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104 Cards in this Set
- Front
- Back
% as a cause of death |
the 3rd leading |
|
types of CVD |
1-ischemic
2-heamorrhagic |
|
% of ischemic vs hrgic stroke |
ischemic 80 %
hrg 20 % |
|
ischemic stroke definition ?? |
-focal neurological deficit -lasting > 24 hrs -bcoz of loss of blood flow to a portion of brain -resulted in irreversible cell death
|
|
ischemic stroke mechanisms |
1-large vessels atherosclerosis
2-embolic diseases
3-small vessel disease (lacunar)
4-nonatherosclerotic vasculopathy
5-hematological / coagulopathy
6-watershed infarction
7-other : drug abuse / migraine / venous infarct |
|
TIA's definition |
transient focal neurological deficit caused by loss of regional blood flow
lasts < 24 hrs
typically only ( 10 - 60 ) minutes |
|
intracerebral hrg definition |
bleeding into the brain paranchyma |
|
SAH : subarchynoid hrg |
bleeding around the brain in the subarchinoid space |
|
risk factors for ischemic stroke |
1-age
2-male
3-african american
4-Hypertension / DM / Dyslipedemia
5-smoking
6-obesity / sedentary life-style
7-drug of abuse
8-family Hx |
|
drugs of abuse that increases your risk stroke |
1-cocaine
2-amphetamine |
|
embolic stroke risk factors
cardiac |
1-arrhythmia 2-dilated myopathy 3-left ventricular aneurysm 4-valvular (rheumatic / prosthetic) 5-endocarditis ( infective and non-infective 6-cardiac thrombus (left vent. or atrium) 7-cardiac myxoma 8-tASD / VSD / PFO :patent foramen ovale |
|
types of arrythmias that increases your risk of stroke |
1-A.Fib
2-sick sinus syndrome
|
|
TIA duration |
usually 10 - 15 min
most resolves within 60 min
by definition up to 24 hrs |
|
TIA future significans ??
life-time risk of stroke |
1-high correlation with future stroke 2-predictor of MI / vascular death
lifetime stroke risk : 33 %
|
|
amaurosis fugax |
form of TIA
temporary monocular blindness
2ry to carotid atherosclerosis with embolization |
|
subarchnoid hrg what's the subarcnoid space ?? |
space between brain and pia archnoid |
|
mortality in SAH ?? |
50 % |
|
one of best predictors for mortality p |
coma at presentation |
|
usual age for SAH ?? |
35 - 65 yo
younger presentation than stroke |
|
provocations for SAH ?? |
not specific , anytime exertion rest at sleep |
|
complication of SAH ?? |
1-re-bleeding
2-Hydroceph
3-vasospasm with late ischemic stroke
4-Hyponatremia
5-autonomic dysfunction |
|
re-bleeding in SAH
timing ??
mortality ?? |
within 2 weeks
50 % mortality |
|
pathogenesis of hyponatremia in SAH |
atrial natriuretic factor |
|
epidural hematoma causes |
trauma / skull Fx |
|
epidural hematoma classic shape / CT |
lense shape pushing on parenchyma |
|
subdural hematoma shape / CT |
cresent shape |
|
subdural hematoma
risk factors |
old age on anticoagulant with Hx of trauma |
|
diagnosis / evaluation of suspected CVA |
1-imaging
2-cardiac evaluation
3-coagulopathy / toxicology / blood culture
4-DDx |
|
DDx of stroke / TIA ?? |
1-focal seizure with todd paralysis
2-complicated migraine
3-brain mass
4-periphral vestibular disorders
5-cardiac arrythmias |
|
imaging in CVA |
1-brain CT / CT angio 2-Brain MRI / MRA 3-carotid duplex 4-transcranial doppler 5-cerebral angio |
|
brain CT advantages |
high sensetivity for blood |
|
MRI advantages |
higher sensitivity to -lacunatr - brain stem -post.fossa -acute stroke |
|
"gold standard " for CVA evaluation ?? |
Cerebral angio |
|
cerebral angio advantages
|
better anatomic localization
|
|
CT angio Risks / complications ?? |
1 % risk of stroke during procesure |
|
cardiac evaluation in stroke ??? |
1-ECG (rhythm / old CAD)
2-Echo (trans-esophageal / thrombus / valves)
3-Holter monitoring |
|
when to evaluate for coagulopathy ?? |
young pt
|
|
ischemic stroke
manegment ?? |
1-supportive
2-vitals / blood sugar goals monitoring
3-brain edema
4-antiplatelet
4-anti-coagulation
6-thrombolytics
7-carotid endartrectomy / stenting |
|
stroke admission order ?? |
-admit to
-observe vitals Q
-Glucocheck Q
-aspiration precautions
-seizure precautions
-pressure sores / change posision Q
-activity
-dysphagia screen / NG tube / mouth care
-NPO / diet / via NG
-foley's
-Keep BP : sys (( 120 - 220)) / dias ((60 - 120))
-keep B.Sugar
-Keep Temp.
-Labs : CBC / KFT / TSH (arrythmia) /LP / HbA1c drug screen / cardiac panel / thrombophila screening
-ECG +/- echs
-imaging : CT / MRI / MRA / carotid doppler... -consultation : cardiac / physio / speech therapiest
-monitor for hyponatremia |
|
stroke medication order |
-DVT prophx
-GI prophx
-Anti-platelet
-warfarin (in A.fib / Thrombus)
-statin |
|
BP goals |
in acute setting
systolic : 120 - 220
Diastolic : 60 - 120 |
|
fever manegment |
must be aggressive , fever may worsen the outcome |
|
blood sugar monitoring |
must be aggressive may eorsen outcome |
|
cerebral edema peak time |
48 hrs |
|
use of anticoagulant in stroke ?? |
heparine ??? no benifite & increase bleeding risk
warfaine : if A.fib / thrombus for 2ry prevention
dabigatran (thrombin inhi) same as warfarin |
|
advantage of warfarin over thrombin inhib / dabigatran |
can be reversed by FFP |
|
thrombolytics therapy which one is approved ?? |
only tPA only in acute stroke |
|
thrombolytic therapy criteria |
1-acute / ischemic stroke
2-administration / window : 3 hrs ((4.5 may))
3-no contraindications for thrombolytics therapy
|
|
thrombolytics therapy
exclusion |
time of onset : unkown or > 3 hrs
minor stroke
resolving symptoms
suggested / waitnessed seizure
BP > 185 / 110
CT scan : lesion/mass , early hypodensitiy
|
|
tPA protocol for stroke |
1-dose / kg , 10 % bolus , 90% over 1 hr
2-no invasive procedures within 24 hrs
3-BP keep < 180/110 |
|
tPA dose / administration |
0.9 mg / kg 10 % bolus 90% over 1 hr infusion
___________________________-
max dose = 90 mg |
|
carotid atherosclerosis ttt options |
1-observation
2-surgical endartrectomy
3-stenting |
|
carotid endartrectomy indications |
- > 70 % symptomatic stenosis
- 50 - 70 % symptomatic , modest benefit , individualized ttt |
|
carotid stenting |
endartrectomy is better |
|
carotid art stenosis % and Rx for each |
< 30 % = antiplatelet
50 - 70 % = modest benefit from endartrectomy
> 70 % endartrectomy |
|
Rx for vertebrobasilar disease |
antiplatelet |
|
Rx of lacunar infarction |
antiplatelet |
|
cardiac embolism Rx |
warfarin |
|
endocarditis Rx |
ttt of it
no warfarin : high bleeding risk |
|
fibromuscular dysplasia Rx |
antiplatelet |
|
arterial dissesection causing stroke Rx |
antiplatelet |
|
antiphospholipid synd |
anti-coagulation |
|
watershed area infarction Rx |
water repletion |
|
cerebral vein thrombosis |
anti-coagulation |
|
whats watershed infarction |
infarction 2ry to hypotension/shock |
|
watershed infarction presentation |
bilateral proximal weakness of both arms / legs |
|
causes of non-atherovascular vasculopathy |
1-fibromuscular dysplasia
2-arterial sissection
3-vasculitis |
|
how to suspect arterial dissection |
neck pain hx of trauma / exercise stroke |
|
what's the location of embolism in brain imaging |
gray-white junctionw |
|
whats lacunar infarction |
atherosclerosis of small penetrating vessels |
|
lacunar infarctions risk factors |
1-HTN
2-DM |
|
lacunar infarct presentation |
pure motor ipsilateral
pure sensory ipsilateral |
|
pure sensory ipsilateral lacunar infarction lacunar infarction |
thalamic lesionp |
|
pure motor ipsilateral lacunar infarction / location |
internal capsule
or
the pons |
|
carotid atherosclerosis (intra/extracranial presentation |
1-aphasia / dysarthria
2-ipsi (face / hand) numbness /weakness
3-amaurosis fugax |
|
vertibrobasilar disease presentation |
5 D's : _________________________ Dysarthria
Disphagia
Diploapia
Dizziness
Drop attacks / ataxia |
|
epiduarl hrg
cause |
trauma |
|
epidural hrg presentation |
headache
decrease LOC |
|
epidural hrg Dx
site |
CT : lense blood sign
between dura and skull pusj=hing on parynchyma |
|
epidural hrg Rx
|
urgent surgical evacuation |
|
subduaral hrg cause |
trauma ( often mild) in elderly |
|
subdural hrg presentation |
headach
confusion
seizure |
|
subdural hrg Dx |
CT : concave/cresent may mass effects |
|
subdural hrg ttt |
supportive
consider surgiacl evacuation |
|
subarchnoid hrg causes |
1-aneurysm
2-AVM |
|
subarchnoid hrg presentation |
siudden severe headach / the worst ever
meningismus
decreased LOC
focal deficit is possible
oculomotor palsy |
|
severe headache with oculomotor palsy ??? |
subarchnoid hrg |
|
subarchnoid hrg Dx |
CT : most sensitive
MRI : insensitive
cerebral angio : for aneurysm |
|
CT sensetivity in hrg ?? |
> 90 % |
|
if negative CT for SAH with high suspicion ?? |
do LP : __________________________ 1-xanthochromia
2-RBC's in tube 1 + 4 |
|
ttt of SAH ?? |
-supportive
-NIMOdipine for associated vassospasm
-early surgical clipping
-endovascular therapy |
|
early surgical clipping when ?? |
if minor defecit |
|
endovascular therapy types |
-coiling |
|
intracranial hrg cause / etiology ?? |
1-chronic HTN
2-AVM
2-tumor
3-drugs
4-other : vasculiis /coagulopathy/endocarditis / low plt
cerebral amyloid angiopathy |
|
most common cause of ICH ?? % |
HTN
50 -80 % |
|
whats cerebral amyloid angiopathy ?? |
old pt with alzheimer disease |
|
tumors that commonly cause hrg ??? |
renal cell ca
choriocarcinoma
melanoma
glioma |
|
drugs increasing risk of intracerebral hrg |
cocain
amphetamine
phynolpropranolamine |
|
intracranial hrg presentattion |
headach
vomitting
coma seizure
sudden or gradual
|
|
intracerebral hrg most locations |
1-lobar = most
2-basal ganglia/thalamus
3-cerebellum
4-pons |
|
how to detect AVM ?? |
MRI with gadolinium
or cerebral angio |
|
ICH when LP is contraindicated |
when mass effect |
|
intracerebral hrg Rx |
BP control
ventilation / airway protection
manegment of increaed ICH
surgical evacuation if possible |
|
Rx of increased intracerebral pressure in ICH |
1-elevat the head of the bed
2-avoid hypotonic fluid
3-??? mannitol
4-hyperventelation |