Stroke and TIA

Question 1

1. Definition of Stroke and TIA in general?
2. What are the causes of brain ischemia? 2
3. What are the causes of brain hemorrhage?

Answer 1

1. Definition: Alteration of cerebral blood flow
2. Brain ischemia
   - Thrombosis,
   - embolism or systemic hypoperfusion
3. Brain hemorrhage
   - Intracerebral hemorrhage

Question 2

Name the vessels in the cerebral arterial circulation (circle of willis)

8

Answer 2

See picture

Question 3

Arterial cerebral circulation

Note the posterior circulation and it’s major blood supply. Why is this interesting?

What is the most common vessel for ischemic stroke?

Answer 3

Posterior circulation in the area of the cerebellum and brainstem strokes are not as common but since they involve the brainstem they have terrible outcomes

MIddle cerebral artery

Question 4

What is the most common type of stroke?

What are the cardiac sources of ischemic stroke?6

What are the other causes of ischemic stroke? 4

Answer 4

Ischemic stroke is the most common stroke type.

CARDIAC CAUSES

1. Atrial fibrillation
2. ASD/VSD
3. Recent AMI
4. Endocarditis
5. Caradiac tumor
6. Valvular disorder

OTHER CAUSES

1. Atherosclerotic plaques
2. Vasculitis
3. Prothrombotic state
4. Cerebral hemorrhage

–(20% of strokes)

Question 5

How could atherosclerotic plaques cause stroke?

2

Answer 5

1. Emboli from rupture
2. Lack of perfusion from stenosis of vessels

Question 6

AFIB cause of stroke:

1. Commonly from what?
2. What area does it come from in the heart mostly?
3. Therapy to decrease the risk of stroke? 2

Answer 6

1. Embolization of intracardiac thrombi
2. Most commonly from the left atrial appendage

3.

• Anticoagulation decreases the risk of stroke by up to 70%
• Aspirin decreases the risk of stroke by 20-25%

Question 7

What are two congenital sources of stroke?

Answer 7

1. Atrial septal defect
2. Ventricular septal defect

Question 8

If atrial septal defect is associated with what it can cause stroke?2

What about VSD?

1

Answer 8

ASD

1. If associated with a R to L shunt can cause stroke
2. Patent foramen ovale

Ventricular septal defects

1. If associated with a R to L shunt can cause a stroke

Question 9

1. When is stroke most common in MI?
2. What area of the heart is most responsible for this?
3. What are the factors of the event that lead to stroke? 3

Answer 9

1. Most common in patients after an anterior wall infarction
2. Left ventricular wall mural thrombi

3.

• Large infarctions
• LV dilation
• CHF

Question 10

1. The emboli from endocarditis is from what?
2. Cardiac tumors can cause strokes how? 3

Answer 10

1. Endocarditis
   - Emboli from vegetations
2. Cardiac tumor
   - Obstruction of blood flow
   - Can lead to arrhythmias (like afib)
   - Embolization of tumor fragments

Question 11

1. What is the most common valve disorder that causes stroke?

Answer 11

Rheumatic mitral stenosis is the most commonly associated with stroke

Question 12

What are the two kinds of hemorrhagic strokes that equally make up the 20% of strokes?

Answer 12

1. Spontaneous intracerebral hemorrhage (10% of all strokes)
2. Subarachnoid hemorrhage (the other 10% of hemorrhagic strokes)

Question 13

Subarachnoid hemorrhages can be from what? 2

Answer 13

1. Intracranial aneurysm
2. Arteriovenous malformations

Question 14

Causes of spontaneous intracerebral hemorrhage

3

Answer 14

1. Associated with poorly controlled hypertension
2. Bleeding disorders
3. Amyloid angiopathy

Question 15

1. Spontaneous intracerebral hemorrhages associated with poorly controlled hypertension are often found where?
2. Less commonly where?
3. What are also associated with HTN or DM?

Answer 15

Commonly located in the

1. basal ganglia and
2. less commonly in the pons, thalmus, cerebellum or cerebral white matter
3. Lacunar infarcts are associated with HTN or DM

Question 16

How does amyloid angiopathy cause stroke?

Answer 16

Amyloid deposits lead to weakening of the cerebral blood vessels resulting in stroke

Question 17

Causes of subarachnoid hemorrhage

6

Answer 17

1. Trauma
2. Spontaneous SAH is usually related to a ruptured AVM or aneurysm
3. Abnormal vascular composition (amyloid angiopathy or dissection)
4. Illicit drug use such as cocaine or amphetamines
5. Intracranial arterial dissections
6. 20% may have no identifiable cause

Question 18

1. Intracranial aneurysm is most commonly located where?
2. How do aneurysms typically present?
3. What determines the risk of ruptures? 2
4. In general, size over ____carries a high risk of rupture

Answer 18

1. Most commonly located in the circle of Willis
2. Aneurysm is usually asymptomatic until rupture
3. Size and location determine the risk of rupture
4. In general, size over 1 cm carries a high risk of rupture

Question 19

Describe the pathophysiology of Arteriovenous malformations?

2

Answer 19

1. Abnormal arterial to venous connection
2. The venous side will often develop pressures as high as arterial which leads to rupture.

Question 20

1. Arteriovenous malformation pts are at risk for stroke and what else?

Answer 20

seizures

Question 21

Name the subtypes of hemorrhagic stroke? 2

Name the subtypes of ischemic strokes? 3

Answer 21

1. Hemorrhagic

Intracerebral hemorrhage

Subarachnoid hemorrhage

2. Ischemic

Anterior circulation

Posterior circulation

Lacunar

Question 22

1. Intracerebral hemorrhage definition?
2. Major causes? 6
3. Accumulation of blood over minutes to hours forms what?
4. As this grows what increases?

Answer 22

1. Arterial bleeding directly into the brain parenchyma
2. Major causes:
   - HTN,
   - trauma,
   - bleeding disorder,
   - amyloid angiopathy,
   - illicit drug use,
   - AVMs
3. Accumulation of blood over minutes to hours forming a localized hematoma
4. Neurologic symptoms increase gradually as the hematoma grows

Question 23

Intracerebral hemorrhage:

1. What is destroyed as the hematoma enlarges?
2. What makes this life-threatening?
3. How would this stroke have a higher morbidity and mortality?
4. Goal of treatment?

Answer 23

1. Brain tissue is destroyed as the hematoma enlarges.
2. Pressure created by blood and surrounding brain edema is life-threatening
3. Large hematomas have a high mortality and morbidity.
4. The goal of treatment is to contain and limit the bleeding.

Question 24

1. What are the two major causes of subarachnoid hemorrhages? 2
2. Bleeding into where? 2
3. Aneurysm bleeds into the CSF under arterial pressure and increases what?
4. How long does bleeding last? and what is a common risk?

Answer 24

1. 2 major causes are ruptured aneurysm (most common) or AVM
2. Bleeding into the CSF and the space surrounding the brain
3. increases the intracranial pressure
4. Bleeding lasts a few seconds but rebleeding is common

Question 25

Subarachnoid hemorrhage Main treatment goal? 2

Answer 25

1. Main treatment goal is identification of source of bleeding and treatment before rebleeding occurs. 2. The other goal of treatment is to prevent brain damage due to delayed ischemia related to vasoconstriction of intracranial arteries.

Question 26

The other goal of treatment is to prevent brain damage due to delayed ischemia related to vasoconstriction of intracranial arteries. Blood within the CSF induces what?

Answer 26

vasoconstriction, which can be intense and severe

Question 27

2/3 of all ischemic strokes affect the anterior circulation: Which vessels? 2

Answer 27

Middle cerebral artery Anterior cerebral artery

Question 28

MCA is the most commonly involved vessel in ischemic stroke due to what?

Answer 28

the direct flow from the internal carotid artery and it’s large size

Question 29

Blood supply to the posterior portion of the brain, including the occipital lobes, cerebellum and brainstem. What are arteries are involved?

Answer 29

1. Vertebral artery 2. Basilar artery (90% mortality) 3. Posterior cerebral artery

Question 30

Ischemic strokes: Lacunar infarcts are what? Where can you see them? 6

Answer 30

Small lesions (less than 5mm) that occur in the penetrating arterioles in the 1. basal ganglia, 2. pons, 3. cerebellum, 4. internal capsule, 5. thalamus and 6. deep cerebral white matter

Question 31

1. How would you describe the prognosis of lacunar strokes? 2. What are they often seen as on a CT? 2

Answer 31

Less morbidity and mortality than other strokes On CT sometimes seen as 1. “punched-out hypodense areas” but sometimes 2. no abnormalities can be seen

Question 32

1. What is by far the most common subtype of stroke? 2. What is the culprit vessel in most ischemic strokes? 3. Anterior strokes occur from what? 4. Posterior strokes occur from what?

Answer 32

1. By far the most common type of stroke is ischemic 2. The MCA is the culprit vessel in most ischemic strokes 3. Anterior strokes occur from occlusion off the internal carotid artery or it’s branches 4. Posterior strokes occur from occlusion off the vertebral artery or it’s branches

Question 33

1. What kind of strokes can HTN cause? 2 2. There is an overlap of ICH and SAH. What does the diagnosis depend on?

Answer 33

1. Hypertension may cause - intracerebral hemorrhages (vessel rupture) - lacunar infarcts from small vessel occlusion 2. It all depends on the depth of the vessel that has ruptured.

Question 34

Risk factors for strokes?

Answer 34

Hypertension Diabetes mellitus Hyperlipidemia Cigarette smoking Cardiac disease Elevated blood homocysteine levels AIDS Recreational drug abuse Heavy alcohol consumption Family history of stroke Overweight Ischemic heart disease Peripheral vascular disease Sedentary lifestyle Men \> 45 and women \> 55 years old Oral contraceptives when combined with smoking in women Hypercoagulopathy Polycythemia Prior stroke Sleep apnea Bleeding disorders

Question 35

1. What is aphasia? 2. What does it impair? 2 3. Experience difficulty with what?

Answer 35

1. Acquired communication disorder 2. - Impairs ability to process language but does not affect intelligence - Impairs ability to speak and understand others 3. Experience difficulty reading and writing

Question 36

What are the types of aphasia? 4

Answer 36

1. Global 2. Anomic 3. Broca’s 4. Wernicke’s

Question 37

What is the most severe from of aphasia? What are the clinical symptoms? 3

Answer 37

Global aphasia 1. Produce few recognizable words 2. Understands little or no spoken speech 3. Can neither read or write

Question 38

What is anomic aphasia? What are the characteristics of this? 4

Answer 38

Persons who are left with a persistent inability to supply words for the things that they want to talk about. 1. Significant in nouns and verbs 2. Understand speech well\*\* 3. Read adequately 4. Poor writing ability

Question 39

1. What is the broca's area supplied by? 2. What is severely reduced? 3. What else is affected? 2 4. What is Broca's aphasia also called?

Answer 39

1. Broca's area supplied by superior division L MCA 2. Speech output severely reduced limited mainly to short utterances of less than four words 3. Reading, writing are affected also 4. AKA expressive aphasia

Question 40

1. What does the speech sound like in Broca's aphasia? 2. How is cognition and comprehension affected?

Answer 40

1. Formation of sounds often laborious/clumsy 2. Comprehension fair, cognitively intact

Question 41

Wernickes aphasia 1. Wernicke's area is supplied by what? 2. How will their speech be affected? 3. How is the pts comprehension affected? 2 4. Writing and reading affected? 5. Also known as?

Answer 41

1. Wernickes area supplied by inferior division of the L MCA 2. - Fluent, but meaningless spontaneous speech—jargon of real words and nonwords - Individual unaware of language errors unlike in Broca's aphasia 3. Comprehension poor 4. Writing, reading affected the same 5. AKA receptive aphasia

Question 42

1. What is dysarthria? 2. What is dysconjugate gaze? 3. What is apraxia?

Answer 42

1. Dysarthria- Problem with the muscles that produces speech 2. Dysconjugate gaze- Failure of the eyes to turn together in the same direction 3. Apraxia- Difficulty with the motor planning to perform tasks or movements when asked

Question 43

1. What is dystaxia? 2. What is agnosia?

Answer 43

1. Dystaxia- Lack of muscle coordination 2. Agnosia- Inability to process sensory information. Often there is a loss of ability to recognize objects, persons, sounds, shapes, or smells.

Question 44

Describe the fast campaign? 4

Answer 44

F Facial droop A Arm weakness S Speech difficulties T Time to call 911

Question 45

Which patient has symptoms of a stroke? A. Sudden onset severe headache B. Severe dizziness, nausea and vomiting C. Acute speech deficit D. Sudden onset impaired consciousness without focal neurologic deficits E. Right sided facial droop with weakness of the right arm and leg

Answer 45

ALL OF THEM

Question 46

Subarachnoid hemorrhage 1. Onset of symptoms? 2. Sudden increase in ICP may cause what? 3. Sudden severe headache described how? What is this followed by? 4. Usually what do we NOT see? 5. They may have signs of what kind of irritation? 6. Symptoms may be preceded by what? 2

Answer 46

1. Symptoms begin abruptly 2. cessation of activity (knees may buckle, loss of memory) 3. Sudden, severe headache “thunderclap” followed by vomiting 4. Usually no focal neurologic signs\*\*\*\* 5. May have signs of meningeal irritation 6. Symptoms may be preceded by heavy physical exertion or sex

Question 47

Intracerebral hemorrhage 1. Onset? 2. Symptoms increase in correlation with what? 3. What symptoms occur in half of pts? 2 4. Symptoms may be preceded by what? 2

Answer 47

1. Symptoms are slower in onset than SAH and increase over minutes to hours 2. Symptoms worsen as the hematoma enlarges 3. - Headache - vomiting occur in about half of patients 4. Symptoms may be preceded by heavy physical exertion or sex

Question 48

1. Intracerebral hemorrhage: Neurological symptoms will vary based on what? 2. With a large hematoma what may you have?

Answer 48

1. depending on location and size of bleed and may be similar to ischemic symptoms 2. With large hematoma may have decreased LOC

Question 49

The brain damage on one side results in neurologic deficits where?

Answer 49

on the opposite (contralateral) side of the body

Question 50

General symptoms of an anterior circulation stroke (ACA and MCA) May have one or all of the following symptoms: 3

Answer 50

1. Face-hand-arm-leg contralateral hemiparesis 2. Aphasia 3. Dysarthria

Question 51

Anterior cerebral artery occlusion may cause what? 3

Answer 51

1. Leg weakness and sensory loss - Contralateral side affected 2. Arm (esp. proximal) weakness and sensory loss - Contralateral side affected 3. Urinary incontinence

Question 52

Middle cerebral artery occlusion may cause: 5

Answer 52

1. Contralateral hemiplegia in the face-arm-leg 2. Homonymous hemianopsia 3. If on the L and it is the dominant hemisphere = aphasia (wernickes or brocas aphasia) 4. Nondominant right hemisphere = confusion, spatial disorientation, sensory and emotional neglect 5. Apraxia

Question 53

Structures that rely on the posterior circulation blood supply

Answer 53

1. Brainstem 2. Thalamus 3. Hippocampus 4. Cerebellum 5. Visual cortex 6. Temporal lobes 7. Occipital lobe

Question 54

The brainstem has 3 parts and houses cranial nerves III-XII What nerves are in the midbrain? 2 What nerves are in the pons? 4 What nerves are in the medulla? 4

Answer 54

Midbrain III, IV Pons V, VI, VII, VIII Medulla IX, X, XI, XII

Question 55

Symptoms of posterior circulation stroke 5

Answer 55

1. Vertigo (must rule this out if someone has vertigo!!!) 2. Diplopia, dysconjugate gaze, ocular palsy, homonymous hemianopsia 3. Sensorimotor deficits – ipsilateral face and contralateral limbs (crossed findings), drop attack 4. Dysarthria 5. Ataxia

Question 56

5 D’s of posterior stroke symptoms

Answer 56

1. Dizziness 2. Diplopia 3. Dysarthria ---Difficulty speaking (loss of motor control for speech) 4. Dysphagia --Difficulty swallowing 5. Dystaxia --Difficulty controlling voluntary movement

Question 57

Lacunar stroke symptoms 4

Answer 57

1. Pure motor loss (weakness) ---Most common presentation in up to 2/3 of cases 2. Or pure sensory loss 3. Sensorimotor stroke (2nd most common) 4. Ataxic hemiparesis

Question 58

Symptoms that may be unique for the followng stroke locations: 1. Anterior cerebral artery 3 2. Middle cerebral artery 4 3. Brain stem 3 4. Lacunar 2

Answer 58

See picture

Question 59

Describe the NIH Stroke Scale 5

Answer 59

see picture

Question 60

Acute evaluation

Answer 60

1. Timing of the onset of symptoms is critical 2. Assessment of stroke risk factors 3. Physical exam looking for stroke sources

Question 61

Blood work - Labs for strokes? 6

Answer 61

1. Lipid Profile 2. Blood sugar 3. CBC 4. CMP 5. PT/PTT 6. Cardiac biomarkers to R/O cardiac ischemia

Question 62

Diagnostic work up for strokes? 5

Answer 62

1. Acute work up = noncontrast CT of the head --only rules out/in hemorrhagic stroke 2. Later = MRI ± MRA of the brain 3. EKG 4. Ultrasound of carotids 5. Echocardiogram

Question 63

Window of opportunity to start treating stroke patients is \_\_\_\_\_hours, but to be evaluated and receive treatment, patients need to get to the hospital within \_\_\_\_\_\_\_\_?

Answer 63

3 60 minutes.

Question 64

Medical Tool bag 4

Answer 64

1. ASA 2. Heparin or Lovenox 3. Fibrinolytics 4. Percutaneous intracerebral intervention in selected cases

Question 65

1. Treatment for Ischemic stroke? (timeline this must be given) 2. Hemorrhagic stroke?

Answer 65

1. "Clot-busters" Must give within 3 – 4.5 hours and within an hour of arrival to the hospital 2. correct cause of hemorrhage

Question 66

What is tPA (Tissue Plasminogen Activator)? 2 What is the biggest risk with this?

Answer 66

1. Clot busting drug aka fibrinolytic aka thrombolytic 2. Dissolve the clot in ischemic strokes and the neurologic deficits are more likely to improve 3. If mistakenly give to hemorrhagic stroke patients = death

Question 67

Inclusion criteria for thrombolytics 3

Answer 67

1. Clinical diagnosis of ischemic stroke causing measurable neurologic deficit 2. Onset of symptoms less than 4.5 hours before beginning treatment 3. Age ≥18 years

Question 68

Exclusion criteria (History) 15

Answer 68

1. Significant stroke or head trauma in the previous three months 2. Previous intracranial hemorrhage 3. Intracranial neoplasm, arteriovenous malformation, or aneurysm 4. Recent intracranial or intraspinal surgery 5. Arterial puncture at a noncompressible site in the previous seven days 6. Symptoms suggestive of subarachnoid hemorrhage 7. Persistent blood pressure elevation (systolic ≥185 mmHg or diastolic ≥110 mmHg) 8. Serum glucose \<50 mg/dL (\<2.8 mmol/L) 9. Active internal bleeding 10. Acute bleeding diathesis, including but not limited to conditions defined in 'Hematologic‘ 11. Head CT scan Evidence of hemorrhage Evidence of a multilobar infarction with hypodensity involving \>33 percent of the cerebral hemisphere 12. Platelet count less than 100,000/mm3 13. Current anticoagulant use with an INR \>1.7 or PT \>15 seconds 14. Heparin use within 48 hours and an abnormally elevated aPTT 15. Current use of a direct thrombin inhibitor or direct factor Xa inhibitor with evidence of anticoagulant effect by laboratory tests

Question 69

Additional relative exclusion criteria for treatment from 3 to 4.5 hours from symptom onset 4

Answer 69

1. Age \>80 years 2. Oral anticoagulant use regardless of INR 3. Very severe stroke (NIHSS score \>25) ( ≥ 20 NIHSS is severe) 4. Combination of both previous ischemic stroke and diabetes mellitus

Question 70

Hospital Treatment for Stroke Who should be involved in the management? 6

Answer 70

1. Dietary 2. Neurology 3. Physical & Occupational Therapy 4. Speech Therapy - Swallowing evaluation - Speech retraining 5. Nursing 6. Physical medicine and rehab Dr. consultation

Question 71

Discharge medications for stroke? 6

Answer 71

1. Aspirin 2. Statin 3. Anticoagulation? 4. Plavix? 5. Antihypertensives (but only if its really really high, they need the perfusion pressure to help the brain heal) 6. Assess adequacy of blood sugar control if DM

Question 72

Recovery from Aphasia: After stroke – If symptoms last longer than \_\_\_\_\_\_\_\_\_\_months, complete recovery is unlikely

Answer 72

two or three

Question 73

Some residual effects of strokes 5

Answer 73

1. Emotional lability (mood swings, depression) 2. Perceptual effects: Difficulty recognizing, understanding familiar objects 3. Difficulty planning and carrying out simple tasks 4. Loss of awareness (one-side neglect) 5. Dysphagia (difficulty swallowing) and aspiration

Question 74

Medical complications of stroke 12

Answer 74

1. Bladder dysfunction 2. Bowel dysfunction 3. Pressure ulcers 4. Malnutrition 5. Dehydration 6. Falls and injuries 7. Recurrent strokes 8. Venous thromboembolism 9. Dysphagia 10. Aspiration pneumonia 11. Seizures 12. Spasticity

Question 75

1. What is a Transient ischemic attack (TIA)? 2. What about the symptoms makes TIAs different? 3. What kind of strokes are they?

Answer 75

1. A stroke like event lasting less than 24 hours (usually 20 minutes) that occurs secondary to cerebral ischemia 2. Symptoms resolve completely 3. All TIAs are ischemic

Question 76

TIA types 4

Answer 76

1. Amarosis fugax 2. Low flow 3. Embolic 4. Thrombotic

Question 77

TIA workup? 3

Answer 77

1. CT or MRI 2. Carotid ultrasound 3. Evaluation for source of emboli or thrombus

Question 78

Treatment for TIAs?

Answer 78

1. Consider admission to the hospital if seen within 72 hours of the symptoms 2. Risk factor management is the same as if the patient has had a stroke

Question 79

1. When should we activate stroke team? 2. What are questions to ask that we need to know? 2 3. What kind of workup should you do for TIAs?

Answer 79

1. Activate the stroke team ASAP even if you are not 100% sure it is a stroke they are there to help 2. - Need to know the onset of symptoms - Need to know the patient’s baseline neurologic function 3. Take all TIA’s serious – they warrant a complete workup

Question 80

1. What kind of treatment do we need to avoid in ischemic stroke? 2. Up to how many hours can thrombolytics be given?

Answer 80

1. In ischemic stroke avoid aggressive BP control (want to increase cerebral perfusion) 2. Thrombolytics can be given up to 4.5 hours from symptom onset (0-3 hours best outcomes)