NCS > Stroke I > Flashcards

Stroke I Flashcards

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1
Q

How many individuals who have a suspected TIA will have a stroke within 90 days?

A

Nearly 1 in 5

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2
Q

What is an ischemic stroke?

A

When a clot blocks or impairs blood flow, depriving the brain of essential oxygen and nutrients
- 87% of all strokes

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3
Q

What is a hemorrhagic stroke?

A

When weak blood vessels rupture, causing a leakage of blood in or around the brain
- 13% of all strokes

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4
Q

What are non-modifiable risk factors for stroke? (6)

A
  • increasing age
  • M > F
  • women are more likely to die from stroke
  • hereditary
  • race: African Americans and Hispanics > Caucasians
  • history of stroke
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5
Q

Potentially modifiable risk factors for stroke? (12)

A
  • HTN
  • tobacco use
  • diabetes
  • high cholesterol/obesity
  • physical inactivity and obesity
  • atherosclerosis
  • hx of TIA
  • atrial fibrillation
  • excessive alcohol intake
  • illegal drug use
  • oral contraception (ischemic)
  • anticoagulants (hemorrhagic)
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6
Q

What is a cerebral thrombosis?

A

*ischemic
Caused by atherosclerotic plaque formation inside brain arteries, leading to progressive blood flow blockage
- may involve large vessels or small penetrating vessels

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7
Q

What is a cerebral embolus?

A

*ischemic
Occurs when a blood clot or other material travels to the brain and obstructs a vessel
- common sources: heart or internal carotid artery

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8
Q

What is an intracerebral hemmorrhage?

A

Bleeding directly into brain tissues d/t vessel rupture
- typical sites: basal ganglia, cerebellum, brainstem, cortex

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9
Q

What are frequent causes of intracerebral hemmorrhage? (3)

A
  • long-standing HTN
  • alcohol or drug use
  • anticoagulant therapy
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10
Q

What is a subarachnoid hemorrhage?

A

Bleeding into the space between the brain and the skull (subarachnoid space)

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11
Q

What are the key signs of a subarachnoid hemorrhage? (3)

A
  • sudden, severe HA
  • neck pain
  • nausea or vomiting
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12
Q

What are common causes of a subarachnoid hemorrhage?

A

rupture of a cerebral aneurysm

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13
Q

What can be another cause of stroke outside of hemorrhage, embolus, or thrombosis?

A

reduced overall blood pressure or flow, limiting brain perfusion
*typically a watershed stroke

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14
Q

What is a cryptogenic stroke?

A

Strokes without a known cause

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15
Q

What is a Transient Ischemic Attack (TIA)?

A

Temporary blockage of blood flow to the brain
- clot usually dissolves on its own or gets dislodges
- “warning sign” signaling a possible full-blow stroke ahead (w/n next 90 days)

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16
Q

How long do symptoms for a TIA last?

A

< 5 min
(15 min max)
*few min to a few hours

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17
Q

Does a TIA cause permanent damage?

A

No

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18
Q

What is a crescendo TIA?

A

2 occurrences within 24 hrs
OR
3 occurrences within 3 days
OR
4 occurrences within 2 weeks

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19
Q

Do you call 911 if someone has a TIA and symptoms disappear?

A

Yes

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20
Q

Prognosis of stroke

A
  • higher mortality rate w/hemorrhagic stroke within the first 3 months
    *no difference after 3 months
  • survival negatively impacted by increased age
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21
Q

What are specific risk factors for ischemic stroke (6)

A
  • diabetes
  • afib
  • previous MI
  • previous stroke
  • intermittent arterial claudication
  • oral contraceptives
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22
Q

What does the clinical prediction rule: ABCD2 determine?

A

The risk of having a CVA following a TIA

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23
Q

What are the components of the ABCD2?

A

Age: >/= 60 years (1 pt)
BP: systolic > 140mm/Hg or diastolic > 90mm/Hg (1 pt)
Clinical features: unilateral weakness (2 pts), speech impairment w/o unilateral weakness (1 pt)
Duration of symptoms: >/= 60 min (2 pts), 10-59 min (1 pt)
Diabetes: 1 pt

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24
Q

What score indicates LOW risk of CVA using the ABCD2 prediction rule?

A

0-3 pts

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25
What score indicates MOD risk of CVA using the ABCD2 prediction rule?
4-5 pts
26
What score indicates HIGH risk of CVA using the ABCD2 prediction rule?
6-7
27
US guidelines for ABCD2 score >/= 3 - Assessment
Admission to hospital for a specialist assessment and treatment as soon as possible after the event
28
US guidelines for ABCD2 score < 3 - Assessment
Admission to hospital if there is uncertainty that diagnostic workup can be complete within 2 days as an OP
29
US guidelines for ABCD2 score >/= 3 - Imaging
Undergo neuroimaging evaluation w/n 24 hours of symptom onset - DWMRI or CT
30
US guidelines for ABCD2 score < 3 - Imaging
Undergo neuroimaging evaluation w/n 24 hours of symptom onset - DWMRI or CT
31
What are warning signs for stroke? (5)
- weakness, numbness, paralysis on one side of your body - slurred speech or difficulty understanding others - blindness in one or both eyes - dizziness - severe headache w/no apparent cause
32
What is timing on intervention so important in stroke?
Save the penumbra - reduce the ischemic penumbra - prevent the penumbra from proceeding to established infarct
33
What is the ischemic pneumbra?
Part of an ACUTE ISCHEMIC stroke that is at risk of progressive to infarction but is still salvageable if re-perfused *usually located around an infarct core which represents the tissue which has already infarcted or is going to infarct regardless of re-perfusion
34
Role of imaging in stroke treatment - CT
Aids in decision whether to administer tissue plasminogen activator (tPa)
35
Role of imaging in stroke treatment - MRI
Detects edema in the sub-acute phase of stroke that may no be visible on CT scans
36
Role of imaging in stroke treatment - CT Angiogram
Provide clear images of cerebral blood vessels to allow identification of stenosis, occlusion, aneurysms, and vascular abnormalities
37
Role of imaging in stroke treatment -MRA
Can detect high grade atherosclerotic lesions and less common causes of ischemic stroke
38
Role of imaging in stroke treatment - PET
Allows imaging of regional blood flow and cerebral metabolism
39
Medical Intervention - Ischemic Stroke
1. r-TPA: within 3 hours of onset *GOLD STND* 2. Mechanical removal of clot: w/n 6 hours + tPA 3. Anticoagulation therapy: Heparin, Warfarin 4. Anti-platelet therapy: Aspirin 5. BP management
40
Medical Intervention - Hemorrhagic Stroke
1. Stop anti-platelet and anticoagulant therapies 2. Normalize BP and decrease intracranial pressure - Surgery: for bleeding AVM, stereotactic radiosurgery, clipping of aneurysm, endovascular surgical blocking
41
What is allowed for permissive HTN?
*in ischemic stroke <185/110 before tPA <180/105 after administration of tPA
42
S&S of Anterior Cerebral Artery Syndrome (8)
- contralateral hemiparesis (LE>UE) - contralateral hemisensory loss (LE>UE) - urinary incontinence - problems w/imitation, bimanual tasks, apraxia - slowness, delay, motor inaction - poor judgement, decreased attention, decreased motivation, difficulty regulating emotions - contralateral grasp reflex - sucking reflex
43
Why are ACA strokes relatively rare?
Good collateral circulation
44
What do patient's with ACA strokes have difficulties with bimanual tasks?
Corpus callosum is affected *ACA supplies middle part of brain
45
How to remember clinical features of ACA stroke?
ACA >> ABCs >> kids/babies - contralateral grasp/sucking reflex - urinary Incontinence - babies imitate to learn - move slow, poor judgement, difficulty regulating their emotions
46
S&S of Middle Cerebral Artery Syndrome (5)
- contralateral hemiparesis (UE and face>LE) - contralateral hemisensory loss (UE and face>LE) - language and speech impairments: Broca, Wernicke, Global aphasia - perceptual disorders (unilateral neglect) - contralateral homonymous hemianopsia
47
What stoke is Alien Hand Syndrome associated with?
ACA *medial frontal lobe/supplementary motor area and the anterior corpus callosum
48
What is Alien Hand Syndrome?
rare neurological disorder where a patient experiences involuntary, purposeful movements of one hand (usually non-dominant) that feels foreign or "not under their control"
49
Key clinical features of Alien Hand Syndrome? (5)
- involuntary, seemingly goal-directed hand movements (grasping, manipulating objects, touching face) - verbal complaints that hand acts independently - often associated w/inter-manual conflict (one hand acts against the other) - usually no weakness; strength preserved - loss of sense of agency
50
What is the most common stroke artery?
MCA
51
How to remember clinical features of MCA syndrome?
MCA >> MPH >> (M)outh aka. language, (P)erception, (H)omoynmous hemianopsia
52
What sided MCA strokes are typically associated with language deficits?
L sided
53
What sided MCA strokes are typically associated with perceptual deficits?
R sided
54
What is Broca's aphasia?
*expressive/non-fluent aphasia - FRONTAL lobe - patient has slow, hesitant speech
55
Treatment approach for Broca's aphasia?
Yes/No questions
56
What is Wernicke's aphasia?
*receptive/fluent aphasia - TEMPORAL lobe - patient cannot comprehend - word salad
57
Treatment approach for Wernicke's aphasia?
Gestures and demonstration
58
What is global aphasia?
Broca + Wernicke aphasia
59
MCA superior division infarct is associated with which language deficit?
Broca's aphasia
60
MCA inferior division infarct is associated with which language deficit?
Wernickes aphasia
61
MCA stem infarct is associated with which language deficit?
Global aphasia
62
What is unilateral neglect?
*R MCA - lack of awareness of the weak side
63
Treatment considerations for unilateral neglect
- encourage awareness and use of the environment on the hemiparetic side and use of hemiparetic extremities - active visual scanning > turning of the head and axial trunk rotation to the more involved side
64
Tests to assess unilateral neglect?
- clock drawing test - line cross out
65
Lesions to the optic nerve result in...
blindness
66
Lesions to the optic chiasm result in...
bitemporal hemianopsia
67
Lesions to the optic tract result in...
C/L homonymous hemianopsia
68
What is Gerstmann Syndrome?
Neurobehavioral syndrome caused by damage to the dominant (usually L) inferior parietal lobe, especially the angular gyrus * MCA - inferior division *defined by a tetrad of deficits 1. Agraphia/Dysgraphia 2. Acalculia/Dyscalculia 3. Finger Agnosis 4. Left-right disorientation
68
What is contralateral homonymous hemianopsia?
Loss of contrateral visual field in both eyes -e.x. in R MCA = LHH; cannot see from L side of both eyes (loss of L temporal field and R nasal field)
69
What is Agraphia/Dysgraphia?
Inability or severe difficulty with writing despite normal motor function of the hand
70
What is Acalculia/Dyscalculia?
Impaired ability to perform simple arithmetic or calculations
71
What is Finger Agnosis?
Inability to name or distinguish one's own fingers or those of another
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What is Left-right disorientation?
Confusion in discriminating left vs. right sides of the body or space
73
What is a lacunar stroke?
stroke of deep branches of MCA - lenticulostriate artery - supplies thalamus and basal ganglia
74
What is the clinical presentation of a lacunar stroke?
pure motor, pure sensory, sensory motor - ataxia hemiparesis - dysarthria-clumsy hand
75
Long term effects of a lacunar stroke?
Dementia
76
Prognosis of lacunar stroke?
Favorable
77
Risk factors for a lacunar stroke?
Older age HTN
78
S&S of Posterior Cerebral Artery Syndrome - Peripheral Territory (7)
- contralateral homonymous hemianopsia (w/macular sparing) - visual agnosia - prosopagnosia - dyslexia WITHOUT agraphia - color discrimination - memory deficits - topographical disorientation
79
S&S of Posterior Cerebral Artery Syndrome - Central Territory (6)
Thalamus: Central Post Stroke THALAMIC PAIN syndrome - choreoathetosis (subthalamic) - intention tremor (subthalamic) - hemiballismus (subthalamic) - Weber's syndrome (midbrain) - oculomotor nerve palsy - contralateral hemiplegia
80
What are watershed cerebral infarctions?
"border zone infarcts" Occur at the border between cerebral vascular territories where the tissue is furthest from arterial supply and thus most vulnerable to reductions in perfusion - hypotension, stenosis - commonly seen in elderly
81
Clinical presentation of watershed infarction
"man in barrel" - can move distal extremities but not proximal
82
What location is affected with Anterior Inferior Cerebellar Artery (AICA) Syndrome?
Lateral PONTINE syndrome Cerebellum: ipsilateral balance and ataxia
83
What tracts are affected with Anterior Inferior Cerebellar Artery (AICA) Syndrome?
C/L Spinothalamic (lateral tract) - pain and temp
84
What cranial nerves are affected with Anterior Inferior Cerebellar Artery (AICA) Syndrome?
ipsilateral CN VII, VIII
85
What location is affected with Posterior Inferior Cerebellar Artery (PICA) Syndrome?
Lateral MEDULLARY syndrome/Wallenberg Cerebellum: ipsilateral balance and ataxia
86
What tracts are affected with Posterior Inferior Cerebellar Artery (PICA) Syndrome?
C/L spinothalamic (lateral tract) - pain and temp
87
What cranial nerves are affected with Posterior Inferior Cerebellar Artery (PICA) Syndrome?
ipsilateral CN IX, X, XI *V (sensory fibers)
88
What artery supplies the PONS?
Basilar a.
89
What artery supplies the MEDULLA?
Vertebral a.
90
Where does the basilar artery stem from?
2 vertebral a.
91
Where does PICA stem from?
Vertebral a.
92
Where does AICA stem from?
Basilar a.
93
What are key clinical features of a brainstem stroke?
Ipsilateral facial involvement (CN) Contralateral body involvement (tracts) Vs. Cerebral stroke = contralateral face and body
94
What is locked-in syndrome?
Catastrophic brainstem disorder where the person is awake and cognitively intact but has complete paralysis of nearly all voluntary muscles EXCEPT vertical eye movements and blinking
95
Where is the lesion in locked-in syndrome?
**basilar artery ventral pons > destroys corticospinal and corticobulbar tracts *reticular activating system and vertical eye movement centers remain intact
96
Bramford Stroke Classification for Total Anterior Circulation Stroke (TACS)
All 3 of the following: - unilateral weakness (and/or sensory deficit) of the face, arm, and leg - homonymous hemianopia - higher cerebral dysfunction (dysphasia, visuospatial disorder)
97
Bramford Stroke Classification for Partial Anterior Circulation Stroke (PACS)
Two of the following: - unilateral weakness (and/or sensory deficit) of the face, arm, and leg - homonymous hemianopia - higher cerebral dysfunction (dysphasia, visuospatial disorder)
98
Bramford Stroke Classification for Lacunar Stroke (LACS)
One of the following: - unilateral weakness - pure sensory stroke - ataxic hemi-paresis
99
Bramford Stroke Classification for Posterior Circulation Syndrome (POCS)
One of the following: - Cerebellar or brainstem syndromes (ataxia, nystagmus, vertigo) - LOC - Ataxic hemiparesis
100
General Tips - What type of stroke if all sensation types are lost?
Cerebral
101
General Tips - What type of stroke if select sensory tracts are lost?
Brainstem
102
General Tips - What type of stroke if cranial nerves lost on same side?
Brainstem
103
General Tips - What type of stroke if cranial nerves lost on opposite side?
Cerebrum
104
General Tips - What type of stroke if cognition, aphasia, judgement impaired?
Cerebral
105
General Tips - What type of stroke if vitals, breathing impaired?
Brainstem
106
Features of a R Hemisphere stroke (6)
- L hemiparesis/hemisensory loss - visual/perceptual impairments - difficulty with visual cues - quick, impulsive, safety risk - rigidity of thought - difficulty w/negative emotions
107
Features of a L Hemisphere stroke (6)
- R hemiparesis/hemisensory loss - language impairments - difficulty w/verbal cues - slow, cautious - highly distractible - difficulty w/positive emotions
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