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Stroke
Neurology
| Question | Answer |
|---|---|
| Ischemic stroke pathogenesis | atheroembolic (50%); cardioembolic (30%) |
| Venous infarction RFs and presentation | OCP/SMK. HA; aphasia, weakness |
| Atheroembolic Stroke is characterized by: | Single vascular territory; Warning signs; Stepwise progression |
| Atheroembolic presentation | Hx HTN, CAD; transient language disturbance; transient weakness; Normal head CT; Doppler US: high grade stenosis (e.g., L ICA) |
| Ant cerebral art infarct: likely fx: | contralateral leg (motor > sensory) |
| MCA infarct: likely fx: | face/arm more than leg/vision; gaze preference to affected side. If left side affected, possible aphasia. If right side, apraxia, hemi-neglect |
| Vertebrobasilar art infarct: fx: | Midbrain: 3d nerve nuclei; ipsilateral ptosis; eye deviated outward (bc CN VI is fine, but III is affected); crossed signs: pt has CNIII probs on one side and sensory probs on opp side of body |
| Subcortical infarct fx: | face = arms = legs |
| Cortical infarct fx: | gradation btw face, arms, & legs |
| Lacunar syndromes | Pure Motor Stroke; Pure Sensory Stroke; Ataxic Hemiparesis; Clumsy Hand Dysarthria |
| Atheroembolic stroke: additional eval | Neuroimaging; Carotid US; MRA; CTA; Catheter angiography |
| Cardioembolic stroke presentation | Aphasia; hemiparesis/hemisensory deficit affecting face and arm; Carotid US normal (no brain lg vessel prob) |
| Cardioembolic: dx | Maximal deficit at onset; Multiple vascular territories; Cardioembolic source; Hemorrhagic infarction (Wedge shaped infarct towards cortical surface) |
| Cardioembolic: possible sources | A-fib; cardiomyopathy; acute MI; mural thrombus; valvular heart dz; bacterial endocarditis; atrial myxoma |
| Cardioembolic stroke: additional eval | pulse; EKG; 24-48 hr EKG; TTE (microcavitation); TEE |
| TIA | Acute focal neuro deficits; ischemic, usually embolic (carotid / vertebrobasilar) etiology; Sx/Sx resolve within 24 hr; no radiological evidence of infarct |
| Modifiable RF for first stroke | *HTN*; A fib; carotid stenosis; DM; hyperlipidemia; prior stroke/TIA |
| Lifestyle mods affecting BP | wt reduction; DASH diet; sodium reduction; exercise; moderate EtOH consumption |
| Stroke comorbid RF’s | CHD, CHF, DM, stroke |
| Prevention of A fib RF: | Low risk (0-1) ASA; mod (2) ASA or warfarin (but AE/bleed risks); high risk (>2) warfarin |
| Asx carotid stenosis: eval | Carotid bruit; Doppler US; MRA, CTA |
| Stroke prevention DM pts | glucose ctrl: no fx on stroke/macrovascular comp; tight BP ctrl (<130/80) effective; statins |
| Stroke prevention: hyperlipidemia | chol reduction w/statins |
| ASA recommended for 10-yr stroke risk of: | 6-10% |
| Ischemic stroke: Tx | tPA (within 4.5 hrs of sx onset); head CT w/o evidence of hemorrhage/complicating lesion |
| tPA absolute CI (<3 hr) | CT: bleed/comp (AVM); SBP >185 or DBP >110; recent stroke/ICH; bleed elsewhere; anticoag use; plt <100K; h/o seizure preceding stroke |
| tPA CI (3-4.5 hr) | >85 yo; NIH-SS >25; h/o both stroke/DM |
| If pt not tPA candidate: Tx: | poss endovascular tx; MERCI clot retriever? |
| Acute stroke mgmt | Temperature; Fluids/Glucose; BP; Antithrombotic agents |
| Acute ischemic stroke: tx BP? | No (drop in MAP can drop CBF, make things worse) |
| Secondary stroke prevention | Platelet antiaggregants (ASA vs Aggrenox / Plavix); Anticoagulants; BP; Lipid lowering; Endarterectomy |
| Antihypertensives & stroke risk | each 10 mmHg drop in BP = 28% decrease stroke risk |
| Stroke w/L paresis and R facial droop = | Right pons infarct |
| Hemiplegia (leg>arm), abulia, urinary incontinence, primitive reflexes: site of lesion = | ACA |
| Hemiplegia (arm/face > leg), hemianesthesia, homonymous hemianopia, aphasia, apraxia/neglect of nondominant side, drowsiness: site of lesion = | MCA |
| MCA: characteristic aphasia = | aphasia of dominant hemisphere (superior division: expressive; inferior division: receptive) |
| Thalamic syndromes (allodynia) with contralateral hemisensory disturbance & aphasia; macular-sparing homonymous hemianopia: site of lesion = | posterior cerebral artery |
| Wallenberg syndrome: numb in ipsilateral face & contralateral limbs; diplopia, dysarthria, ipsilateral Horner syndrome: site of lesion = | vertebral artery |
| Pinpoint pupils, long tract sxs (quadriplegia & sensory loss), CN abnormalities, cerebellar dysfunction: site of lesion = | basilar artery |
| Vertigo, N/V, diplopia, nystagmus, ipsilateral limb ataxia: site of lesion = | cerebellar artery |
| Sxs: (pure hemiplegia, pure hemianesthesia, ataxic hemiparesis) OR (clumsy hand & dysarthria): site of lesion = | lacunar CVA |
| Definition Apraxia | inability to do learned purposeful movements, including apraxia of speech |
| Definition Ataxia | incoordination of muscular movements |
| Definition Aphasia: (1) Broca; (2) Wernicke | (1) expressive: few words/written or spoken; difficulty producing words; may comprehend others. (2) receptive: word salad; decreased comprehension |
| Definition Dysarthria | poor verbal articulation due to neuro injury |
| CVA labs (Acute) | CMP (lytes, glucose, BUN/Cr, LFT), CBC, PTT/INR, ESR, tox screen. If suspect endocarditis, get blood cultures |
| CVA labs (when pt is stable) | Lipids, HbA1c, TSH, homocysteine, lipoprotein (a). If pt <65 yo or cryptogenic stroke: hypercoagulability workup (before anticoagulant tx is initiated) |
| CVA: diagnostic studies | Labs, ECG, noncontrast head CT acutely (then CTA / perfusion to eval CV patency & areas of reversible ischemia (if considering intra-arterial/catheter interventions), carotid US, Holter monitor, TTE |
| TIA tx | 1) ? heparin IV -> warfarin IF: presumed cardioembolic TIA; or bridging to mech intervention (CEA, stent) for Lg vessel atherothrombotic dz (2) Antiplatelet tx: ASA, Plavix, or ASA+Aggrenox. (3) carotid revascularization if sx >70% ipsilateral stenosis |
| ABCD2 score criteria: | Age>/=60 (1 point); BP>/=140/90 (1); Clinical: unilateral weakness (+2); speech impaired w/o weakness (1); Duration >60min (2) or 10-59min (1); DM (1) |
| ABCD2 stroke risk scoring: CVA risk at 2 days: | 0-3 pts: low (1%); 4-5 pts: moderate (4.1%); 6-7 pts: high (8.1%). Risk of progression higher in TIA due to large artery / lacunar disease (vs cardioembolic) |
| Ischemic stroke Tx | IV thrombolysis; antiplatelet; permissive HTN (lower acutely only if SBP>200) or MI/CHF. BP to <180/110 with nitrate/labetolol pre-tPA. Cerebral edema mgmt; DVT Ppx; statin |
| Ischemic stroke tx: cerebral edema mgmt: | (edema peaks at 3-4 days post-CVA) Increased ICP requires elevate HOB 30degrees, intubate / hyperventilation to PaCO2 = 30. Osmotherapy: mannitol IV 1gm/kg ->0.25g/kg Q6h. +/-hypertonic saline. ?Surgical decompression |
| Ischemic stroke tx: carotid revascularization | Carotid endarterectomy (if hospital M&M <6%). CEA indicated for: (1) Sx Stenosis >/=70% (?50-69% if female, >75yo or recent sxs): 65% decrease in CVA; (2) Asx stenosis >/=70% & >75yo: 50% decrease in CVA |
| PFO & CVA risk | 27% of popn. 0.1% annual CVA risk in healthy popn. Inc CVA risk if >4mm separation, R->L shunt at rest, inc septal mobility. |
| If PFO and stroke/TIA: tx | No evidence of warfarin > ASA. If pt is at increased risk or hx of DVT/PE, consider anticoagulation |
| Amaurosis fugax (transient monocular blindness): site of lesion = | Internal carotid artery / ophthalmic artery |
| Types of lacunar stroke (physiologically): | small vessel, penetrating arteries, atheroma, lipohyalinosis |
| Types of large vessel thrombosis: | atherosclerosis, dissection |
| Lacunar infarct (stroke): | 15-20% of strokes; small vessel ischemia; HTN; usually pure sensory OR motor |
| Risk of progression of TIA to CVA: | 11% risk of stroke within 3 mo; 63% of strokes occur within the first week, 85% within first month; higher risk of CVA in DM / HTN |
| Crescendo TIA = | increasing number & frequency of TIAs, highly likely to evolve to CVA (esp if 2 or more attacks within 24 hr) |
| Ischemic stroke pathophysiology | atheroembolic (50%); cardioembolic (30%); OR 2/3 thrombotic & 1/3 embolic |
| Stroke pathophysiology | 80% ischemic, 20% hemorrhagic |
| Hemorrhagic stroke pathophysiology | parenchymal ICH (10-15%); subarachnoid (5-10%) |
| Anterior circulation consists of: | Ant choroidal, ant cerebral, MCA |
| Anterior circulation supplies: | Cortex, subcortical white matter, basal ganglia, internal capsule |
| Anterior circulation stroke | Hemispheric s/s: aphasia, apraxia, hemiparesis, hemisensory loss, visual field defects |
| Posterior circulation consists of: | Verterbral & basilar arteries |
| Posterior circulation supplies: | Brain stem, cerebellum, thalamus, parts of temporal & occipital lobes |
| Posterior circulation stroke | Sxs of brainstem dysfn: coma, drop attacks, vertigo, N/V, ataxia |
| Thrombotic vs embolic stroke sx progression | Thrombotic: stepwise progression, often preceded by TIA; Embolic: abrupt & without warning |
| Amyloid angiopathy stroke: patho | Blood vessel degeneration; Dementia; Lobar hemorrhage |
| Amyloid angiopathy: presentation | Dementia; Episodic worsening; No h/ o HTN; poss acute limb weakness; BP less severe than in ICH; stroke d/t cerebral microhemorrhages |
| Venous infarction presentation | h/o OCP/SMK; HA; aphasia, weakness |
| Atheroembolic stroke characterized by: | Single vascular territory; Warning signs; Stepwise progression |
| Atheroembolic stroke presentation | Hx HTN, CAD; transient language disturbance; transient weakness |
| Ant cerebral art infarct: likely fx: | contralateral leg (motor > sensory) |
| Subcortical infarct effects by body area: | face = arms = legs |
| Cortical infarct fx by body area: | gradation btw face, arms, & legs |
| Cardioembolic stroke presentation | h/o A fib; aphasia; hemiparesis/hemisensory deficit affecting face and arm |
| Cardioembolic CVA: dx | Maximal deficit at onset; Multiple vascular territories; Cardioembolic source; Hemorrhagic infarction (Wedge shaped infarct towards cortical surface) |
| Cardioembolic CVA: possible etiology | A fib; Cardiomyopathy; Acute MI; Valvular heart dz |
| TIA S/S | Acute focal neuro def; S/S resolve within 24 hr; No rad evidence of infarction; Ischemic etiology, usu carotid or vertebral vascular distn |
| TIA: risk of subsequent stroke: | 11% risk of stroke within 3 mo; 1/3 of TIAs have stroke within 5 yrs; 63% of strokes occur within the first wk, 85% within first month |
| Modifiable RF for first stroke | *HTN*; A fib; carotid stenosis; DM; hyperlipidemia; prior stroke/TIA |
| Prevention of A fib RF: | Low risk (0-1) ASA; mod (2) ASA or warfarin (but AE/bleed risks); high risk (>2) warfarin |
| Stroke prevention DM pts | glucose ctrl: no fx on stroke/macrovascular comp; tight BP ctrl (<130/80) effective; statins |
| TIA carotid: S/S | contralat hand-arm weak & sensory def; ipsilateral visual sx & aphasia or amaurosis fugax; poss carotid bruit (absent in high grade stenosis) |
| TIA vertebrobasilar S/S | diplopia, ataxia, vertigo, dysarthria, CN palsies, LE weak, blurred vision, perioral numbness, poss drop attacks |
| TIA DDx | Sz, migraine, syncope, hypoglycemia, mass lesion |
| 2/3 of all cerebral infarcts are: | MCA stroke |
| Cause of Amaurosis Fugax | embolization of retinal arteries |
| Hollenhorst plaque | cholesterol emboli from carotid |
| Diplopia, dysphagia, dysarthria = | vertebrobasilar insufficiency |
| Types of stroke | ischemic (thrombotic, embolic 20%, hypoperfusion); hemorrhagic (intracerebral, subarachnoid) |
| Contralateral weakness (lower > upper), AMS, incontinence; likely source of stroke = | anterior cerebral artery |
| Contralateral weakness (face/arm > lower), contra sensory deficits, poss dysphasia; likely source of stroke = | MCA |
| Contralateral visual field deficits, AMS, cortical blindness; likely source of stroke = | posterior cerebral artery |
| vertigo/nystagmus, syncope, dysarthria, dysphagia, contralat pain/temp deficits; likely source of stroke = | vertebrobasilar arteries |
| stroke PE | neuro, CV (carotid bruit), EKG (A-fib, AMI/hypoperfusion) |
| Elevated troponins and ECG changes c/w MI can be seen in pt with acute stroke because of: | an imbalance of the autonomic nervous system, with resulting excess of sympathetic activity and increased catecholamine effect on myocardial cells |
| Capsular warning syndrome = | deep lacunar infarcts (eg, hemiplegic TIAs) with a fluctuating sx course that may predict an acute internal capsule infarct |
| smaller deep lacunar infarcts that often fluctuate, sometimes over the course of days, are known as the: | capsular warning syndrome |
| Lacunar stroke: 5 types of clinical presentation | Pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, dysarthria-clumsy hand syndrome, multiple subcortical infarcts & dementia |
| contralateral hemiplegia, hemisensory loss, & homonymous hemianopia (& global aphasia if dominant hemisphere is affected) = | MCA stroke |
| MCA stroke: anterior main div occlusion vs posterior | anterior occlusion: expressive dysphasia; posterior: receptive/ Wernicke |
| posterior cerebral artery occlusion leads to: | thalamic syndrome: contralateral hemisensory deficit, spont pain & hyperpathia |
| anterior comm artery occlusion causes: | weakness & cortical sensory loss in contralateral leg, poss arm weakness |
| ischemic stroke tx | ASA, some get thrombolytics (dipyridamole, heparin for cardioembolic) |
| hemorrhagic stroke tx | supportive; poss surg (stroke/AVM); aneurysm clipping/coil embolization |
| MCA stroke: anterior main div occlusion vs posterior | anterior occlusion: expressive dysphasia; posterior: receptive/ Wernicke |
Created by:
Abarnard
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