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When an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue (cerebral infarction) and causing sudden symptoms.

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When does a stroke occur?

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1) Bleeding - Hemorrhage 2) Lack of blood flow - Thrombotic - Embolic

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What are the two mechanisms of action for a stroke?

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1.) Cells loose blood supply 2.) Aerobic metabolism stops 3.) Cells die 4.) Dead cells swell 5.) The amount of swelling depends on the volume of dead tissue 6.) Enlarging tissue increases the Intercranial pressure 7.) Blood flow decreases to the head - Remember what drives blood flow? 8.) Increased ICP (intercranial pressure) decreases blood flow which makes cerebral perfusion worse 9.) The area around an infarct becomes progressively hypoxic causing more swelling 10.) More swelling causes worse blood flow 11.) Eventually the brain becomes too big to stay in the cranium 12.) HERNIATION occurs (Next card, wait for it.....)

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Why does death occur as a result of a stroke?

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#1) Midline shift #2) Downward displacement of the cranium #3) Uncus and hippocampus herniate into the tentorial notch #4) Cerebellar tonsils herniate through the foramen magnum = DEATH

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What is herniation?

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80% Ischemic Stokes : 20% Hemorrhagic

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Which occurs most, ischemic or hemorrhagic stroke?

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STROKE!

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What is the most common disabling neurologic disorder?

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Arterial Hypertension!!!! (Systolic and diastolic BP are independent risk factors)

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What is the most IMPORTANT risk factor for stroke?

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1) A. Fib 2) Smoking 3) Lipids 4) Diabetes 5) Previous TIA 6) 1/3 will have a full stroke in 5 years Age

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What are some other risk factors for stroke?

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1) Migraine 2) Seizures 3) Syncope 4) Transient global amnesia 5) Peripheral nerve disorders 6) Intracranial hemorrhage 7) Intracranial masses 8) Neuroses (panic, anxiety) 9) Metabolic disorders

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What are the diagnoses that may mimic stroke (AKA the differential diagnosis)

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Thrombotic strokes

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This is described as when a thrombus formation in an artery causes decreased perfusion downstream and subsequent cell death

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***Large vessel disease (inside & outside the head)*** 1) Circle of Willis 2) Carotids 3) Vertebral blood vessels

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What large vessels are affected in ischemic stroke??

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1) Atherosclerosis 2) Vasoconstriction 3) Arterial Dissection

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What are the causes of large vessel disease?

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Lacunar Infarcts

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What is another name for Small Vessel Disease ?

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****Small (.5-1.5 mm) arteries from**** 2) Distal vertebral artery 3) Basilar artery 4) Middle cerebral artery stem

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What arteries are affected in small vessel disease?

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1) Lipohyalinosis 2) Atheroma formation (when cholesterol and fatty sub. that is carried in the blood accumulates on the inside lining of the arteries and form a yellow deposits)

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What are the causes of small vessel disease?

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1) Silent at first 2) AKA Lacunar infarcts 3) Step-wise progression 4) Slowly accumulates deficits - Pure motor hemiplegia - Dysarthria - Ataxic hemiparesis - Dementia (recall: multi-infarct dementia)

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What are the clinical features of small vessel disease?

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Ischemic Strokes

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This is described as is death of an area of brain tissue (cerebral infarction) resulting from an inadequate supply of blood and oxygen to the brain due to blockage of an artery.

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1) A particle from elsewhere that lands in the brain 2) Variable clinical picture

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What is an emboli?

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1) Cardiac - Atrial fibrillation - Valvular Disease (endocarditis) 2) Carotid - Atheroma 3) Aortic atheroma 4) Unknown

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What are the sources of an embolus that causes a stroke?

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Anoxic Brain injury

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What is another name for hypoperfusion?

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1) Sepsis 2) Shock 3) Bleeding

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What does decreased oxygen supply in hypoperfusion (Anoxic Brain injury) cause?

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Hemorrhagic stroke

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This is caused by include bleeding within the brain (intracerebral hemorrhage) and bleeding between the inner and outer layers of the tissue covering the brain (subarachnoid hemorrhage).

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When blood vessels of the brain are weak, abnormal, or under unusual pressure, a hemorrhagic stroke can occur. In hemorrhagic strokes, bleeding may occur within the brain, as an intracerebral hemorrhage. Or bleeding may occur between the inner and middle layer of tissue covering the brain (in the subarachnoid space), as a subarachnoid hemorrhage

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OK so how does bleeding cause a hemorrhagic stroke?

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1) Hypertension 2) Trauma 3) Illicit drug use (cocaine and/or methamph.)

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What are the causes of intercerbral hemorrhage?

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1) Confined to the tissues that contain bleeding 2) Evolve over minutes-hours 3) Do NOT BEGIN ABRUPTLY 4) ARE NOT MAXIMAL AT ONSET 5) Symptoms are progressive

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What are the symptoms of an intercerabral hemorrhage?

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1) Vomiting 2) Decreased level of consciousness

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What are the signs and symptoms of an intercerbral hemorrhage that has caused an elevated intracranial pressure (ICP)?

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Arteriole-Venous Malformations (AVM)

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This is defined as: 1) Congenital Arterial-Venous connections w/o a capillary bed in-between 2) High flow of blood 3) Not completely normal blood vessels

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A bulge (dilation) in the wall of an artery, usually the aorta.

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What is an Aneurysm?

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Berry Anuerysm

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This is a small aneurysm at the base of the brain in the Circle of Willis

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1) very common in elderly 2) rupture can be life threatening 3) 35% fatality on 1st hemorrhage 4) Sudden, severe headache followed by coma 5) **Associated with polycystic kidney disease**

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Describe a Berry Anuerysm

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Rupture usually comes from increased intracranial pressure - Valsalva/coughing/sneezing **Note** Bleeding is white

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What usually causes a rupture of an aneurysm?

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1) Blood is NOXIOUS to the Brain 2) Blood spreads throughout the CNS 3) Causes elevated ICP -->Coma-->Death

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What happens when there is Arterial bleeding into the CSF?

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Cerebral hemorrhage

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This is hemorrhage within the brain substance

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Subarachnoid hemorrhage

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This is bleeding into subarachnoid space, causing elevated intracranial pressure, vasospasm, and toxic effects.

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Subdural or epidural hemorrhage

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This produces mass lesion that can compress the underlying brain.

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1) Bleeding typically short - Arterial spasm common - Rebleeding very common o And fatal 2) Clot formation causes vasospasm 3) Distal hypoperfusion - Results in Ischemic damage

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Describe what happens during an aneurysm

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Abrupt onset v. gradual 1) Severe--> Subarachnoid hemorrhage (SAH) 2) Headache--> (97% of cases of SAH) 3) "Worst headache of my life"--> SAH 4) Vomiting 5) Consciousness - Initially brief w/ Lucid interval to follow 6) Neck Stiffness 7) Aseptic Meningitis

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What are the symptoms of a stroke?

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SUBARACHNOID HEMORRHAGE

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This is bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the tissue covering the brain (meninges).

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Rupture of a bulge (aneurysm) in an artery

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What is the most common cause of subarachnoid hemorrhage?

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Because a Subarachnoid hemorrhage can occur as a result of trauma as well

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Why is a Subarachnoid hemorrhage is considered a stroke ONLY when it occurs spontaneously

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1) Sentinal bleeds (Warning bleed) 2) TIA

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What are the "warning shots" of a stroke?

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1) Sudden and severe headache 2) Typically 6-20 days before "THE BIG ONE"

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Describe the onset of a Sentinal bleeds (Warning bleed)

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1) Brief episode of neurological dysfunction 2) Resulting from decreased perfusion 3) Impeding stroke!!! 4) Symptoms resolve in less than an hour

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What is a TIA (transient ischemic attack)?

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1) Identifiy the cause of neurologic deficit - IF NOT stroke, then what? Can it be treated - Said another way, not all neurologic deficits are from stroke! 2) Plan an immediate plan of action - Candidate for lytics? Anticoagulation? 3) Long term management Can we prevent future strokes?

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What are the three goals of managing a stroke?

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1) Asymmetric facial paresis 2) Arm drift/weakness 3) Abnormal speech (dysarthria) **Note** Ischemia is dark (black)

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What are the three most predictive examination findings for acute stroke (Ischemic)?

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Noncontrast CT

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What is the mot important diagnostic test for a stroke?

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Looks dark - may be normal in first 24 hours

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How does Ischemic stroke look on non-contrast CT?

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Looks bright/white - should show up earlier

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How does hemorrhagic stroke look on a non-contrast CT?

question

acute hemorrhage appears bright on CT scan, whether in the brain itself, or outside the brain parenchyma (subarachnoid, subdural hemorrhage).

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How does a acute subarachnoid hemorrhage appear on Non-Contrast CT?

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Sensitivity: 89%; specificity: 100%

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What is the sensitivity/ specificity of a non-contrast CT in diagnosing a Subarachnoid hemorrhage?

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MRI

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What is much better than CT for detecting brainstem and cerebellar strokes?

question

True

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T or F. Acute infarction is seen sooner with MRI than CT

question

1) Elevated BP that cannot be controlled 2) Bleeding disorder 3) Stroke or head trauma in the prior 3 months 4) Prior history of intracranial hemorrhage 5) Major surgery in the past 14 days 6) GI or GU bleeding in the previous 21 days 7) MI in the prior 3 months 8) LP within the past 7 days 9) Evidence of hemorrhage on head CT 10) Symptoms suggestive of SAH, even if CT is normal 11) Pregnancy or lactation 12) Active bleeding or acute trauma/fracture

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What are the contraindications to using thrombolysis?

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BLEEDING!! DO NOT PUSH LYTICS IN THE DARK

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What is the Big complication of pushing throbolytics?

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Aspirin, after exclusion of hemorrhage on CT.

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If a stroke patient is not a candidate for thrombolytics, what shoule be prescribed?

question

220mgHg and/or DBP over 120mmHg

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Most guidelines recommend that BP NOT be treated acutely in the patient with ISCHEMIC stroke unless SBP over

question

220/120

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I say again, what is the threshold in ISCHEMIC stroke?

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- Ischemic stroke causes decreased blood flow distal to obstruction, with blood flow in the distal blood vessels dependent upon systemic BP - Elevated BP may be a chronic condition or may be a response to decreased cerebral perfusion

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Why should I be permissive with the Blood pressure in ISCEHMIC stroke?

question

Labetolol (Beta Blocker) Works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure.

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If by chance the BP gets over 220/120, what should be prescribed?

question

Keep SBP between 140-160mmHg and monitor for signs of cerebral hypoperfusion induced by fall in BP

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OK. BP control in HEMORRHAGIC stroke is handled a little differently. What should I keep the BP at in a Intracerebral hemorrhage or a subarachnoid hemorrhage?

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1) IV nitroprusside (Nitropress) - A vasodilator that works by relaxing the muscles in your blood vessels to help them dilate (widen). This lowers blood pressure and allows blood to flow more easily through your veins and arteries. 2) Nicardipineis (Cardene) - used to treat high blood pressure. It relaxes your blood vessels so your heart does not have to pump as hard. It also increases the supply of blood and oxygen to the heart to control chest pain (angina). 3) Labetalol

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What should be prescribed if a patient with a Intracerebral hemorrhage or a subarachnoid hemorrhage has a Systolic BP over 160?

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Labetalol (Because a patient will get increased blood flow with nitroprusside vasodilation)

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What is the DOC in a patient with a subarachnoid hemorrhage and why?

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***Liberal use of antipyretics*** - Decreased stress - Watch for worsening disease - Think edema--> Increased ICP o Neuro checks q2 hrs o Vitals q2 hrs

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Manage the Temperature! But how?

question

1) Keep head of bed elevated 2) Consider sedation (barbiturate coma) 3) Consider mannitol 4) Consider hyperventilation

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What are the ways to prevent elevated intracranial pressure in patients with intracerebral hemorrhage and subarachnoid hemorrhage?

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1) Prophylaxis for DVT and PE 2) Physical therapy, speech therapy, occupational therapy, swallowing studies 3) Recall that, of the patients who survive the acute period, only a little over half regain independent function - 30% remain incapacitated and require long-term care.

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What should be done after a intracerebral hemorrhage and subarachnoid hemorrhage that cause a stroke?

question

Transient ischemic attack (TIA)

answer

This is a sudden or rapid onset of neurologic deficit caused by cerebral ischemia. It may last for a few minutes or up to 24 hours and clears without residual signs. "a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of acute infarction."

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1) Determine type and location of TIA 2) Non-contrast CT scan 3) Duplex ultrasound and transcranial doppler 4) MRI/MRA can demonstrate circulation, evaluate for stenosis 5) ECG and transesophageal echocardiography 6) Hospitalization may expedite workup 7) Consider hospitalization for patient with first TIA in the past 24-48 hours, as well as those with symptoms that are worsening or last for more than one hour, if there is a known carotid artery stenosis, afib, or hypercoagulable state

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What should I do with Patients who have had a suspected TIA and require urgent evaluation?

question

1) * Consider thrombolytic therapy 2) Antiplatelet therapy - Aspirin reduces risk of subsequent TIAs or stroke - 325mg po qD - Ticlopidine 250mg po BID may be more effective than aspirin in preventing stroke but it's a lot more expensive - Clopidogrel (Plavix) 75mg po qD is another antiplatelet option. 3) Carotid endarterectomy (may be indicated for patients with 70% or more carotid stenosis (of course, only works for patients with stenosis of common or internal carotid artery, not in treatment of vertebrobasilar TIAs) 4) Angioplasty or stenting? ****Either way, antiplatelet agents should be started ****

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What is the treatment of a patient with a TIA?

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1) HTN --> Control it baby! If you don't its badness 2) Other cardiac risk factors - Risk of stroke is 50% higher in smokers than in nonsmokers 3) Aspirin 4) Consider anticoagulation for patients with A-fibrillation

answer

What is the PRIMARY prevention of stroke and TIA?

question

STATINS 1) Statin therapy provides protection for all-cause mortality and nonhemorrhagic strokes 2) Statin therapy for all-stroke prevention: RR 0.84 (95% CI 0.79-0.91) 3) Statin therapy for all-cause mortality RR 0.88 (95% CI 0.88-0.93)

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How can I control my patient's lipids?

question

1) Lipid-lowering therapy (aggressive) - LDL 100 or less 2) Smoking cessation 3) Other cardiac risk factors 4) Stroke survivors average 10 outpatient visits/year

answer

What is the secondary prevention of stroke and TIA?

question

Carotid Doppler

answer

What is used in the evaluation "screening" of suspected stenosis of the intracranial internal carotid artery, middle cerebral artery, or basilar artery.

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Conventional angiography

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**What is the s "gold standard" for AVM or SAH but has a 1% risk of stroke during procedure.**?

question

Transthoracic and transesophageal echocardiography (TTE or TEE)

answer

What is used to detect cardiogenic and aortic sources for cerebral embolism?

question

True

answer

T or F. Transthoracic and transesophageal echocardiography can be postponed until after the acute treatment phase

question

Coumadin

answer

Which is better in Atrial Fibrillation, Coumadin or Aspirin?

question

Surgical clipping or placement of coil for aneurysm Ligate or embolize AVM. Evacuation

answer

What are the surgical options for patietns with TIA/stroke?

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