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
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sensory deficits with middle cerebral CVA
Contralateral deficit
• Arms > legs
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if a pt has a CVA in the middle cerebral of dominant hemisphere
If affecting the dominant hemisphere: aphasia (either receptive or expressive
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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