Stroke

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Author:
lazzsant
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127236
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Stroke
Updated:
2012-01-11 19:37:43
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Combined lecture
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Stroke
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  1. Nonmodifiable risk factors for stroke
    • Age
    • race
    • sex ethnicity
    • history of migraine headaches
    • sickle cell disease
    • fibromuscular dysplasia
    • heredity
  2. Modifiable risk factors of stroke
    • HTN
    • obesity
    • smoking
    • diabetes mellitus
    • Cardiac disease
    • hypercholesterolemia
    • hyperhomocystinemia
    • oral contraceptive
    • carotid stenosis
    • lifestyle
  3. 5 arteries of the internal carotid
    • 1. ophthalmic artery
    • 2. anterior choroidal artery
    • 3. posterior communicating artery
    • 4. middle cerbral artery
    • 5. Anterior cerebral artery
  4. 3 arteries of the vertebral artery
    • 1. Anterior spinal artery
    • 2. Posterior spinal artery
    • 3. posterior inferior cerebellar artery
  5. 6 arteries of the basilar artery
    • 1. Anterior inferior cerebellar artery
    • 2. superior cerebellar artery
    • 3. Posterior cerebral arteries
    • 4. Paramedian Pontine arteries
    • 5. Long circumferential branches
    • 6. short circumferential branches
  6. Lateral Medullary Syndrome
    • Wallenberg Syndrome
    • Vertebral artery occlusion
    • nystagmus and ataxia (vestibular N, spino & olivo cerebellar tracts)
    • I/L loss of sensory, no gag, hoarseness (Nucleus ambiguus, solitarius, nerves V, IX, X)
    • I/L horners syndrome (sympathetic fibers)
    • C/L loss of pain & temp (spinothalamic tract)
  7. Medial Medullary syndrome
    • Anterior spinal artery
    • C/L paralysis (corticospinal tract)
    • C/L vibration/ position sense loss (medial lemniscus)
    • I/L hemi-atrophy tongue (Nucleus CN XII)
  8. Superior Alternating syndrome
    • Webers
    • Posterior cerebral/ basilar arteries
    • I/L CN III palsy
    • C/L hemiplegia
  9. Benedicts Syndrome
    • Posterior cerebral/ basilar arteries --> ventral & tegmental regions
    • I/L CN III palsy
    • C/L hemiplegia, ataxia, tremor
  10. Difference between Core and penumbra
    • Core is the area with no blood flow. Minutes to revive.
    • Penumbra is the area recieving minimal blood flow. Must preserve this area. Hours to revive.
  11. Thrombotic storkes in younger patients causes
    • hypercoagulable state (antiphospholipid ab, Pro C or S def)
    • sickle cell
    • fibromuscular dysplasia
    • arterial dissections
    • vasoconstriction assoc. w/ substance abuse
  12. Causes of lacunar infarcts
    • Hispanics most likely
    • HTN**
    • microatheroma
    • lipohyalinosis
    • fibrinoid necrosis secondary to HTN or vasculitis
    • hyaline ATS
    • amyloid angiopathy
  13. Presentation of watershed infarct
    • Shoulders and trunk are weak but hands feet and face are still good and strong.
    • Differentiate from Myopathy via onset. Watershed is sudden onset not gradual like a myopathy.
  14. Presentation of hemorrhagic stroke
    • Pounding headache
    • sitff neck
    • focal long tract signs
  15. Monitoring for Aneurysm
    • hydrocephalus within 24 hours
    • rebleeding day 2- 2 weeks
    • vasopasm- within 2 weeks
  16. Intracerebral hemorrhage associated with
    • HTN
    • diabetes
    • ATH
  17. How to prevent further damage to the penumbra
    • Monitor
    • Blood glucose
    • BP
    • Cardiac monitor
    • IV fluids (NO D5W)
    • Oral intake (NPO)
    • O2
    • Temperature (acetaminophen)
  18. What leads to hypotensive encephalopathy?
    Prolonged hypotension & hypoxia
  19. Factors affecting hypotensive encephalopathy
    • Age
    • duration
    • Temperature (hot)
  20. Classification of CVA
    • Complete stroke (necrotic)
    • Evolving stroke (penumbra)
    • TIA (CNS disturbance less than 24 hours. No morphological changes)
  21. Ischemic vs Hemorrhagic stroke
    • Ischemic: older, ATH, may survive
    • Hemorrhagic: younger, HTN, usually die
  22. Etiology for brain infarct
    • Atheroma
    • thromboemboli
    • Aneurysm
    • Vasculitis
    • Trauma
    • SAH
    • cardiac arrest
  23. Stroke timeline
    • 8-12 hours Ischemic neuronal changes & inflammation
    • 36-48 hours: Necrotic area swollen & soft
    • loss of definition between white & grey matter
    • Interstitial & intracellular edema --> mass effect
    • Areas of hemorrhage present
    • DAYS: Macrophage
    • liquefactive necrosis
    • astrocytes & gliosis
  24. Gross features of brain infarct
    • Liquefactive necrosis
    • wedge shaped with broad cortical basis
    • Narrow cortical layer is always spared
    • small hemorrhage in periphery
    • Hemosiderin
  25. Distribution factors
    • Site of occlusion
    • Time to develop
    • Presence of arterial anastomoses
  26. Definition of HTN encephalopathy
    Brain edema & petechial hemorrhage or herniation lead to a rise in ICP which leads to an acute rise in BP of over 220/110 mmHg.
  27. Pathology of intraparenchymal hemorrhage
    • 1. Preexistent damage of vessel wall
    • 2. HTN
    • 3. After phycal effort
    • Involves deep arteries supplying basal ganglia
    • IF enters ventricles = death
  28. Hamartoma
  29. Saccular aneurysm
    Factors
    Sites
    Clincial presentation
    • FACTORS:
    • Polcystic kideney disease
    • Fibromuscular dysplasia
    • Coarctation of aorta
    • AV malformation
    • Ehlers Danlos
  30. SITES: Bifurcation of internal carotid arteries
    • CLINCAL:
    • abrupt onset- inc ICP & dec consciousness
    • Meningeal signs
    • complications- cerebral infarct, hydrocephalus, brain herniation
  31. Fibrinolytic Therapy Requirements
    • Stroke w/ persistent neuro defect
    • < 3 hrs for best result (no more than 4.5 hrs)
    • No anticoagulants 24 hours afterwards
    • CT 24 hours after to look for hemorrhagic transformation
  32. Fibrinolytic therapy contraindications
    • Head trauma X 3 mos
    • Stroke X 3 mos
    • IC hemorrhage
    • SAH
    • BP > 185/110
    • dec platelet count
    • dec glucose
    • surgery X 14 days
    • GI bleed X 21 days
    • MI

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