Term
What 5 questions need to be answered when assessing a stroke? |
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Definition
1. Is it a vascular event?
2. Is hospitalization req'd?
3. is the event hemorrhagic or ischemic?
4. Does the event localize to ant or post location?
5. What is the mechanism? |
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Term
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Definition
| A transient ischemic attack is a focal event w/focal sxs that totally resolves w/in 24 hrs. |
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Term
| What sxs are present with a migraine that are not present with a TIA? |
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Definition
| scintillating scotomas (lighting bolts in peripheral vision) & tingling paresthesias (unilateral UE or around mouth) |
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Term
| What time frame shows highest risk of stroke after a TIA? |
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Definition
| Highest rate is in the first month (especially the first 48 hours) after TIA |
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Term
| What are the "negative" sxs that accompany an ischemic attack? |
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Definition
| Can't feel arm, can't see on the R-side - visual or sensory deficits |
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Term
| What are sxs that can help distinguish a partial seizure from a TIA? |
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Definition
Partial seizures:
-tend to produce "positive" signs
-focal tonic/clonic movement of an extremity
-time to maximal deficit longer in a partiel seizure (tendency for seizures to "march")
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Term
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Definition
1. inner ear dysfxn (labrynthitis, vestibulopathy) - vertigo w/o other brainstem/cerebellar sxs (no crainal nerve abnormalities; no face drop) OR vertigo w/auditory sxs.
2. MS - sxs are not restricted to a single vascular area, pts usu are younger w/o CVA risk factors
3. Hemorrhage into a tumor present w/sudden but not transient sxs (keeps getting worse)
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Term
| What are some reasons that you might hospitalize a pt w/a vascular event? |
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Definition
1. high risk for recurrent events
2. pt would benefit from IV anticoag therapy (w/in 3hrs of event)
3. if cardiac emboli is suspected (or in those w/AFIB or recent MI) |
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Term
| A pt calls stating she had an episode three days ago where it felt like a "shade was being pulled over her left eye". She said she couldn't come in that day and would like to know what to do now? The pt has no cardiac history. What do you tell her? |
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Definition
1. start taking 325mg ASA immediately
2. come in to the office within the next 1-2d for workup |
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Term
| A pt comes to your office to discuss an event that happened 1 week ago. Based on her description of sxs it appears as if she has a TIA. The pt has no cardiac history or risk factors for recurrent attack. What meds do you start her on? |
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Definition
| Plavix, 75mg qd with 325mg qd (add a PPI if needed) |
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Term
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Definition
weakness, clumsiness, sensory loss - opposite leg affected |
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Term
| What areas of the brain do the ACA, MCA & PCA supply? |
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Definition
ACA - medial surface of cerebrum
MCA - lateral surface of cerebrum
PCA - brainstem, visual area of cerebrum, cerebellum |
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Term
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Definition
affects the lateral surface causing:
1. hemiparesis (contralateral arm & face)
2. hemisensory loss (contralateral arm & face)
3. homonymous hemianopia (contralateral)
4. aphasia (if on L) mainly expressive d/t trauma of Broca's area |
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Term
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Definition
1.hemianopia or quadrantanopia w/macular sparing
2.contralateral hemiplegia w/possible dysmetria, cerebellar ataxia, tremor
3.CN III palsies |
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Term
| sxs of vertebrobasilar stroke |
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Definition
(at base of brain)
1.diplopia
2.CN signs
3.B/L motor & sensory signs
4. ataxia
5.vertigo
6.facial weakness or palsy (ipsilateral) |
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Term
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Definition
1. severe, horrible HA
2. fluctuating LOC
3. meningeal signs: nuchal rigidity |
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Term
| What test is ordered if a stroke is suspected? |
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Definition
| CT w/o contrast first. If no bld is found add contrast. If still nothing then MRI. |
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Term
| Which is more common, an ischemic or a hemorrhagic stroke? |
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Definition
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Term
| How many vascular areas are involved in an ischemic stroke? |
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Definition
| Only 1. It is a involves only a single vascular territory w/sxs worst at the event - improving as time goes on. |
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Term
| What sxs of a thalamic hemorrhage can drive pts to suicide? |
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Definition
| burning pain similar to that of phantom limb pain |
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Term
| What imaging is best for small infarcts, especially in the posterior or veretbrobasilar circulation? |
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Definition
| MRI is superior to CT for small infarcts. Imaging may take 24-48h to appear abnormal. |
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Term
| What arteries supply the anterior circulation? |
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Definition
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Term
| What arteries supply the posterior circulation |
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Definition
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Term
| What 4 grps of dx are assoc. w/CVAs? |
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Definition
1. Cardiac disorders
2. Lrg vessel, craniocervical occlusive dx
3. sm vessel, intracranial occlusive dx
4. hematologic disorders
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Term
| Most common mechanism of CVA |
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Definition
| Embolus from a proximal artery or the heart. Commonly atherosclerotic dx of carotid artery @ carotid bifurcation. |
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Term
| What is a lacunar infarct |
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Definition
| microinfarcts (<1cm) of small penetrating brain arteries in deep cortical sites & brainstem. |
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Term
| If imaging shows >1 vascular territory what is most likely cause of CVA? |
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Definition
| Cardiac emboli (multiple infarcts do not happen w/carotid etiology) |
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Term
| What are sxs of retinal ischemia? |
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Definition
1. Amarosis fugax - transient monocular blindness
2. may have carotid bruit
3. possible retinal hemorrhages on fundoscopic exam |
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Term
| What artery is occulded to cause amarosis fugax? |
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Definition
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Term
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Definition
1. either pure motor hemiparesis or pure sensory hemianesthesia
2. dysarthria (clumsy hand syndrome)
3. step-wise progression of deficits |
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Term
| Etiology of lacunar infarcts |
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Definition
| atherosclerosis assoc. with uncontrolled DM or HTN |
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Term
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Definition
| 325mg ASA qd immediately & control of risk factors |
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Term
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Definition
1. CT of head w/o contrast -> w/contrast -> MRI
2. Labs: CBC, platelets, PT/PTT, ESR, serum chemistry, lipid profile
3. EKG (to r/o MI)
4. CXR (to r/o CHF) |
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Term
| Txt of TIA if happened previously |
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Definition
1. txt all CV risk factors
2. if no cardiac history: 325mg ASA qd
3. if cardiac source: PO warfarin, 5mg qd for 3-6mos - maintain INR btwn 2.0-3.0 |
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Term
| Non-modifiable CVA risk factors |
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Definition
1. >55yo
2. male
3. heredity
4. race/ethnicity (Black/Hispanic) |
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Term
| Modifiable CVA risk factors |
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Definition
1. HTN: every decrease in diastolic bp of 7.5mmHg = 46% risk decrease
2. Post-MI: EF<28%, Afib, presence of LV thrombi - txt w/warfarin & statins
3. Afib w/valvular heart dx (17x risk) - Afib pts >75yo w/ or w/o risk factors txt w/warfarin
4. DM: atherodclerosis ACCELERATED d/t glycosylation induced injury (promotion of plaque formation thru hyperinsulemia)
5. Carotid artery stenosis: >60% w/no sxs=endarterectomy; txt w/antiplatelet therapy
5. EtOH: >5 drinks/d |
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Term
| What chronic dx is assocaited w/lacunar infarcts? |
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Definition
| DM - tight control of serum glucose is best txt |
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Term
| Why do deficiencies of B6, B12 or folic acid increase chance for stroke? |
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Definition
| B/c their deficiencies lead to increased homocysteine levels which in turn increases one's chance for a CVA. |
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Term
| Why is lupus a risk factor for stroke? |
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Definition
| Lupus is an autoimmune dx that presents with vasculitis from antiphospholipid antibodies that become stuck in vasculature thus placing the pt in a hypercoaguable state. |
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Term
| The presence of what type of sxs indicates an increase risk of stroke? |
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Definition
| cerebral hemisphere sxs (i.e. LA numbness) are indicative or a higher risk of stroke than say retinal sxs (amaurosis fugax) |
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Term
| Sxs of interal carotid artery dx |
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Definition
| amaurosis fugax, contralateral hemiparesis, hemianesthesia, hemianopia, aphasia (L hemisphere), hemineglect (R hemisphere) |
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Term
| What structures does the internal carotid artery supply? |
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Definition
| frontal, parietal, temporal lobes & medial surface of the cerebral hemisphere. |
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Term
| P/E findings of Internal Carotid Artery dx |
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Definition
1. retinal emboli
2. bruits |
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Term
| Who are candidates for an endarterectomy? |
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Definition
| In pts w/symptomatic carotid artery stenosis or in pts w/>70% stenosis. |
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Term
| Risk factors for endarterectomy |
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Definition
| HTN, recent MI, angina, COPD, morbid obesity, >70yo |
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Term
| Thrombolytic therapy candidiates must present to ER within ______ hrs. |
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Definition
| Onset of sxs must be within 3 hrs before txt is started. If your pt awakened w/neuro deficits the time of sxs onset is considered time they went to bed. If t-PA given w/in this time frame it effectively imporves neuro status |
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Term
| Exclusion criteria for thrombolytic therapy |
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Definition
1. rapidly improving deficit
2. obtundation or coma (usu hemorrhagic stroke)
3. seizure
4. mild deficit
5. BP> 185/110
6. GI/GU hemorrhage w/in 21 d
7. ischemic stroke or serious head trauma within preceding 3mths
8. hx of intracranial hemorrhage or bleeding dx
9. major surgery w/in preceding 2wks
10. Heparin in last 48h w/inc. activated partial thromboplastin time (NL:30-40s, if >100s NO txt)
11. Anticoag txt w/PTT>15sec (NL: 11-12.5s)
12. Glucose level <50 or >400 |
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Term
| Relative contraindication for thrombolytic therapy |
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Definition
| arterial/lumbar puncture w/in 1 wk |
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Term
| Major complication of thrombolytic therapy |
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Definition
| Intracranial hemorrhage - suspect if neuro status deteriorates by the hour. A CT will confirm hemorrhage - if it does give platelets & cryoprecipitate w/neruo consult. |
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Term
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Definition
Pt must be monitored in ICU - 0.9mg/kg dose (max 90mg) - 10% given as bolus w/remaining given over 60mins. BP<185/105mmHg & no heparin/ASA for 24 hours post-txt |
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Term
| What CT findings must be absent for T-PA therapy to be initiated? |
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Definition
1. no midline shift
2. no hemorrhage
3. no mass effect |
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Term
| #1 & #2 causes of hemorrhagic stroke |
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Definition
1. Aneurysms
2. Vascular malformations
(w/HTN, bleeding disorders, tumors, drug as other causes) |
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Term
| Possible warning signs of aneurysm |
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Definition
1. HA
2. transient unilateral weaknes
3. transient numbness & tingling
4. transient speech disturbance
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Term
| Most common cause of intracerebral hemorrhage |
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Definition
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Term
| Clinical presentation of hemorrhagic stroke |
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Definition
| Dependent on location but HA, decreased LOC, seizures are typical |
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Term
| What may hide under hematomas in the brain? |
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Definition
| tumors or vascular abnormalities |
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Term
| Why shouldn't you immediately lower the BP of a pt who just suffered a HTN hemorrhagic stroke? |
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Definition
B/c it can affect the cerebral autoregulation & further compromise ischemia. If BP>200 it is ok to lower to 170-200 w/continuous monitoring. After 2 wks lower it to <140/90 (this can be done b/c whatever swelling is present is usu gone) |
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Term
| When should PT be started for stroke pts? |
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Definition
| Immediately! Early mobilization & active rehab is extremely important for recovery of pt. Passive movements aid in preventing contractures. |
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Term
| Only proven effective therapy for CVA |
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Definition
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