Cva

Front 1

Name the 2 kinds of strokes and describe the pathology.

Back 1

ischemic stroke (85% of strokes) caused by thrombotic stroke, precursors are TIAs. Embolic Stroke under this category too. Other kind is Hemorrhagic stroke--dont treat with thrombolytics.

Front 2

TIA--patho

Back 2

temporary loss of neurological function, at rest or sleep when BP lowered and cant perfuse past plaque, resolves within 24H without any deficits.

Front 3

TIA S/S

Back 3

weakness
slurred speech (carotid artery involvement feeding the middle cerebral artery in Broca's area)
loss of words (temp. aphasia)
visual changes

Front 4

What are the most common areas to get a thrombotic stroke?

Back 4

on top of artherosclerotic plaque: carotids (5 x more common than other arteries), middle cerebral artery, vertebral artery. Internal carotid is most devestating.

Front 5

Thrombotic Stroke: Vertebral Artery Signs and Symptoms

Back 5

dizziness, ataxia, dysphasia, syncope, numbness, vertigo, visual field disturbances

Front 6

Thrombotic Stroke: Middle cerebral artery and carotids signs and symptoms

Back 6

blindness in one eye
hemiparesis or hemiplegia
hemianesthesis
speech disturbances
confusion
symptoms progress as cerebral edema develops

Front 7

Embolic Stroke--patho

Back 7

Frequently cardiogenic in origin.
A-Fib clots and subsequent clot formation is the most common cause.
occur when pt awake and active
most frequent route is thru the middle cerebral artery (straightest route from heart)
Symptoms appear rapidly, seconds to minutes
Emboli begin to break up in 12H and smaller emboli may contribut to further neurological deficits.

Front 8

CVA--history data to get

Back 8

when was the pt last neurologically intact? any recent trauma or surgery? are you on anticoagulants antihypertensives, anticonvulsants, are you diabetic?clock starts when you start asking questions, you have to give thrombolytics in <3H or may have significant neurologic deficit.

Front 9

CVA--embolic stroke--evaluation

Back 9

CT scan to r/o hemorrhagic BUT ischemic strokes dont show up for a while. MRI may be better to assess for an ischemic injury. Check PT, is it < 15? more than 14 days since major surgery, more than 3 months since previous stroke or head trauma. SBP < 185 or DBP<110. Must have SIGNFICANT neurologic deficits because its so risky to give a thrombolytic. is it worth it?

Front 10

CVA evaluation

Back 10

rt-PA given within 90-180 min. reduces the extent of the neurological damage (if less than 1/3 of a hemisphere--if more wont respond). They are increased risk for intra-cerebral hemorrhage.

Front 11

CVA TESTS to assess ischemic stroke

Back 11

Require a baseline CT to determine if ischemic or hemorrhagic
If embolic, recommend anticoagulation (ASA). 80% will secondary event. Recommend ASA 325mg within 48 H unless hypertensive or have a large infarct--then wait 10-14 days. If a-fib, start ASA during the acute phase (as soon as documented that it is non-hemorrhagic)

Front 12

CVA--ischemic-- Clinical Mgmt

Back 12

hyperglycemia increases neuronal damage and extends the infarct!! it may be a marker of severity of brain injury. Monitor carefully!!
Treat fevers: fevers may worsen the prognosis and look for the cause.

Front 13

CVA--ischemic--clinical mgmt 2

Back 13

HT may be protective. Ischemic penumbra has lost autoregulation. it may require higher pressures to perfuse it. Avoid anti-Htn meds unless SBP > 220 or DBP >140.
Dont lower the BP more than 10-15% in 24H
Recommend: Labetalol (10-20mg) IV or Nicardipine (5mg/hr).
Prophylactic seizure control NOT recommended for ischemic stroke.

Front 14

CVA--ischemia--other things to watch

Back 14

naubtaub euvolumia, BR w/ HOB 30-35%, laxatives, DVT prophylaxis, mild sedation, pulmonary care, speech and swallowing assessment (40% will have abnormalities), nutrition--may use dobhoff for swallowing difficulties but usually resolves in 7-10 days.
Treat fevers--look for the source. ASA if anticoagulation is desired.

Front 15

CVA--Hemorrhagic Stroke--patho

Back 15

2 kinds Subarachnoid 25% and Intracerebral (75%). Subarachnoid is from a ruptured aneurysm, or its a bleed from an AV malformation. Intracerebral, more common, bleeding into the parenchema. Most commonly assoc. w/ HTN. see in elderly doing valsalva. s/s quick and progress over hours. Hematoma enlarges and increase ICP leads to herniation.

Front 16

CVA--Hemorrhagic stroke--Right Hemisphere

Back 16

L sided hemiplegia
L sided Hemoparesis
spatial-perceptual deficits
denial of affected side *****
impulsive behavior
poor judgement
deficits in L visual fields

Front 17

CVA--Hemorrhagic stroke--Left Hemisphere

Back 17

Right sided hemiplegia
Right sided hemiparesis
Expressive, receptive or global aphasia
Decreased performance on cognitive tests (math)
shows cautious behavior
deficits in R visual field
difficulty distinguishing R from L

Front 18

CVA--hemorrhagic stroke--vertebral artery

Back 18

pain in face, nose, eye
ipsilateral numbness and weakness of face
dizziness
staggering gait
nystagmus
clumsiness
dysphagia

Front 19

CVA--Hemorrhagic--Diagnosis

Back 19

CT without contrast. get tox screen on young ppl

Front 20

CVA goals of care

Back 20

restore circulation, stop ischemic process, reduce ICP. Might have reflexive HTN to protect cerebral perfusion. decline starts in 24H, gradually normalizes in 7-10 days. Hematoma impairs autoregulation in the surrounding area and can extend injury. Recommendation to gradually lower BP if SBP>200 or DBP > 110
Start Rehab early!!!

Front 21

Hemorrhagic stroke--treatment

Back 21

rest, treat HTN, d/c anticoagulation drugs for 1-2weeks. watch for seizure activity. can put in an ICP monitor, or do surgical decompression of hematoma >3cm if s/s. start rehab on admission!!

Front 22

CVA--complications

Back 22

DVT
decubitus ulcers
Gastric ulcers (curlings ulcer)
aspiration PNA
hydrocephalus (more likely with hemorrhagic stroke)

Front 23

Ranchos Scale

Back 23

used for stroke patients to guide for determining treatment modalities. the highert the number the better the function. goes from level 1 to VIII