2) CVA pathology and medical management

what is a stroke

a sudden onset of a focal neurologic deficit resulting from cerebrovascular disease

Stoke is the ________ leading cause of death in the US?

5th

strokes are _____ and _____

preventable and treatable

prevalence of a stroke increases with

age in both men and women

Transient Ischemic Attack (TIA)

minor stroke

full resolution within 24 hours

ischemic stroke

blockage of blood flow (thrombic/embolic)

hemorrhagic stroke

intracerebral hemorrhage

Subarachnoid hemorrage

in ischemic strokes, it can be caused by

thrombus or embolus

thrombus

a blood clot attached to the interior wall of an artery or vein

embolus

blood clot that has come loose

a part of a thrombus can come loose

if the embolus gets stuck in the venous side it can cause a

pulmonary embolism

damage from a hemorrhagic stroke can cause

ischemic changes due to pressure on the brain tissue

ischemic CVA mortality

8-12% within the first month

hemorrhagic CVA mortality

37-38% within the first month

stroke risk in the US is nearly twice as high for

non-hispanic black adults than for white adults

mortality risk in the US is highest in

non-Hispanic black adults and pacific islander adults

risk factors for ischemic strokes

hypertension

diabetes

high cholesterol

smoking

heart disease

drug/alcohol use

obesity

risk factors for hemorrhagic strokes

hypertension

increasing age

black ethnicity

low cholesterol with low LDL

loer triglycerides

FAST acronym for stroke

face droop

arm weakness

speech difficulty

time is critical

acute stroke examination (medical)

PMH

meds (anticoagulants)

recent surgeries

vital signs

blood glucose

head CT scan

last known normal

what is the time point that the patient was normal (prior to stroke)

ABC workup for acute stroke

artery, blood, cardiac

when doing a CT scan for a stroke, what are we looking for?

looking for bleeding

signs of stroke - all signs can be seen in 24 hours

hemorrhagic stroke CT scan

there will be a light spot where the bleeding is

ischemic stroke management

thrombolytics

Thrombolytics

Medications that dissolve blood clots

if thrombolytics are used 4.5 hours after symptom onset

there is danger of conversion to hemorrhagic stroke

intra-arterial thrombectomy (IAT)

manual removal of arterial blockage

patient selection is critical for an IAT

less than 6 hours

NIHSS less than 6

ASPECTS less than 6

hemorrhagic stroke presentation

Symptoms are progressive over 48-72 hours

headache

nausea/vomiting

seizure

focal neurologic deficits

herniation syndromes (brain being pushed)

acute ICH (intra-cerebral hemorrhage) management

BP control, reverse coagulopathy, intracranial pressure management, surgical management

surgical management of ischemic CVA

posterior fossa decompression

- performed in the case of a potentially fatal brainstem compression

neurological findings of strokes are going to be impacted by

size of lesion

location of lesion

amount of collateral blood flow

what location of a lesion is better? peripheral or central?

peripheral

unilateral deficits happen due to damage to the

carotid vascular system

bilateral deficits happen due to damage to the

vascular supply to the basilar system

acute stroke symptoms include

weakness

numbness

difficulty with speech

confusion

altered vision - loss of vision

Impaired gait/balance

vertigo

headache

acute stroke symptoms will vary depending on

the location of the pathology

dysarthria

slurred speech, difficulty with articulation

signs of lower motor neuron (LMN) syndrome

flaccid paralysis

muscle atrophy

hyporeflexia

examples of LMN

polio, peripheral

when the UMN is injured, there can be a combination of problems

postive signs - exaggerate normal functions

UMN syndrome postitve signs

Spastic paralysis

hyperreflexia

altered muscle tone

athetosis

dystonia

emergence of primitive reflexes

athetosis

involuntary squirming

dystonia

muscle turning on and stays on

Spastic paraylsis

inability to isolate individual muscle movement

negative signs of UMN syndrome

-fatigue

-dyscoordination

-impaired motor planning and control

ischemic stroke are named for the artery involved

- middle cerebral artery

- anterior cerebral artery

- internal carotid

- posterior cerebral

- vertebral

- basilar

Left middle cerebral artery (MCA) syndrome

R hemiparesis

R sensory loss

aphasia

R visual field cut

left gaze preferance

Right middle cerebral artery (MCA) syndrome

L hemiparesis

L sensory loss

neglect/anosognosia

L visual field cut

right gaze preferance

MCA syndrome is the ________ common location for ischemic stroke

most

what is processed on the lateral side of the left eye, it is processed on the

right side of the brain

what is processed on the medial side of the left eye, it is processed on the

left side of the brain

ACA syndrome (anterior cerebral artery)

contralateral weakness (LE>UE>face)

contralateral sensory loss (LE>UE>face)

abulia (left)

gaze preference

incontinence

central PCA syndrome

visual field cut

thalamic involvement

thalamic involvement in central PCA syndrome

weakness

sensory changes - anesthesia, thalamic pain syndrome

hemiballismus - random movement of limbs

peripheral PCA syndrome

alexia (inability to read) but they can write

amnesia

visual deficits - cortical blindness, visual field cut

basilar artery syndrome

altered mental status

brainstem findings - cranial nerve deficits, weakness, anesthesia

basilar artery syndrome can be catastrophic due to pons damage

tetraplegia

coma

locked-in syndrome

stroke of the cerebullum leads to

nystagmus

dizziness

nausea

ipsilateral ataxia

hemorrhagic strokes are named after their

depth and location

intracranical hemorrhage (ICH)

bleeding from an arterial source into the brain parenchyma

- most fatal of all CVA

subarachnoid hemorrage (SAH)

bleeding into the subarachnoid space between the arachnoid and the pia mater

aneurysms and vascular malformations are

the most common non-traumatic causes of SAH

most common sites for SAH

anterior communicating artery

posterior communicating artery

middle cerebral artery

dangers of SAH

- spewing blood, under high pressure, into brain tissue

- susceptibility to re-rupture

- obstruction of the SA space which can lead to hydrocephalus due to CSF blockage

hemorrhagic CVA syndromes tend to be

less focal than ischemic due to more generalized area of tissue involvement

putaminal hemorrhage

similair to MCA CVA but with greater alteration of consciousness

thalamic hemorrhage

Results in contralateral hemiplegia with disproportionately greater sensory loss

cerebellar hemorrhage

results in ataxia and vestibulopathy

pontine hemorrhage

Offers the poorest prognosis

Tetraplegia and coma

lacunar CVA

characteristics of ischemic and hemorrhagic

symptoms of lacunar CVA

pure motor

pure sensory

ataxic hemiparesis

clumsy hand dysarthria

mixed sensory and motor

three stages of recovery

acute/early

late

chronic

initial improvements

reduction of cerebral edema

absorption of damaged tissues

improved local vascular flow

damaged areas of the brain