Stroke Lecture Powerpoint

Question 1

Cerebrovascular disease

Answer 1

A collective term for a range of conditions that affect and decrease blood flow to brain such as carotid stenosis, aneurysms, vascular malformations, stroke, etc.

Question 2

Risk factors for CVD (also which is MOST important?) (8)

Answer 2

• HTN (MOST important)
• atherosclerosis
• hyperlipidemia
• diabetes
• smoking
• diet
• obesity
• increasing age/male/african americans

Question 3

Carotid stenosis definition, when is it symptomatic, diagnostic studies (3), treatment options

Answer 3

• A type of cerebral vascular disease caused by atherosclerosis plaque in the arteries that are main supply to brain
• Often asymptomatic until a TIA
• PE might find carotid bruit, doppler ultrasound, or cerebral angiography
• In less than 50% occlusion treated conservatively with antihypertensives, statins, anticoags while >50% require stenting but NOT endarterectomy (too risky)

Question 4

Cerebral aneurysm causes (4), epidemiology, types, signs/symptoms, diagnosis

Answer 4

• Caused by hypertension, atherosclerosis, trauma, congenital defect
• most prevalent in ages 50-60 and more common in women
• 2 types: saccular (rounded outpouching containing blood also called berry) and fusiform (balloons or bulges out on all sides of artery)
• Signs and symptoms unruptured are asymptomatic but occasionally have cranial nerve palsy, dilated pupils, double vision, or pain - ruptured have localized headache, nausea and vomiting, stiff neck
• Diagnosed via MRA and carotid angiogram, rupture can also be detected by CT or lumbar puncture then cerebral angiography

Question 5

Vertebrobasilar insufficiency cause, signs/symptoms, diagnosis (2), treatment options (3)

Answer 5

• Caused by decreased blood flow to vertebral and basilar arteries, affects the brainstem, occipital lobes, and cerebellum
• vision loss, diplopia, vertigo, dysarthria, ataxia, confusion
• MRA or angiography
• lifestyle modifications, meds, surgery

Question 6

Arteriovenous malformations definition, cause, signs/symptoms (2), diagnosis (2), treatment (1)

Answer 6

• Groups of abnormal/poorly formed blood vessels resulting in increased rate of bleeding
• typically congenital found incidentally
• seizure and headache (4/100 people will hemorrhage per year)
• MRI and angiography
• Treated by neurosurgery

Question 7

Stroke definition, how does it clinically present?

Answer 7

• Abrupt onset of neurological deficit attributable to focal vascular disease, acute brain injury caused by decreased blood supply (ischemia) or hemorrhage
• clinical manifestations are variable because of the complex anatomy of the brain and its vasculature

Question 8

Stroke is a ____ diagnosis

Answer 8

clinical

Question 9

Stroke pathophysiology

Answer 9

• Brain is 2% of body weight but takes 17% of cardiac output and 20% o2
• ischemia is caused by decrease in blood flow that lasts longer than a few seconds
• neurons lack glycogen so energy failure is rapid and necrosis occurs faster than in other tissue

Question 10

Stroke epidemiology

Stroke is the leading cause of what?

Answer 10

• 5th leading cause of death, 87% are ischemic rather than hemorrhagic,
• leading cause of serious long term disability

Question 11

2 types of stroke based on dysfunction and their subclasses

Answer 11

• focal brain dysfunction (ischemic and intracerebral hemorrhage)
• diffusion brain dysfunction (subarachnoid hemorrhage)

Question 12

80% of ischemic strokes occur from occlusion of ____ caused by _____.

Majority of strokes are ____ rather than ____

Answer 12

• large or small vessels
• thrombosis (clot), embolism (dislodged flowing object), or systemic hypoperfusion (circulatory problem of whole brain)
• ischemic, hemorrhagic

Question 13

Ischemic stroke vs TIA

Answer 13

Ischemic stroke is infarction with sequelae (symptoms don’t completely go away while body tries to compensate) vs TIA has no infarction and no sequelae but is a transient “mini stroke”

Question 14

Transient ischemic attack (TIA)

Answer 14

Transient episode of focal ischemic cerebral neurologic deficits without infarction, symptoms typically less than 1 hour but varies, risk of stroke rises if not treated early enough

Question 15

Transient ischemic attack clinical presentation (3) and which set of symptoms does carotid TIA belong to and which does vertibrobasilar ischemic belong to?

Answer 15

• abrupt and rapid recovery
• weakness and heaviness of contralateral arm, leg, or face with possible numbness (carotid)
• vertigo, ataxia, diplopia, dysarthria, changes in vision (vertebrobasilar ischemic)

Question 16

TIA diagnostic studies (5)

Answer 16

• CT of head
• echo
• EKG (afib)
• CBC (infection)
• blood glucose (hypoglycemia)

Question 17

TIA treatment options (4)

Answer 17

• carotid endarterectomy if surgery accessible stenosis
• anticoagulants
• aspirin 325mg po daily
• clopidogrel (plavix)

Question 18

Penumbra

Answer 18

Zone of reversible ischemia around core of irreversible infarct, salvageable in first few hours after ischemic stroke onset and goal to save with treatment to reverse and minimize permanent damage

Question 19

Lacunar infarct ischemic stroke definition and presentation (3)

Answer 19

• A common type of ischemic stroke usually caused by small lesions often in patients with no memory of CVA found incidentally, usually progress over 24 hours then stabilize
• Present with contralateral motor and sensory deficits, ipsalateral ataxia, and dysarthria

Question 20

Carotid circulation ischemic stroke definition and presentation (1)

Answer 20

-A common type of ischemic stroke that is usually asymptomatic but can present with amaurosis fugax (collateral circulation brings vision back)

Question 21

LEFT sided MCA ischemic stroke should raise worry for….

Answer 21

….broca’s or wernicke’s aphasia

Question 22

anterior cerebral artery ischemic stroke key points (2)

Answer 22

• emotional symptoms

- unilateral occlusion well tolerated because of collateral blood flow

Question 23

middle cerebral artery ischemic stroke key point (1)

Answer 23

-wernicke and broca’s aphasia if on left side of brain

Question 24

posterior cerebral artery ischemic stroke key points (2)

Answer 24

• thalamic syndrome: contralateral hemisensory disturbance followed by spontaneous pain and increased sensation
• memory loss

Question 25

Older infarcts often appear ____ while fresh appear ____ on a CT

Answer 25

Darker, lighter

Question 26

Anterior portion of pons locked in syndrome

Answer 26

An absence of movement except for eyelids despite sensation and consciousness preservation associated with incomplete occlusion of the vertebral or basilar arteries

Question 27

Patients having a stroke are generally not in....

Answer 27

....pain, they don't seek assistance on their own (time is tissue)

Question 28

ED stroke care timeline

Answer 28

-Triage (10 min) -medical care (25 min) -CT and labs (45 min) Treatment (60 min)

Question 29

NIH stroke scale (NIHSS)

Answer 29

Standardized method used to measure the level of impairment caused by a stroke, scored from 0-42 to determine the severity, includes CN, motor, sensory, cerebellar, inattention, language, etc.

Question 30

Differential diagnosis of stroke (5)

Answer 30

- seizure - syncope - migraine - hypo/hyperglycemia - drug toxicity

Question 31

Stroke diagnostic studies (which is the most important) (6)

Answer 31

- CT without contrast (most important) - Standard MRI - MRA - Angiography - EKG - CXR

Question 32

Labs to order in a suspected stroke patient (7)

Answer 32

- Blood glucose - Troponin I - Pt/PTT - CBC with diff - Chem 7 - lipid panel - urinalysis (looking for elicit drugs)

Question 33

Contraindications to treating ischemic stroke with tPA (3)

Answer 33

- Recent surgery - GI bleed - High blood pressure even after treatment

Question 34

Ischemic stroke treatment options (2)

Answer 34

- IV tPA | - mechanical thrombectomy

Question 35

Many ischemic strokes present with ___ blood pressure. This is because....

Answer 35

high, | ....it is a response, not a cause (don't lower it unless its super high! (>185/110))

Question 36

Ischemic stroke supportive therapy (5)

Answer 36

- fluids - glucose management - swallowing eval to prevent aspiration - treat fevers - seizure prophylaxis

Question 37

If a patient comes in with a stroke that is not a stroke center, best course of action is to...

Answer 37

....stabilize best as possible (prob give tPA) and then transfer to a stroke center

Question 38

CT/MRI appearance cannot determine the etiology of ____

Answer 38

Small cerebral infarcts

Question 39

Prescriptions post ischemic stroke as secondary prevention (4)

Answer 39

- antithrombotic agent based on cause - ACEI or ARB regardless of BP - Statin regardless of cholesterol - lower BMI, alcohol intake, cigarrete smoking, estrogen

Question 40

Intracerebral hemorrhage definition

Answer 40

A type of hemorrhagic stroke from bleeding into the brain that spreads along white matter, occurs over minutes to hours and is progressive with gradual onset, not abrupt

Question 41

Subarachnoid hemorrhage definition

Answer 41

Type of hemorrhagic stroke that is most often caused by aneurysm rupture with bleeding into CSF, abrupt and severe thunderclap "worst headache of life" with no focal neuro symptoms but generalized vomiting and progressive impairment alongside nuchal rigidity

Question 42

One of the reasons important to get immediate CT in evaluation of stroke is to determine if patient has....

Answer 42

....hemorrhage which would contraindicate tPA and indicate immediate need for neurosurgery

Question 43

Biggest risk factor for intracerebral hemorrhage and 2 other ones(3)

Answer 43

- Hypertension - aneurysm - cocaine or amphetamine use

Question 44

Lumbar puncture is contraindicated in a ___ hemorrhage but useful in a ____ hemorrhage

Answer 44

intracerebral, subarachnoid

Question 45

If CT is ___ on a subarachnoid hemorrhagic patient, then must perform ___ looking for ____

Answer 45

negative, lumbar puncture, xanthrochromia (yellowish appearance of CSF after bleeding)

Question 46

subarachonid hemorrhage treatment

Answer 46

uhhh

Question 47

TIA's should be treated as though they are....

Answer 47

....strokes

Question 48

Ischemic strokes of the vertebral or basilar arteries characteristics (4)

Answer 48

- consciousness changes - vision deficits - coordination issues - lack of balance

Question 49

Ischemic strokes of the cerebellar arteries characteristics (3)

Answer 49

- vertigo - nystagmus - ataxia

Question 50

Ischemic strokes of anterior spinal artery characteristics (2)

Answer 50

- Flaccid paralysis below level of lesion | - loss of sensation below level of lesion

Question 51

Ischemic strokes of posterior spinal artery characteristics (1)

Answer 51

-sensory loss

Question 52

In the initial assessment of the suspected stroke patient, provider should establish a...

Answer 52

....time of symptom onset (last known normal) as this will dictate the treatment

Question 53

MRI vs MRA

Answer 53

MRA is used specifically to examine blood vessels

Question 54

There are more consequences for doing what regarding tPA?

Answer 54

Not giving, compared to giving in case of acute treatment for ischemic stroke

Question 55

Intracerebral hemorrhage treatment options (3)

Answer 55

- supportive care - intracranial pressure monitoring - potential neurosurgical consult

Question 56

Subarachnoid hemorrhage treatment options (4)

Answer 56

- operative treatment - pain medication - gradual BP treatment but maintenance of DBP >100 - prophylactic anti seizure medication such as pheyntoin