Ischemic Stroke

Question 1

Stroke

Answer 1

• acute onset of neuro dysfunction
• 24 hours or more
• ischemia/hemorrhage

Question 2

Transient episodeof neuro dysfunction

• focal brain, spinal cord, retinal ischemia
• no acute infarction
• no Imaging evidence of damage

Answer 2

TIA

Question 3

CVA? Ministroke?

Answer 3

NO

Question 4

Majority of strokes?

Answer 4

Ischemic strokes

2) primary hemorrhages
3) subarachnoid hemorrhages

Question 5

Ischemic stroke

Answer 5

“Blockage stroke”

Also hypoperfusion/hypotension

Question 6

Arteries to brain

Answer 6

Common carotid R/L
Left vertebral artery R/L
Internal external carotid R/L

Question 7

Main Circle of willis arteries to brain

Answer 7

ACA
MCA
PCA

Question 8

Most reliable stroke symptom

Answer 8

ACUTE ONSET

Question 9

Medical risk factors

Answer 9

HTN
Afib
Hyperlipidemia
DM
Carotid Stenosis

Question 10

Behavioral riskfactors

Answer 10

Cig smoking
Sedentary lifestyle
Illicit drugs
ETOH heavy

Question 11

Other risk factors

Answer 11

Pre-eclampsia/eclampsia
Migraines w/ aura
Cardiac (list)
Genetic (list)

Question 12

Stroke subtypes

Answer 12

• Large artery atherosclerosis
• cardioembolism
• lacunar infarctions

Question 13

Large artery atherosclerosis

Extracranial

Answer 13

Carotid a

Vertebral a

Question 14

Lacunar infarction (small vessel)

Answer 14

Large arteries becoming blocked or hardened

• brain stem pons
• deep structures (putamen)
• thalamus

DM/HTN

Question 15

Acute Stroke Management

Answer 15

• activate brain attack
• Start ABCs
• Assess patient + perform a basic neuro exam
• NIHSS exam
• Basic Hx
• establish last known normal time

Question 16

Acute Imaging

Negative CT rule out ischemic stroke?

Answer 16

NO

Good for hemorrhagic stroke

Question 17

Diffusion weighted imaging MRI

Answer 17

MOST sensitive!

But CT scan best – time
If CT neg, still treat

Question 18

Apparent diffusion coefficient

Answer 18

Dark = stroke

Question 19

Diffusion Weighted Imaging

Answer 19

White = stroke

Question 20

rT-Pa

Answer 20

• give w/in 3-4.5 hours of onset = up recovery at 90 days
• no improvement after 24hours
• *some have hemorrhages

Question 21

Tissue loss /time

Answer 21

1.9 million neurons/minute

NOT TOTALLY TRUE

Question 22

Giving blood thinner Tpa

NOT to

Answer 22

High risk bleeder

• prev surgery
• anticoag Rxs
• Etc.

Question 23

Acute endovascular thrombectomy (catheter)

Answer 23

(Pulling out clot with catheter)

Up to 6 hours from onset

• unless posterior (basilar stroke)
• must be proximal

Question 24

Early stroke management goal

Answer 24

• BP management
• Dysphagia/Aspiration Pneumonia
• DVT/PE
• recurrent stroke

Question 25

BP management

Answer 25

Balancing hypoperfusion and hemorrhage * BP goal w/ rt-Pa = less 180/105 * w/o rt-PA = less 220/120

Question 26

DVT prophylaxis

Answer 26

LMW heparin/unfrac heparin Ealry ambulation Pneumatic compression device SCD= down VTE

Question 27

Recurrent stroke managemetn

Answer 27

Many w/in 3 months Most 2-5 days after onsel Aspirin 325mg w/in first 48 after stroke

Question 28

A fib management

Answer 28

Cardiac monitoring inpatient + outpatient -24/48 Holter, 30d loop recorder, implantable monitor *anticoags

Question 29

Coumadin vs others

Answer 29

If stop others, they stop that day If miss coumadin, it will linger a few days

Question 30

Carotid stenosis management

Answer 30

* Carotid imaging - MRA,CTA, Ultrasound, Conventional Cerebral angiogram * Think Carotid endarterectomy - depending on stenosis degree of symptomatic Internal carotid artery (ICA same side as stroke)

Question 31

Preventing a recurrent stroke management

Answer 31

Work up for risk factors * HTN * Afib * CAD * DM * Hyperlipidemia * Smoking * Diet/exercise

Question 32

Last known normal

Answer 32

If they went to sleep, and woke up w/ stroke, it was when they went to sleep

Question 33

Internal carotid artery to

Answer 33

Brain = anterior circulation

Question 34

External carotid artery to

Answer 34

Scalp

Question 35

Vertebral artery (vertebrobasilar system) to

Answer 35

Brain = posterior circulation

Question 36

Stroke s/s

Answer 36

ACUTE

Question 37

Ischemic stroke subtype = Cardioembolism - Where?

Answer 37

Common in LAA (left atrial appendage)

Question 38

Early ischemic stroke management Dysphagia / Aspiration Pneumonia

Answer 38

Bedside swallow evaluation + formal speech evaluation B/F ORAL MEDS

Question 39

Migrane w/ aura people More likely to have

Answer 39

Foramen ovale UP stroke risk