Stroke 1

Question 1

64 y/o R hand dom female w/ PMHx of HTN/HLD awakes w/ slurred speech and R arm wkness. Presents to ED within 30 mins, what is next step in tx?

Answer 1

CT scan of head without contrast (look for head bleed)

Question 2

Which vessel provides large part of blood to brain?

Answer 2

MCA superior division

(Middle Cerebral aa)

Question 3

Sudden focal neurological deficit or acute impairment caused by the interruption of blood flow to a specific region of the brain

• Sudden brain damage
• Lack of blood flow

Answer 3

Stroke

Question 4

2 types of stroke

Answer 4

• Hemorrhagic
• Ischemic

Question 5

• 85% of strokes are _____.
• 50 - 80% of all strokes are ____ through risk factor management
• 5th leading cause of death in US.
• Leading cause of serious disability in US w/ over 7 million survivors

Answer 5

• ischemic
• preventable

Question 6

• FAST
• List the prevalence of stroke by race (3)

Answer 6

• F: Face drooping
• A: Arm weakness
• S: Speech difficulty
• T: Time to call 911

1. Blacks
2. Hispanic/Latino
3. White

Question 7

• Which race compared to Caucasians have nearly double the incidence of strokes?
• And suffer more extensive physical impairments
• And are twice as likely to die from stroke

Answer 7

African Americans

Question 8

5 risk factors of African Americans for Stroke

Answer 8

• HTN
• Obesity
• DM
• Smoking
• Sickle Cell Anemia

(HODSS)

Question 9

• Which race has a higher incidence of strokes as compared to Caucasians, but not as much as African Americans?

Answer 9

Hispanics

Question 10

Which race?

• Increased risk for all types of stroke and Transient Ischemic Attacks (TIA) at younger ages than Caucasians?

Answer 10

Hispanics

Question 11

Which race are less likely to know the stroke sxs?

Answer 11

Spanish-speaking Hispanics

Question 12

Males or females suffer strokes more often?

Which age range?

Answer 12

Females (only slightly more)

80+ yrs

Question 13

The 3 R’s

Answer 13

• Reduce: stroke risk
• Recognize: stroke sxs
• Respond: at first sign of stroke, call 911 immediately

Question 14

3 components of the Cincinnati Pre-Hospital Stroke Scale

What is the sensitivity/ specificity if pt has all 3?

Answer 14

• Facial Droop
• Arm Drift
• Abnormal Speech

Sens: 100% Spec: 88%

Question 15

• Unilateral weakness
• Unilateral numbness / tingling
• Incoordination / clumsiness on one side of body
• Sudden speech/language change
• Acute confusion
• Loss of vision in both or esp. ONE eye
• Diplopia
• Sudden/Severe HA

Answer 15

Focal sxs of stroke

Question 16

When taking a focused hx of stroke, ask what 3 things to which 3 people?

Answer 16

• When was pt last at neuro baseline (normal)
• Pattern of onset (sudden or gradual)
• Sz at onset w/ associated bladder/bowel incontinence

Question 17

5 goals of examination

Answer 17

• ABCDEFG’s (glucose)
• R/o mimics of stroke
• Localize lesions (focal vs diffuse) (UMN/LMN)
• Identify comorbidities
• Identify conditions which may influence tx decisions (recent surg/trama/active bleed/infection)

Question 18

6 components of focused physical exam of stroke pt

-What scoring system should be used?

Answer 18

• Level of consciousness
• Language
• Visual fields / eye movements
• Strength / drift / reflexes
• Coordination
• Sensation

NIHSS (National Institutes of Health Stroke Scale)

Question 19

• Standardized method used by health care professionals to measure level of impairment caused by stroke
• Used to see if tPA needs to be given
• Usable for research (objective comparison of efficacy of diff stroke txs)
• Determines if change in exam has occurred
• Scores are totaled to determine level of severity

Answer 19

National Institiute of Health Stroke Scale

(NIHSS)

Question 20

• NIHSS is a ___ item scoring system w/ a __ minute exam.
• Integrates ____ exam components
• 6 components of exam?
• Minimal score is ___ (normal)
• Max score is ___ (severe stroke)
• Scores greater than ___ to ___ are more severe

Answer 20

• 13 / 7
• neurologic
• CN (visual), motor, sensory, cerebellar, inattention, language, LOC
• 0
• 42
• 15-20

Question 21

NIHSS Interpretation

• Score for no stroke
• Score for Severe Stroke

Answer 21

• 0
• 21 - 42

Question 22

• < ___ to ___ will have an 80% good/excellent outcome
• ___ to ___ will have a less than 20% good/excellent outcome
• _____ pts had the BEST outcomes**

Answer 22

• 12 - 14
• 20 - 26
• Lacunar Infarct

Question 23

National Institute of Neurological Disorders & Stroke

• Benefit at ___ hours is not significant
• ____ dependent
• Tx pts are ___ % more likely to have minimal/no disability at ___ months.

Answer 23

• 24 hours
• Time (earlier the better)
• 30% / 3 months

Question 24

Stroke Types:

• Clot occluding artery
• Bleeding INTO brain
• Bleeding AROUND brain

Which ones cause focal brain dysfunction?

Which ones cause diffuse brain dysfunction?

Answer 24

• Ischemic stroke (MC at 85%)
• Intracerebral Hemorrhage (10%)
• Subarachnoid Hemorrhage (LC at 5%)

Focal: Ischemic / Intracerebral

Diffuse: Subarachnoid / Intracerebral

Question 25

**2 Types of Stroke** 1. Caused by blocked blood vessel in brain or vessel that feeds brain 2. Caused by ruptured blood vessel in brain

Answer 25

1. Ischemic 2. Hemorrhagic

Question 26

Most common type of ischemic stroke, and results from the occlusion of small penetrating arteries that provide blood to the brain's deep structures.

Answer 26

Lacunar Infarct / Stroke

Question 27

What is the most common vascular obstruction leading to thrombosis? (thrombotic stroke)

Answer 27

Atherosclerosis

Question 28

What are the 2 most common sources of emboli? (embolic stroke)

Answer 28

* Left sided cardiac chambers * Artery to artery stroke (detachment of a thrombus from ICA-internal cardotid artery at site of plaque)

Question 29

3 etiologies of Ischemia Stroke

Answer 29

* Cardioembolic * Large Vessel Disease (atherosclerosis) * Small Vessel Disease (Lacunar infarction)

Question 30

* Sudden onset * Focal neuro sxs * Interuruption in blood supply to part of brain * \>24 hrs * Typically \>1 hr * Permanent damage

Answer 30

Acute Ischemic Stroke (AIS)

Question 31

* Sudden onset * Focal neuro sxs * Transient lack of blood supply & focal ischemia * \<24 hours * Typically \<1 hr (90%) NO permanent damage to brain

Answer 31

Transient Ischemic Attack (TIA)

Question 32

**TIA** * Originally defined as a focal neurologic event lasting \<24 hours * Revised guidelines change this to consider \_\_\_\_\_, NOT \_\_\_\_\_.

Answer 32

* Consider **amount of injury**, NOT timeline

Question 33

**TIA** * _____ can lead to permanent brain damage * Will injury show up on MRI? * What is the pathophys of TIA?

Answer 33

* Brief ischemia * Up to half of traditionally defined pts w/ TIA show injury on MRI * Similar to stroke, but unknown why similar events produce TIA only

Question 34

What % of people who experience TIA do not report it?

Answer 34

50%

Question 35

**AHA - Endorsed Revised Definition of TIA** * A transient episode of neurological dysfunction caused by focal \_\_\_, \_\_\_, or \_\_\_\_\_ischemia, WITHOUT acute infarction * The reference to _____ was not helpful as is does not demarcate events with and without tissue infarction.

Answer 35

* brain, spinal cord, or retinal * a 1 hour time point

Question 36

One quarter to one half of strokes that occur within 3 months of TIA occur within what time frame?

Answer 36

Within the first 2 days

Question 37

Which 2 risk stratifications predict short term risk of stroke well in independent popualations of pts presenting acutely after a TIA?

Answer 37

* The California score * ABCD score

Question 38

What is the newer score which provides a more robust prediction standard and incorporates elements from both the prior scores?

Answer 38

* ABCD²

Question 39

**ABCD²** * Age ___ or older * BP \_\_\_/\_\_\_ or over on first evaluation * Clinical sxs of ___ or \_\_\_\_ * Duration of ___ minutes or greater or __ - ___ mins * D?

Answer 39

* 60+ * 140/90 * Focal weakness w/ spell or Speech impairment w/o weakness * 60 mins / 10-59 mins * Diabetes

Question 40

* What dx test (including diffusion sequences), should be considered a preferred test in investigation of pt w/ potential TIAs? * May confirm focal ischemia as cause of pt's deficit improves accuracy of dx of vascular localization & etiology of TIA * Assesses extent of pre-exisiting cerebrovascular injuries

Answer 40

MRI

Question 41

**Class 1 Recommendations:** * Pts w/ TIA should preferably undergo ____ within ____ hours of symptom onset. * What is the preferred brain dx imaging modality? * What is second best brain dx imaging?

Answer 41

* neuroimaging evaluation / 24 hrs * MRI, including DWI (diffusion weighted imaging) * Head CT

Question 42

**Class 1 Recommendations of TIA** * What should be performed routinely as part of evaluation of pts w/ suspected TIAs?

Answer 42

Non-invasive imaging of the cervicocephalic vessels

Question 44

**Class 1 Recommendations of TIA** * ___ reliably excludes the presence of intracranial stenosis * Pts w/ suspected TIA should be evaluated as soon as possible after event

Answer 44

* Non-invasive testing of the intracranial vasculature

Question 45

**Class 2 Recommendations** * Initial assessment of extracranial vasculature may involve what 4 tests? (depending on local availability and expertise)

Answer 45

* Carotid US * TCD (transcranial doppler) * MRA * CTA

Question 46

**Class 1 or 2? (TIA)** * Electrocardiography should occur as soon as possible after TIA * Prolonged cardiac monitoring (Holter Monitor) is useful in pts w/ unclear etiology

Answer 46

2

Question 47

**Class 2 Recommendations of TIA** * _____ is reasonable in eval of pts w/ suspected TIAs, esp when pt has no cause identified by other elements of work up. * Is useful in identifying Patent Foramen Ovale and Aortic Arch Atherosclerosis, and Valvular disease

Answer 47

* Echocardiography (at least TTE) * TEE

Question 48

Zone of reversible ischemia around the core of irreversible infarction (salvageable in first few hours after ischemic stroke onset)

Answer 48

Penumbra

Question 49

Penumbra is damaged by what 4 things?

Answer 49

* Hypoperfusion * Hyperglycemia \>400 * Fever * Seizure