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General Q's of SCRN

What areas does the ACA feed? (i.e. lobes and/or structures) Medial portion of the frontal and parietal lobes ("mohawk"); corpus callosum
What areas does the MCA feed? (i.e. lobes and/or structures) Majority of the frontal, parietal, temporal lobes; the basal ganglia, internal capsule, as well as Broca's and Werneckies Area
What areas does the PCA feed?(i.e. lobes and/or structures) Occipital lobe, midbrain, THALAMUS, pineal gland
What are the major S/S of MCA stroke? Contralateral hemiplegia, contralateral hemianesthesia, Arm weaker than leg, face droopy, eye deviation towards side of lesion, contralateral homonymous hemianopia, if DOMINANT SIDE, global aphasia, if NON-DOMINANT, anogsagnosia
What are the major S/S of ACA stroke? Contralateral motor deficits (some/few sensory), Foot & leg weaker than arm, face and tongue usually spared, abulia (decreased activity and speech), emotionally labile
What are the major S/S of PCA stroke? Depends heavily on portion occluded; on DOMINANT HEMISPHERE: alexia (inability to see words/read) with or without agraphia (inability to write), visual agnosia (inability to interpret sensation or recognize things); NON-DOMINANT HEMISPHERE: neglect on con
What are the major S/S of a lateral Thalamic stroke? Hemiparesthesia, followed by isolated hemisensory deficit in face, arm, & leg, may include trunk, pain may develop resistant to treatment; can also have abnormal movements (inability to stand or walk--thalamic astasia); hyper-reflexive tendons, babinski
What are the major S/S of basal ganglia strokes? Cognition & behavior, memory dysfunction, dysarthria, aphasia, motor abnormalities, if on (L), verbal amnesia, if on (R), visual amnesia
Is ASA recommended for a patient in A-Fib already on Warfarin? Only if history of CAD, especially if they have stents
What is the target INR for stroke prevention? 2.5
What is the target LDL after stroke? (Which would indicate initiation of statin therapy) 100
What is the target blood pressure AFTER stroke or TIA (secondary prevention)? 140/90
What cranial nerves originate from the medulla? Cranial nerves 9-12
What cranial nerves originate from the midbrain? Cranial nerves 3-4
What crania nerves originate from the pons? Cranial nerves 5-8
What are the S/S of carotid dissection? ptosis, myosis (pupillary constriction), and anhidrosis---known as Horner's syndrome
What "important feature" does the internal capsule possess? Nerve tract for the motor cortex
What important "pathways" does the thalamus contain? Nearly ALL sensory pathways coming from the cerebral cortex
Regarding LOC, what can a stroke cause if the thalamus is infarcted? Hyper-somnolence
What can a stroke in the hypothalamus disturb? BODY TEMPERATURE ; also (but less prolific), affect circadian rhythm and body H20/osmo
What is Broca's aphasia? Speech is 'broken,' otherwise, expressive aphasia
Where is Broca's area located? Posterior aspect of frontal lobe
What is Werneckies aphasia? 'What?'; otherwise, receptive aphasia
Where is Werneckies area located? At the temporo-parietal junction
If a patient is experiencing hallucinations (but is aware of them not being real), what structure of brain is most likely being infarcted? Midbrain
When is treatment for carotid stenosis considered? Stenosis >50% and symptomatic
Where is the tip of a ventricular drain placed within the skull? At the Foramen of Monro (a 'channel' that lies between the lateral ventricles and the third ventricle)
What is the Cerebral Amyloid Angiopathy (CAA)? Disorder in which protein deposits in brain damage vessels, causing micro hemorrhages--and important risk factor for ICH!!
What medication should be avoided in patients with Cerebral Amyloid Angiopathy? Statins
What is the best diagnostic tool for SAH? NECT (Non-contrast CT)
What are the nursing considerations before/after cerebral angiography? Before: NPO 4-6hrs, PT/INR, allergies to shellfish/iodine, consent After: Bedrest 6hrs, HOB only to 30 degrees, assess for bleeding/circulation, avoid flexing & hyper flexing affected extremity for 12-24hrs, liberal fluid intake
What is the gold standard for diagnosing vascular deformities? (such as AVM's, aneurysms, fistulas, dissections) Cerebral Angiography
What is the advantage of MRI's? More sensitive than NECT for ischemic strokes
What is digital subtraction angiography (DSA) used for? Particularly, what is it "best" at detecting? DSA helps visualize vascular lesions and atherosclerotic disease; it is #1 to detect hight grade STENOSIS
What is TCD used for? Identifies intracranial vessel abnormalities, occlusions, and stenosis; Effective to determine VASOSPASM!
What is the gold standard diagnostic for vasculitis? biopsy
What would be the characteristics of CSF after an LP that would indicate SAH? rusty appearance (related to xanthrocrome, a by-product of Hgb breakdown, which is seen 4-6hrs after bleed, and up yo 3-6 days after)
In an echocardiogram, what does a bubble study help detect? PFO (patent foramen ovale)
What is the target SpO2 in stroke patients? Above 94%
What is desired EMS arrival time to possible stroke patient? Under 8 minutes, an to ER in 15min
What are the three structures of the brain stem (in order)? Midbrain, Pons, Medulla (descending order)
What are the structures of the basal ganglia? Caudate nucleus, Putamen, Globus pallidus
What are the structures of the diencephalon? -Thalamus (sensory pathways), -Hypothalamus (visual pathways, body temp, H20/Osmo control) -Pituitary gland (multiple hormone) -Pineal gland (sleep wake cycles)
What are the structures of the limbic system? -Hypothalamus (h20 and body temp) -Amygdala (stress & emotion control, "enhancer") -Cingulate Gyrus (emotions & ecoding memory) -Hippocampus (memory & learning--short term)
Are strokes more prevalent in men or women? More prevalent in males, except for ages 35-44 (related to OC use), and greater than 85 (women live longer)
Does family history of stroke affect one's risk? Increases risk by approximately 30%
What is the #1 modifiable risk factor for preventing both ischemic and hemorrhagic stroke? Hypertension
How much does smoking increase stroke risk? Doubles risk
Having D.M increases stroke risk by how much? 2-6x times risk (varies greatly in studies)
What is the target A1c for stroke patients? Less than 7
Having A-Fib increasing stroke risk by how much? 4-5x times risk; strokes usually larger
What are ICH risk factors? HTN (#1), race (hispanic, black), sex (male), age
Are D.M are smoking risk factors for ICH? Yes, but very weak, in comparison to ischemic
What are SAH risk factors? Smoking (#1), ETOH, HTN, family history, sex (women, men only after 50 more prevalent), race (blacks)
Approximately how many neurons are lost every minute in large strokes? 1.9million!
What is the most important 'patient history' information for EMC crews to attain from a suspected stroke patient? Last time seen normal
What is the goal time for stroke patient to see MD? 10min
What is the goal time for stroke patient to see stroke team? 15min
What is the goal time for stroke patient to get to CT scan? 25min
What is the goal time for stroke patient to get CT scan interpreted/read? 45min
What is the goal time for patient to get TpA? 60min
What will appear white (hyperdense) in a CT scan? Bone, calcium deposits, blood (acute)
What will appear dark gray (hypodense) in CT scan? CSF, edema, fat, infarcted tissue, blood (chronic)
What will appear black in CT scan? Air
How long does it take for infarcted tissue to appear on a CT scan? Approximately 6-8hrs
Is CT or MRI better for diagnosis of SAH? CT scan
How long does it take for blood to appear on a CT scan? Immediately
What is considered the acute phase of an ischemic stroke? 24-72hrs
What is considered the acute phase of ICH an SAH? Admit through discharge
What is one of the drawbacks of the NIH? It does not account for posterior circulation stroke symptoms
If a patient has a NIH score of 14 or more, where can you anticipate he or she will be discharged to? SNF
If a patient has a NIH of 6-13, where can you anticipate he or she will be discharged to? Inpatient rehab
If a patient has a NIH of 5 or less, where can you anticipate he or she will be discharged to? Home
What percentage of stroke patients will deteriorate in the fist 1-2days? 25%
What is the ideal blood glucose for an ischemic stroke patient? It is of DEBATE, yet current consensus is a GOAL of 140-180mg/dL
What is the ideal blood glucose for an ICH stroke patient? It is of DEBATE, yet current consensus is a GOAL of 140-180mg/dL
What is the ideal blood glucose for a SAH stroke patient? NO ideal glucose set; yet, research has shown glucose greater than 105mg/dL in first 10 days is associated with multi-organ dysfunction
What is one of the leading causes of epilepsy in the older population? Ischemic stroke
Is prophylactic seizure medication recommended for strokes? ONLY for SAH and for a short term (3-7days)
Seizure is more likely if a patient suffers a stroke in what areas of the brain? temporal lobe or cerebral cortex
What percentage of stroke patients will get a UTI within 1month? 25%
What percentage of stroke patients will get PNA (pneumonia)? 50% in ICU and stroke unit, and up to 11% in post-acute rehab
What is the rate of urinary incontinence in stoke patients? 60%
When can heparin safely be started as DVT prophylaxis of ICH and SAH patient? After 24-48hrs, given hemorrhage is stable
What is considered ideal for chemical DVT prophylaxis--Lovenox or heparin? Controversial, currently no 'ideal'
When can warfarin be safely restarted in a stroke patient? Of debate, current practice is 10-14 DAYS, longer in larger strokes
What are the major functions of the parietal lobe? Cortex for sensation in front; speech and language (Werneckies area there)
What are the major functions of the occipital lobe? vision; visual cortex
What are the major functions of the temporal lobe? visual memory, language comprehension, auditory processing
Strokes in what area can leave deficits on both 'sides' of the body? Brain stem strokes (cerebellar strokes can have ipsilateral deficits too)
What are the major signs/symptoms of a lateral medulla (medullary) stroke? Wallenberg syndrom, N/V, dysphagia, sensory loss (contralateral limbs and body, ipsilateral face), Horner's syndrome
What are the major signs/symptoms of a medial medulla (medullary) stroke? Contralateral hemiparesis sparing face, ataxia, diplopia, H/A, vertigo
What are the major signs/symptoms of a cerebellar stroke? Vertigo, vomiting, tinnitus, dysarthria, can have facial palsy, auditory loss, ataxia, Horner's syndrome
What are the major signs/symptoms of a pons (pontine) stroke? Hemiparesis, cerebellar symptoms; Lacunar syndromes --> pure motor hemiparesis, transient dizziness, diplopia, nystagmus, dysarthria, dysphagia, ataxic hemiparesis
What are the major functions of the frontal lobe? Behavior/emotions, contains motor cortex in posterior aspect; Broca's area (expressive aphasia)
What are major signs/symptoms of midbrain strokes? 3rd nerve palsies (Weber's, Claude's, Benedikts); locked in syndrome, Ataxia, Upward and/or downward gaze palsies, pendicular hallucinosis (hallucinations depiste pt. knowing they are not real)
What is the only FDA approved Rx for acute stroke? TPA; approved for up to 3hrs, yet endorsed for up to 4.5hrs (yet more restrictive)
What is the usual TpA dose? 0.9mg/kg to a max dose of 90mg
At what rate is tPA administered? 10% as a bolus over a minute, remainder over 60min
What should you do/anticipate if a patient has a decline in neurological status during an TPA infusion? Stop TPA, notify MD, anticipate STAT CT--there are no standardized measures to treat patient if they have indeed bled post TPA--cryoprecipitate and/or platelets can be considered
What are the major S/S of a medial thalamic stroke? CLASSIC TRIAD: Acute decreased LOC (abulia, apathy, hyper-somnolence), Neuropsychological Amnesia (disoriented, aphasia if on [L], Neglect if on [R], difficulty with new memories), Vertical Up-gaze palsies
What can carotid bruit indicate? Carotid dissection
What can Olser nodes and Janeway lesions indicate? Osler nodes and Janeway lesions are nodes/ulcerations on hands and feet (osler nodes are painful) that indicate INFECTIVE ENDOCARDITIS--a big risk factor for stroke
What is the mainstay treatment for vasculitis? STEROIDS mainline, can consider immunosuppressants
What is normal CPP (Cerebral Perfusion Pressure)? 70-90mm/hg (some say up to 150mm/hg)
What is the treatment for cocaine induced hypertension? Cardene
What is the best position to 'place' a patient? On the affected side
What is normal ICP (intracranial pressure)? 5-15mmHg (greater than 20 is considered 'increased')
What is the first line treatment to reduce ICP (intracranial pressure)? MANNITOL to reduce cerebral edema (can also consider hypertonic saline, ventricular drains, decompresive surgery, mild hypocarbbia [hyperventilation to reduce CO2, which vasodilates])
What is normal CO2? 30-35mmHg
Are steroids recommended to reduce ICP (intracranial pressure)? NO, not recommended
What is the duration of aspirin in human body? 5-7 days, which is the same as the life of platelets themselves (therefore, considered irreversible)
What is the duration of Plavix in human body? 5-7 days, which is the same as the life of platelets themselves (therefore, considered irreversible)
Are Brilanta and Effient ideal for secondary stroke prevention? NO, considered only if Plavix is ineffective as demonstrated by PY12 tests
What is the half-life of Warfarin? What is the onset? Onset = 48-120hrs, Half Life = 20-60 hours
Are novel anticoagulants (Pradaxa, Eliquids, Xarelto) indicated for A-FIB CAUSED by a HEART VALVE ISSUE? No! Can actually increase risk of stroke
Orolingual angiodema is a potential side effect of what drug? tPA administration, ESPECIALLY if on an ACE-inhibitor
What should BP be BEFORE starting tPA? What about DURING & AFTER tPA? BEFORE = 185/110 DURING & AFTER = 180/105
How often should vitals be checked during tPA infusion? q15min for 2hrs q30min for 6hrs q60min for 16hrs
How long does TPA remain in body? 80% of TPA is eliminated in 10min, the remainder is eliminated in about 24hrs
What are exclusion criteria for patients with stroke in the 3 - 4.5 hr window? (note, not 3hr exclusion, but the 'extended' window exclusions) -Over 80yrs old -Pt. on anticoagulant therapy (regardless of INR) -NIH greater than 25 -Patients with history of stroke AND diabetes
What are the most common sites of ICH (intracerebral hemorrhage)? #1 BASAL GANGLIA, #2 is thalamus
A stroke in what area can cause ipsilateral 'drunk-like' motor dysfunction? Stroke in the cerebellum
Basilar artery syndrome is also known as what? Locked-in syndrome
What is the most easily modifiable risk factor for stroke? Atrial fibrillation
What is the 'threshold' GCS score that would indicate a need for intubation? GCS of 8 or less
If a patient is not a candidate for tPA, what are the BP goals? Only treat if higher than 220/120; after 24hr period, we can begin to decrease BP by 10-15%
What is the "goal" of TPA and all other interventions? Re-establish blood flow and save the penumbra
When and for how long should nimodopine be started on a SAH patient? Day 1-21
What is the usual dose of nimodopine to prevent vasospasm? 60mg q4h for 21 days (may do 30mg q2h if patient becomes hypotensive)
What does nimodopine do? DECREASES INCIDENCE/prevents vasospasm, DOES NOT TREAT IT
Besides testing for vasospasm, what does TCD help identify? Lets us know if a stroke was cardioembolic (from heart) or thrombotic (from cranial arteries)
What is the gold standard for recognizing cavernous malformations? MRI/MRA with gradient echo
When should LP be considered for SAH diagnosis? ONLY when SAH cannot be diagnosed wit CT
What is constraint-induced movement therapy (CIMT)? Retraining the 'good' arm of the patient to "force them" to use the affected (weaker) side. ONLY USE WITH ARMS--IF USED IN LOWER EXT, CAN CAUSE FALLS!
What does a patient need to 'have' to qualify for an Acute In-Patiet Rehab? Tolerate 3hrs of therapy 5 days a week, need two or more disciplines (OT/ST/PT), be medically stable
When is the peak incidence of vasospasm after SAH? Day 7-10 are peak incidence (but lasts up to 21days)
What is Moyamoya disease? A chronic, vaso-occlusive disease that leads to narrowing and eventual occlusion of the internal carotids and branching vessels. It is very prominent in YOUNG ASIAN WOMEN.
How is Moyamoya disease treated? Generally supportive treatment, such as anticoagulation/anti-platelet, surgical revascularization procedures if needed
What is central venous thrombosis (CVT)? How is it treated? CVT is a rare type of stroke in which a clot forms in the dural sinuses or the cerebral veins. It is treated with acute anticoagulation, start with hep. drip, then oral for a few months; closely monitored
What is the standard treatment for arterial dissections? Anticoagulation!!! Consider stenting
What is the standard treatment for AVM's? BP management, surgical resection, embolization
How many stroke core measures are there? 8! VTE prophylaxis, d/c on antithrombotic, anticoagulation for Afib, TPA, antithrombotic by end of hospital day 2, d/c on statin, stroke education, assess for rehab)
What causes non-obstructive (communicating) hydrocephalus? lack of CSF absorption
What causes obstructive (non-communicating) hydrocephalus? Narrowing of canals that carry CSF, leading to obstruction
What is the penumbra? Brain cells next to the 'core,' which are damaged but not infarcted. Silent but metabolically active
Cell death (after hypoxia) occurs via what two mechanisms? NECROTIC pathway (cells die due to lack of O2 and sugar) and APOPTOTIC pathway (cells die due to 'programmed' death since the one's around them are dying)
What causes secondary injury to brain cells (apart from initial insult of lack of O2)? Release of thrombin at site, vasogenic edema, blood-brain barrier disruption, inflammatory response
What are the two types of aneurysms? Saccular (also known as berry aneurysms) [which are the most common], and fusiform
What is amaurosis fugax, and what can cause it? Transient blindness in one eye; common with internal carotid (ICA) strokes [because the ophthalmic artery branches from the ICA]
What is Marcus Gunn pupil and what can cause it? After shining a light to test patient's pupil reaction. the pupil continues to dilate and constrict for short period of time; it is caused by central retinal artery occlusion (CRAO)
What are watershed strokes? What generally causes them? Small strokes in area between major arterial territories (for example, areas between ACA and MCA territories); usually caused by HYPOTENSION or shower emboli from cardiac or vascular surgery
What is reperfusion syndrome and what can cause it? Defined as ipsilateral cerebral blood flow above brain tissue needs; can occur after revascularization (carotid stent or endarterectomy, TPA)
What are s/s of reperfusion syndrome? ipsilateral headache, contralateral neurological deficits, and seizure if cortical areas involved
What is the treatment for reperfusion syndrome? BP control, and ONLY IF SYMPTOMATIC. If BP greater than 180, IV Rx preferred; if less than 180, oral preferred. Goal is less than 140
A thunderclap headache and neck pain (nuchal rigidity) would be indicative of...? aSAH
If a patient is being considered for TPA (in 3hr window) and is taking anticoagulants, what must his INR be in order to not be 'excluded?' INR 1.7 or less (PT of 15 or less)
Angioedema is a common side effect of what medication? tPA, ESPECIALLY if the are on an ace-inhibitor!
What is the treatment of choice for patients with SYMPTOMATIC carotid stenosis and greater than 70% occlusion? Carotid Endarterectomy
In patients with a patent foramen ovale (PFO), what is the ideal treatment? Anti-platelet and/or Anticoagulation! Surgical closure has NOT shown to be more effective.
What is the mainline treatment for spasticity? Exercise and ROM stretching
What is the goal of rehabilitation for a stroke patient? Teaching a patient to be self-sufficient, decrease dependence on others, and achieve the highest functional level realistically possible
What is a common side effect of Coumadin (aside from bleeding)? Osteoporosis
Created by: DZLJAD