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24 Cards in this Set

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Stroke Facts
780k strokes/year. Each year, 60k more women than men will have a stroke. THIRD leading cause of death in the US
Stroke risk factors
(1) HYPERTENSION == #1; (2) Age > 65; (3) Afib - 5x risk; (4) Diabetes; (5) Smoking; (6) Sedentary lifestyle, obesity; (7) Ethnicity; (8) CAD; (9) HLD
Transient Ischemic Attack (TIA)
Sudden onset of a neurologic deficit that resolves within 24 hours; about 15% of strokes were preceded by TIA
What is Stroke?
An acute clinical event related to impairment of cerebral circulation resulting in a change in neurologic function (lasting more than 24 hrs)
Why care about TIA’s?
90 day risk of stroke after TIA is 3-17 percent- highest risk 1st 30 days! Up to 25% of patients will die (all cause) within a year of having TIA!!! Needs rapid stroke work-up
Hemorrhagic stroke
(1) Subcortical: usually hx or POORLY CONTROLLED HTN - most common in basal ganglia - lacunar infarcts; (2) Cortical - look for aneurysms, AVMs, tumors, amyloid angiopathy
Ischemic stroke - large vessel: causes
(1) Cardioemboli - valve, mural thrombus, tumor, PFO, infection; (2) Atherosclerosis or stenosis + thrombus,embolus,hypotension; (3) Dissection; (4) Arteritis; (5) Hematologic - PCV, TTP, SCD, DIC, APL-Ab, Leukemia; (6) Global anoxia
ACA stroke
Contralateral sensorimotor changes in legs; decreased motivation, organizational behaviors
Dominant MCA stroke
Contralateral weakness/numbness, language/aphasia
Non-dominant MCA stroke
Contralateral weakness/numbness; hemineglect
PCA stroke
(1) Contralateral homonymous hemianopsia; (2) Splenium of corpus callosum - alexia w/o agraphia; (3) May affect thalamus
Vertebrobasilar (Posterior circulation)
(1) Sensory and/or motor abnormalities in any combo of extremities/face; vertigo/clumsiness/ataxia, diplopia, dysarthria, dysphagia
Ischemic Stroke- small vessel
Involves deep penetrating vessels of large arteries -> poor collaterals; Results in “lacunar” infarcts, <1.5 cm; May be silent
5 common lacunar strokes
(1) Pure motor (IC or base of pons); (2) Pure sensory (thalamus); (3) Sensorimotor (thalamus + IC); (4) Ataxic hemiparesis (upper pons); (5) Dysarthria and clumsy hand (base of pons)
Strokes of Venous Origin
May present with HA, pseudo-tumor appearance, focal neurological signs, hemorrhage - SAH or ICH, AMS, seizures. Dx with CTV or MRV - treat with anticoagulation, prevention
Initial Stroke Evaluation
STAT CT Scan to r/o bleed; Evaluate for tPA; Imaging with CTA/MRA; MRI of brain, Echo, Inflammatory labs - ESR, RF, ANA, RPR, Hypercoagulable labs, Stroke tele
Initial Stroke Management - hemorrhagic stroke
(1) STOP BLEEDING; (2) Treat BP - considering ICP, CPP; (3) Avoid fever, hyperglycemia; (4) Manage hydrocephalus; (5) No anticonvulsants unless seizing
Initial Stroke Management - Ischemic Stroke
(1) Evaluate for tPA: <3hrs for IV tPA, or <6hrs for IA tPA; (2) If no tPA, give ASA; (3) Give statin; (4) Avoid fever/hyperglycemia; (5) Watch for hemorrhagic transformation
Ischemic stroke - other management issues
(1) Permissive HTN~210/110 mmHg, Evaluate swalloring, PT/OT, DVT prophylaxis
Ischemic stroke: large vessel - Intervention for symptomatic carotid stenosis
(1) CEA: 15% annual stroke rate if >50% stenosis and treated with medical management; There is a 7% stroke rate for CEA, but 3-6% upfront stroke/death; (2) In general, CEA performed if stenosis >70%, possibly if >50%
Ischemic stroke: large vessel -asymptomatic Carotid Stenosis
(1) 2-4% annual stroke rate with medical therapy (pre-statin era); (2) 1-2% with CEA; relative reduction in all vascular events is ~15% over 3 years
Dissection - ASA vs OAC
No clear evidence one is better - treat with Heparin + Coumadin for 3-6 months, then use ASA
Cardioembolic anticoagulation
Anticoagulation with warfarin is superior to Aspirin or Plavix (WATCH trial) in Cardioembolic strokes. Shoot for INR 2-3
Stroke prevention
(1) Everyone gets ASA; (2) Statins; (3) Treat HTN with lacunar infarcts; (4) May need CEA; (5) May need to treat AVM, aneurysm