Stroke

stroke or cerebrovascular accident (CVA)
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stroke or cerebrovascular accident (CVA)
Defined as an abrupt onset of a neurologic deficit that is attributable to a focal vascular cause
TIA
requires that all neurologic signs and symptoms resolve within 24 h without evidence of brain infarction on brain imaging
embolization
What is an important cause of transient cerebral ischemia?
4-10 min
A decrease in cerebral blood flow to zero causes death of brain tissue within how long?
atrial fibrillation and carotid atherosclerosis
Etiologies of stroke that have proven secondary prevention strategies
20%
Cardio-embolism is responsible for what percentage of all ischemic strokes?
Embolic
Which type of stroke tend to occur suddenly with maximum neurologic deficit present at onset?
-intracranial internal carotid artery
-MCA
-posterior cerebral artery (PCA)
-or one of their branches
Emboli from the heart most often lodge where?
non-rheumatic (often called non-valvular) atrial fibrillation
What is the most significant cause of cardio-embolic stroke in most of the world?
-MI
-prosthetic valves
-rheumatic heart disease
-ischemic cardiomyopathy
Other causes of cardio-embolic stroke include what?
artery-to-artery embolism, rather than local thrombosisUnlike the myocardial vessels, what appears to be the dominant vascular mechanism causing large-vessel brain ischemia?hypertensionSpontaneous, non-traumatic intracerebral hemorrhage in patients with no angiographic evidence of an associated vascular anomaly is usually due to what?-bleeding disorders -anticoagulant therapy -liver disease -drug and alcohol abuseOther causes of spontaneous, non-traumatic intracerebral hemorrhage in patients with no angiographic evidence of an associated vascular anomaly include what?subarachnoidBleeding is primarily into what space when it occurs from an intracranial aneurysm?TraumaWhat is the most common cause of subarachnoid hemorrhage?rupture of an arterial saccular ("berry") aneurysm or from an arteriovenous malformationSpontaneous (non-traumatic) subarachnoid hemorrhage frequently results from what?-thunderclap headache of a severity never experienced previously by the patient -signs of meningeal irritation -obtundationThe characteristic clinical picture of subarachnoid hemorrhage includes what?Facial weakness Arm weakness Speech abnormality TimeWhat does the acronym FAST stand for?TrueTrue or False: Patients with a hemorrhagic stroke will tend to show more neuro symptoms and you'll likely see vomiting and nausea as well<5 for mild 5 to 9 for moderate ā‰„10 for severeWhat are the reasonable cut-points of NIHSS score for mild, moderate, and severe stroke?facial paresis, arm drift/weakness, and abnormal speechWhat are the three most predictive examination findings for the diagnosis of acute stroke?posterior circulationThe NIHSS does not capture all stroke-related impairments, particularly what type of stroke?TrueTrue or False: Abnormalities in MRI occur before those seen on CT during ischemic strokes-Noncontrast brain CT or brain MRI -Finger stick blood glucose -Oxygen saturationAll patients with suspected stroke should have what studies urgently as part of the acute stroke evaluation?-Electrocardiogram -CBC -Troponin -PT/INR -aPTTOther immediate tests for the evaluation of ischemic and hemorrhagic stroke include what?TrueTrue or False: Current guidelines recommend cardiac monitoring for at least the first 24 hours after the onset of ischemic stroke to look for atrial fibrillation (AF) or atrial flutterā‰¤185 mmHg; ā‰¤110 mmHgIf the patient is eligible and will receive IV thrombolytic therapy (which we will talk about in a bit), before thrombolytic therapy is started, treatment is recommended so that systolic blood pressure is ____ and diastolic blood pressure is _____.180/105 mmHgThe blood pressure should be stabilized and maintained at or below _______ for at least 24 hours after thrombolytic treatment-SBP >220 mmHg or DBP >120 mmHg -active ischemic coronary disease -heart failure -aortic dissection -hypertensive encephalopathy -pre-eclampsia/eclampsiaFor patients with ischemic stroke who are NOT treated with thrombolytic therapy, blood pressure should not be treated acutely unless what?>140/90 mmHgFor ischemic stroke patients, it is reasonable to start or restart antihypertensive medications during hospitalization for patients with blood pressure ____ who are neurologically stable, unless contraindicated.-SBP<140 for those who present w/ 150-220 -SBP 140-160 for those who present w/ SBP>220What are the BP goals for acute intracerebral hemorrhage (ICH)?TrueTrue or False: Reducing SBP below 140 mmHg in the first hours after ICH onset is not clearly beneficial for reducing death or disability and may increase the risk of renal adverse events-SBP <160 mmHg or MAP <110 mmHg -Avoid hypotensionWhat are the BP goals for acute SAH?TrueTrue or False: The use of vasodilators such as nitroprusside or nitroglycerin should be avoided in hemorrhage stroke because of their propensity to increase cerebral blood volume and therefore ICP.140 to 180 mg/dLThe American Heart Association/American Stroke Association guidelines for acute ischemic stroke recommend treatment for hyperglycemia to achieve serum glucose concentrations in the range of _____.-increased tissue acidosis from anaerobic metabolism -free radical generation -increased blood brain barrier permeabilityHyperglycemia may augment brain injury by several mechanisms, including what?0.9 mg/kg to a maximum of 90 mg, with 10% given as a bolus over 1 minute and the remainder over 1 hourWhat is the dose of alteplase and how is it administered?4.5 hoursWhat is the time frame of administration of alteplase from stroke symptom onset?-Treat thrombocytopenia with platelets -Reverse coagulopathies with FFP -Consider ICP monitoring and osmotic therapy -Might require ventricular drainage and decompression -Surgical eval if acute decomp -DVT prophylaxisICH specific management includes what?at least 14 days to monitor, prevent, and treat vasospasmHow long and why do patients with SAH need to be hospitalized?