. -Goal: situation/tPA or not/end-organ issues

56

ASA use in ischemic stroke

a. -To prevent recurrent event
b. –OK to give before thrombolytics

57

3. Thrombolytics help with this in ischemic stroke

Maximize flow to penumbra
b. -Save brain tissue
c. -BP must be <185/110 for tPA

58

TPA needs to be given

3-4.5 hours

• May improve outcome
• Hemorrhage risk
• FUNCTION not life-saving

59

goal for ischemic pt

door to TPA <60
stroke center <30 min

60

who benefits from tPA

• Any adult over 18
• ANTERIOR circulation stroke does better
• Moderate neuro deficit
• Known time of onset
• CT: no hemorrhage

61

CI for tPA (8)

• ANY blood on CT, SAH

• Seizure at onset

• Hx hemorrhagic CVA

• Known tumor, AVN

• Very minor strokes

• Recent trauma, LP, arterial puncture*,
surgery, GI bleed

• Can’t control BP

• On coumadin*, recent heparin, <1k
platelets

62

Sudden onset ischemic stroke after trauma, neck manipulation, minor trauma

Carotid Dissection

Spontaneous: family hx, genetic, CAD

63

Carotid Dissection presentation

HA, neck/face pain, partial Horner’s Syndrome (ptosis, miosis, anhydrosis), Cranial Nerve abnormalities

64

dx tests for carotid dissection

Diagnosis: CT angio of neck, MRI

65

we typically see carotid dissection in

Young w/ CVA or CN issues

66

Sickle cell risk

> 20% of patients with sickle cell disease have ischemic CVA’s by the age of 45

Most common cause of stroke in children

c. Think about ICB/SAH too

67

tx of hemorrhagic CVA

ABCDE
control BP

nerusurgical consult
multi-detector CT angiography/MRI

after initial ED dx

68

Stroke mimics

i. Hypoglycemia – get a d-stick right away
ii. Seizure

iii. Complicated migraine (visual symptoms present)

iv. Sepsis

v. Toxic/metabolic/neurologic conditions
demyelinating conditions, Lyme’s, etc

vi. Brain tumor or spinal cord tumor/met

vii. Isolated cranial nerve abnormalities

viii. Functional (psych) disturbance

69

how does seizure mimic a stroke

Prolonged post-ictal state, Todd’s paralysis

70

Toxic/metabolic/neurologic conditions that would mmiic stroke

1. OD, Wernicke’s, peripheral neuropathy,

71

Isolated cranial nerve abnormalities that might mimic stroke

Bell’s Palsy, 6th nerve palsy

72

TIA presentation

weakness and tingling in her left arm and leg that completely resolves

Stroke-like symptoms lasting < 24 hours and usually 1-2hrs which completely resolve

73

TIA definition

Ischemia causing neuro deficit without infarct (official definition)

74

TIA

Risk of CVA measured in 2, 7, 30, 90 days

Big risks, large vessel Dz, significant sx’s - all increase CVA risk

75

ABCD2

helps predict risk of future stroke

1. Age, BP, clinical features of TIA, duration, diabetes
2. > or = 4: higher risk stroke in 2 days; higher score = greater risk

76

anticoagulation for TIA

could be ASA
could be plavix

77

work up of TIA

• CT brain non-con first
• Should be normal if TIA
• O2, IV, monitor + d-stick
• Labs, EKG, PT/INR, troponin
• Aspirin (if no blood on CT)


Workup also includes:
ADMIT for
Duplex US of carotids to look for large
vessel dz

Echocardiography to look for clots in the atria

MRI brain

CTA or MRA of neck vessels

78

when would you admit a TIA pt past the workup


• TIA w/ mod/high ABCD2, high risk pt

• “Stuttering” or “crescendo” TIA (symptoms throughout the day but it got better but then it came back again but worse this time)

79

RF for headaches

• “Worst”, “different”
• Sudden onset- thunder!
• New
• Exertional (HA during sex is classic for SAH)
• Fever-
• Stiff neck
• Vision loss/eye sx’s
• ALOC
• Focal deficit on exam
• Trauma/fall
• Coumadin
• Etoh w/ HA fall down
• Syncope
• HIV, cancer
• Sickle cell disease
• Multiple patients from same location

80

HA with fever

meningitides

81

Multiple patients from same location with HA

carbon monoxide !

82

what is the ddx of a HA

READ THIS

• Subarachnoid Hemorrhage
• Hemorrhagic CVA
• Subdural/Epidural Hematoma
• Meningitis
• Idiopathic (Benign) Intracranial Hypertension (young women, obese, on OCP)
• Hydrocephalus

• Glaucoma -->increased IOP

• Giant Cell (Temporal) Arteritis -->can lose your vision **

• Cavernous Sinus Thrombosis --> facial or dental infxn that causes a thrombosis in the sinus which is right next to 3 CN’s (deadly)

• Carbon Monoxide

• Tumor, mets

• Abscess, encephalitis
• Etc…

83

who gets a CT for a HA

i. Sudden, “worst HA”, especially if onset during exertion (SAH)

ii. HA plus fever, stiff neck (meningitis)

iii. HA plus vomiting and no hx same sx’s in past (SAH)

iv. HA plus neuro findings (CN, focal findings)

v. New HA after/with facial, sinus, dental infection (Cavernous sinus thrombosis)

vi. HA in young, obese female, +/-papilledema (Benign intracranial HTN)

vii. HA plus seizure or syncope

viii. HA plus trauma, fall or EtOH

ix. >50, new HA (likely not new migraine Dx after age 50)

x. New HA plus cancer, HIV (toxic causes), pregnancy, coumadin

84

who needs a LP for a HA

i. Sudden, worst HA
ii. HA plus fever, stiff neck
iii. ALOC plus HA
iv. HA in young, obese female
v. New HA in HIV pt
vi. Looking for infection, blood, increased ICP

vii. CT generally precedes LP b/c looking for a shift. If there is a shift and you extract CSF, you can affect the pressure dynamics and the brain can herniate

viii. No LP if midline shift, blood or mass on CT

85

important points on PE for HA

Mental status, temperature and blood pressure

Eye exam, including fundoscopy

Neuro exam: CN, strength, sensory, gait, cerebellar

Neck: Meningeal Signs

HEENT: periorbital/dental/facial infection? Older pt’s palpate the temporal artery!
Rash

After the Hx and PE cross the unlikely Dx’s off the list. Tx/test for most likely – be able to “tell the story” of each and why it is off or on your list

86

labs for HA if no red flags

Upreg. Special: ESR*, PT/INR*

87

TX for – migraine or non-specific HA


• IV hydration – esp w/ vomiting
• NSAID, anti-emetic, antihistamine IM/IV
• NSAIDS: oral; IM/IV Ketorolac
• Anti-emetics – Metoclopramide, Compazine or Phenergan IM/IV
• Antihistamines – Benadryl IM/IV

88

if the standard tx does not help for HA treat with

• Steroids – Dexamethasone 8-10mg IM/IV
• Serotonin blockers: DHE, triptans – migraine specific
• Avoid narcotics!
• Home if:
• Pain less/gone
• Can take po’s/walk
• No new neuro deficit or change in VS
• Give return precautions, should not drive self home
• Rx oral NSAID, anti-emetic and/or triptan for your dx

89

first steps in managing high BP

High? Check it yourself, both arms, correct sized cuff

BP readings change during visit

Tx pain, anxiety before tx high BP

90

most important questions for pt with high BP

1. Is this an accurate reading?
2. How rapidly did it get this high?
3. Does the patient have symptoms?**
4. Is there evidence of end-organ damage?

91

RF for HTN

• Headache: sudden or severe or new

• Neuro complaints: weakness, confusion, ataxia: CVA, encephalopathy

• Visual changes: CVA, optic ischemia, papilledema

• Chest pain: ACS; TAD – thoracic aortic dissection (pulses equal?)

• SOB, DOE, edema: L/R pump failure: new CHF

• Abdominal/Back pain: AAA

• Urine changes – foamy (protein), blood? Think new renal failure

• Syncope: CVA, SAH

• Seizure: CVA, hemorrhage, Tox

• On meds – still HTN – consider secondary causes

• Pregnancy – preeclampsia, eclampsia

• Hyperthyroid, Tox

• End-organ damage usually involves kidney, heart, brain

92

Neuro complaints w/ HTN

weakness, confusion, ataxia: CVA, encephalopathy

93

EOD with HTN

kidney
heart
brain

94

• Visual changes with hTN

CVA, optic ischemia, papilledema

95

CP with HTN

ACS; TAD – thoracic aortic dissection (pulses equal?)

96

• SOB, DOE, edema with HTN

L/R pump failure: new CHF

97

• Abdominal/Back pain with HTN

AAA

98

• Urine changes with HTN

– foamy (protein), blood? Think new renal failure

99

• Syncope with HTN

CVA, SAH

100

seizures with HTN

CVA, hemorrhage, Tox
• On meds – still HTN – consider secondary causes

101

pregnancy with HTN

– preeclampsia, eclampsia

102

iii. New HTN Testing

: CBC,
CMP,
UA,
Upreg,
Tox screen,
EKG,
CXR;
Urine microalbumin
TSH
Lipids (as outpt?)

103

poorly controlled HTN in ED

1. Long-standing dx, no sx’s, appears well
2. Out of meds common, no secure follow-up
3. Testing as outpt if secure f/u
4. Give meds in ED, refill meds
5. BP must respond to tx
6. Discharge home, educate

104

New Dx of HTN – persistent readings >160/100 in ED

1. No prior dx/tx but no sx’s, appears well
2. Repeat BP after pain control
3. Initiate work up, secure f/u
4. Begin meds: if SBP >180, high risk for cardiac event w/in 1yr (usually amlodapine)
5. Discharge home, educate

105

DPB range fro HTN urgency

DPB 120-140mmHg or persistent systolic BP >180

2. Usually “poorly controlled” HTN – not sudden

106

HTN urgency with NO sxs of EOD

Order labs, UA, EKG, CXR (look for cardiomegaly, CHF, pleural effusions, widened mediastinum)

Oral tx in ED while waiting for labs/diagnostics (amlodipine)

7. Home with Rx if BP responds and still NO signs/sx’s

Secure f/u

Educate

107

HTN emergency (malignant)

1. DBP >130 or persistent sys BP >180 w/ signs/sx’s

Hx HTN; rapid, acute elevation

108

HTN emergency often seen with

flash pulmonary edema

109

sxs with malignant HTN

3. End-organ dysfunction is evident
a. Symptoms: chest pain, SOB, ALOC, hematuria, proteinuria, abdominal pain,etc
b. Lab/Diagnostics

110

Tx of HTN emergency

4. Reduce BP in the ED – goal is 25% reduction of MAP over 30-60min. (IV: Labetolol, Nicardipine, Nitrates)
5. Tx end-organ damage
6. Admit all

111

first cardinal sx of a hemorrhagic stroke

headache and then LOC

112

Todd’s paralysis

prolonged partial or complete paralysis, usually unilateral, after a generalized seizure. Can last up to 36-48hrs