87. Stroke

Question 1

What is stroke?

Answer 1

decrease CBF to specific area

Question 2

Name 2 main categories of ischemic stroke

Answer 2

thombotic - causin large or small vessel occulsion (lacunar)
cardioembolic

Question 3

MC cause of stroke

Answer 3

atherosclerosis

Question 4

RF for stroke

Answer 4

atherscleorsis
Pregnancy, the use of oral contra- ceptives, antiphospholipid antibodies (such as lupus anticoagulant and anticardiolipin antibodies), protein S and C deficiencies, sickle cell ane- mia, and polycythemia all predispose patients to sludging or thrombo- sis, thereby increasing the risk of stroke.

Question 5

List 8 causes of stroke

Answer 5

atherosclerosis
trauma - dissection
fibormuscular dysplasia/ctd
stimulant drugs like cocaine
spinal maniuplation
recent meningitis
vasculopathy
inflammatory processes

Question 6

TIA defn

Answer 6

A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.”

Question 7

Name 2 major causes of hemorrhagic stroke/ICH

Answer 7

HTN
cereral amyloid

Question 8

Why does spontanous hemorrhagic stroke occur from HTN?

Answer 8

degenerative changes in the small penetrating arteries and arterioles, leading to lipohyalinosis of small, deep penetrating arter- ies. Such hemorrhages generally occur in the deep regions, including basal ganglia and thalamus.

Question 9

List 5 factors leading to ICH

Answer 9

underlying vascular malfor- mations (i.e., arteriovenous malformations [AVMs] and aneurysms, drug intoxication [particularly sympathomimetics, such as cocaine], malignant hypertension, saccular aneurysms, blood dyscrasias, venous sinus thrombosis, hemorrhagic transformation of an ischemic stroke, moyamoya disease, and tumors

Question 10

List 3 high risk features for secondary form of ICH

Answer 10

lobar location, presence of intraventricular blood, and younger age.

Question 11

Nmae 3 mc sites of HTN causing ICH

Answer 11

Putamen (44%)
Thalamus (13%)
Cerebellum (9%)
Pons (9%)
Other cortical areas (25%)

Question 12

What is the normal cerebral blood flow rate and at what point do physiologic changes occur (ie drops below…)

Answer 12

normal CBF is approximately 40 to 60 mL/100 g of brain per minute. When CBF drops below 15 to 18 mL/100 g of brain per minute,

Question 13

What is ischemic penumbra?

Answer 13

area of brain surrounding primary injury - tenuous blood supply

Question 14

How does ICH cause injury after acute vessel rupture?

Answer 14

• mass effect of hematoma
• activation of coag cascade
• release inflamm CK
• BBB disruption
  = perihematoma edema and secondary brain injury
  –> continued bleed/hematoma expansion causes further injury

Question 15

Anterior circulation comes from the carotid system and perfuses which parts of the brain?

Answer 15

optic n
retina
frontoparietal
antero-temporal lobes

Question 16

First branch off ICA is the ?

Answer 16

opthalmic a

Question 17

Anterior cerebral a supplies which parts of brain (generally)?

Answer 17

basal and medial aspects of the cerebral hemispheres and extends to the anterior two-thirds of the parietal lobe.

Question 18

What classic sx indicates an opthalmic a potential stroke?
What does this involve?

Answer 18

amarosis fugax

involving the anterior circulation (specifically the ipsilateral carotid artery) at or below the level of the ophthalmic artery.

Question 19

What artery feeds putamen, part of the anterior limb of the internal capsule, the len- tiform nucleus, and the external capsule.

Answer 19

lenticulostriate branches of mca

Question 20

What supplies the lateral surfaces of the cerebral cortex from the anterior portion of the frontal lobe to the posterolateral occipital lobe.

Answer 20

main cortical branches of mca

Question 21

What does the posterior circulation supply?

Answer 21

brainstem (which is critical for normal consciousness, movement, and sensation), cerebellum, thala- mus, auditory and vestibular centers of the ear, medial temporal lobe, and visual occipital cortex.

Question 22

What 2 arteries are part of the posterior circulation

Answer 22

vertebral a
PICA

Question 23

When may anterior circulation strokes progress vs posterior?

Answer 23

first 24h
up to 3d

Question 24

What symptoms are concerning for an ACA stroke?

Answer 24

frontal -
altered mentation coupled with impaired judgment and insight, as well as the presence of primitive grasp and suck reflexes on physical examination.

Bowel and bladder incontinence may be features of anterior cerebral artery stroke. Paralysis and hypes- thesia of the lower limb opposite the side of the lesion are characteris- tic.

Leg weakness is more pronounced than arm weakness in anterior cerebral distribution stroke.

Apraxia or clumsiness in the patient’s gait is often observed.

Question 25

Concerning sx for MCA stroke

Answer 25

- arm and face > leg, contralateral side to lesion - hemianopsia/blin dness -gaze preference TOWARD lesion - aphasia - Wernicke vs broke - dysarthria

Question 26

What is Wernicke's asphasia?

Answer 26

normal speech, unable to understand

Question 27

What is Broca aphasia?

Answer 27

inability to communicate verbally but understand

Question 28

Vertebrobasilar symptoms for stroke are wide - describe some that you may see

Answer 28

- CN deficit - cereellum involvemnt - neurosensory tract disruption including emesis from discritipkn of chemoreceptor trigger zone - visual agnosia (not recognizin obj) - alexia (inability to understand written word) - visual neglect "vertigo, syncope, diplopia, visual field defects, weakness, paralysis, dysar- thria, dysphagia, spasticity, ataxia, or nystagmus may be associ- ated with vertebrobasilar artery insufficiency."

Question 29

Pronator drift - most sn sign for?

Answer 29

mo weakness

Question 30

What are the components of the Cincinati Prehospital stroke scale?

Answer 30

facial dropp n/ab arm drift: normal/abnormal speech: n/abn (slurred)

Question 31

National Institute of Health Stroke Scale form (NIHSS) - name its 11 components

Answer 31

1- LOC - ask age, month, ope n and close eyes/grip and release, 2. horizontal EOM/doll eyes 3. visual field 4. facial palsy 5. mo arm 6. motor leg 7. limb ataxia 8. sensory - safety pin 9. language - describe object, reading 10. dysarthria 11. extinction/neglect

Question 32

List 8 mimickers of ischemic stroke

Answer 32

brain bleed carotid dissection brain tumor brain abscess air embolism seizure low BG wernicke encephalopathy complex migraine bells palsy labrynthinits vestibular neuronitis perupheral n palsy menierre disease GCA

Question 33

What are the 5 components of of the ICH score predicting mortality after acute intracerebral hemorrhage

Answer 33

GCS ICH volume ICH - present/not (blood in ventricles) ICH location age

Question 34

What sx does CVST present with?

Answer 34

variable time frame of symptom onset (from hours to weeks). Patients may have generalized headaches, nausea, vomiting, pare- sis, visual disturbances, depressed level of consciousness, seizures, or symptoms generally ascribed to psychiatric disorders (such as depres- sion)

Question 35

Name 5 RF for CVST

Answer 35

trauma infection hypercoagulability low flow state compression venous sinus dehydration pregnant postpartum androgens/amphetamines/OCP

Question 36

Recommended tests for stroke

Answer 36

CT CTA

Question 37

Why is a CTA used?

Answer 37

identify the presence of intravascular thrombosis, vasculature dissection, or stenosis

Question 38

What ancillary tests to get in stroke (aside from ct/cta)

Answer 38

ecg cbc ptt, inr trop BG

Question 39

List initial steps in managin a suspected stroke

Answer 39

ABC normoxic normogylcemic normothermic ~normotensive

Question 40

BP goals in ischemic stroke

Answer 40

systolic BP is less than 185 mm Hg and their diastolic BP is less than 110 mm Hg

Question 41

How to lower BP in ischemic stroke? (options and doses)

Answer 41

IV labetalol 10 to 20 mg over 1 to 2 minutes; or continuous nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5 to 15 minutes (maximum 15 mg/h); or clevidipine 1 to 2 mg/h IV, titrate by doubling the dose every 2 to 5 minutes (maximum 21 mg/h). Other agents such as hydralazine and enalaprilat can be us

Question 42

How to improve low BP in ischemic stroke

Answer 42

fluid +/- vasopressor therapy

Question 43

How often to check BP in a stroke patient?

Answer 43

Monitor BP every 15 min during treatment and then for another 2 h, then every 30 min for 6 h, and then every hour for 16 h.

Question 44

Options for thrombolytic therapy

Answer 44

tpa: alteplase vs tenecteplase

Question 45

Dose of alteplase for stroke

Answer 45

0.9 mg/kg (maximum dose 90 mg) over 60 minutes with initial 10% of dose given as bolus over 1 minute. then rest as per dosing chart

Question 46

Dose of tenecteplase for stroke

Answer 46

moderate- to high-quality evidence that IV tenecteplase 0.25 mg/kg (maximum 25 mg) given in a single bolus has similar rates of functional outcome, symptomatic ICH, and mortality at 90 days compared with alteplase

Question 47

When can I give tpa

Answer 47

5), or disabiling features but mild stroke, reasonable baseline function and no CI

Question 48

Who cannot have tpA?

Answer 48

BRAIN: - ICH, ischemic stroke within 3mo, head trauma within 3mo (severe), acute head trauma, IC/intrasprinal surgery, hx ICH, SAH -IC neoplasm HEART: - ao arch dissection - IE GUT: - malignancy or bleed HEME: coagulopathy (plt <100, INR >1.7, aptt >40, PT .15) - on a blood thinner

Question 49

Name 8 factors associated with increased risk for sympatomatic ICH after thrombolysis

Answer 49

Older age Greater stroke severity Higher baseline glucose Hypertension Congestive heart failure Renal impairment Diabetes mellitus Ischemic heart disease Atrial fibrillation Baseline antiplatelet use Leukoaraiosis (periventricular white matter disease) Visible acute infarction on brain imaging Cerebral microbleeds

Question 50

What is the risk of sympatomic ICH after tpa?

Answer 50

2-7%

Question 51

ICH after thrombolysis therapy is based on which 2 main factors?

Answer 51

(1) radiographic appearance of the hemorrhage and (2) the presence of associated neurological deterioration

Question 52

Post tpa ICH - grade 1 defn

Answer 52

petechial hemor- rhage along the infarcted tissue margin

Question 53

Post tpa ICH - grade 2 defn

Answer 53

confluent petechial hemorrhage within the infarcted tissue

Question 54

Post tpa ICH - grade 3 defn

Answer 54

parenchymal hema- toma involving 30% or less of the infarcted tissue with slight mass effect

Question 55

Post tpa ICH - grade 4 defn

Answer 55

parenchymal hematoma involving greater than 30% of the infarcted tissue with significant mass effect

Question 56

post tpa - recommendations for when to repeat image

Answer 56

24 hours with repeat neuroimaging if there is any neurological deterioration

Question 57

What are "cerebral microbleeds"?

Answer 57

small accumulations of blood prod- ucts in brain tissue that are associated with cerebrovascular disease, dementia, and aging

Question 58

When are folks considered candidates for mechanical thrombectomy? 0-6 hours from sx onset per Rosen's

Answer 58

no significant prestroke disability (i.e., a mRS score of ≤1); (2) a causative occlusion of the ICA or the M1 segment of the MCA; (3) NIHSS score of ≥6; and (4) ASPECTS of ≥6 (associated with better functional outcome at 3 months)

Question 59

When are folks considered candidates for mechanical thrombectomy? 6-16 hours of symptom onset per rosen's

Answer 59

In selected patients with acute ischemic stroke within 6 to 16 hours of last known normal who have LVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended (with- out thrombolysis

Question 60

When are folks considered candidates for mechanical thrombectomy? 16-24h per Rosen's since sx onset:

Answer 60

LVO in the anterior circulation and meet other DAWN eligibility crite- ria, mechanical thrombectomy is a reasonable approach

Question 61

BP goal for ICH stroke

Answer 61

140-160sbp

Question 62

What are some factors effecting prognosis after ICH?

Answer 62

hematoma vol and location hematoma expansion age gcs on presentation IVentricular extension anticoagulant use

Question 63

Who needs an extraventricular drain with an ICH?

Answer 63

supratentorial ICH with radiographic hydrocephalus, especially in patients with decreased level of consciousness,

Question 64

Who should be considered for ICP monitoring and tx with ICH?

Answer 64

a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with intraven- tricular hemorrhage or hydrocephalus should be considered for ICP monitoring and treatment. A CPP of 50 to 70 mm Hg is recommended

Question 65

Goal CPP for those who present with ICH and need for ICP monitoring/tx

Answer 65

50-70 mmhg

Question 66

Goal of hypertonic saline for ICP management/prevention/tx

Answer 66

sodium goal of 145 to 155 mmol/L

Question 67

Is a cerebellar ICH a neurosurgery emergency?

Answer 67

yes

Question 68

TIA post management

Answer 68

talk to to neuro dapt as long as no CI

Question 69

ABCD2 score for assessing stroke risk in patients with a transient ischemic attack - components?

Answer 69

age, bp, clinical features, duration of sx, diabetes RF: age >60, initial bp >140/90, unilateral weakness speech impairment (w/o weakness, sx 10-50min, >60min, hx diabetes)