[Int. med] cerebrovascular accident from SIMS Lahore
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Transcript of [Int. med] cerebrovascular accident from SIMS Lahore
Stroke is an acute CNS injury that results in neurologic signs and symptoms caused by a reduction or absence of perfusion to a territory of the brain. The disruption in flow is from either an occlusion (ischemic) or rupture (hemorrhagic) of the blood vessel.
Cerebrovascular Accident Ischemic Stroke
Thrombotic Embolic Lacunar infarct TIA
Hemorrhagic Stroke ICH SAH
Occlusion of large cerebral vessel
Older population Sleeping/resting Rapid event, but slow
progression (usually reach max deficit in 3 days)
Embolus becomes lodged in vessel and causes occlusion
Bifurcations are most common site
Sudden onset with immediate deficits
Minor deficits Paralysis and sensory
loss Lacune Small, deep penetrating
arteries High incidence:
Chronic hypertension Elderly DIC
Warning sign for stroke Brief localized
ischemia Common
manifestations: Contralateral
numbness/weakness of hand, forearm, corner of mouth
Aphasia Visual disturbances-
blurring
Deficits last less than 24 hours (usually less than 1 or 2 hrs)
Can occur due to: Inflammatory
artery disorders Sickle cell anemia Atherosclerotic
changes
Intracerebral hemorrhage Intracranial hemorrhage Parenchymal hemorrhage Intraparenchymal hematoma Contusion Subarachnoid hemorrhage
Changes in vasculature Tear or rupture Hemorrhage Decreased perfusion Clotting Edema Increased intracranial pressure Cortical irritation
Hearing/association & Smell & taste Short term Memory
Voluntary Motor
Sensations Pain & Touch Taste
Balance, Coordination of each muscle group
Arms
Head
LegsMom: Bowel/bladder Reasoning/judgment Long term memory
Vision & visual memory
CN 5,6,7,8 P,R, B/P CN 9,10,11,12
Tracks cross over Coordinate movement, HR,B/P
NON-MODIFIABLE MODIFIABLE
Age 2/3 over 65
Gender M=F Female>fatality
Race AA > hispanics, NA Asians > hem
Heredity Family history Previous TIA/CVA
Hypertension Diabetes mellitus Heart disease A-fib Asymptomatic carotid stenosis Hyperlipidemia Obesity Oral contraceptive use Heavy alcohol use Physical inactivity Sickle cell disease Smoking Procedure precautions
EMBOLISMPROTHROMBOTIC STATES
Atrial fib Sinoatrial D/O Recent MI Endocarditis Cardiac tumors Valvular D/O Patent foramen ovale Carotid/basilar artery
stenosis Atherosclerotic lesions Vasculitis
Hemostatic regulatory protein abnormalities
Antiphospholipid antibodies
Chronic HTN** Cerebral Amyloid Angiopathy* Anticoagulation* AVM Ruptured aneurysm (usually subarachnoid) Tumor Sympathomimetics Infection Trauma Transformation of ischemic stroke Physical exertion, Pregnancy Post-operative
Localized dilation of arterial lumen Degenerative vascular disease Bifurcations of circle of Willis
85% anterior 15% posterior
Complications HCP Vasospasm
Triple H Therapy HTN Hemodilution Hypervolemia
Surgical treatment Clip Coil INR
SUDDEN numbness or weakness of face, arm or leg
SUDDEN confusion, trouble speaking or understanding.
SUDDEN trouble with vison.
SUDDEN trouble walking, dizziness, loss of balance or coordination.
SUDDEN severe headache.
Vertebral Artery Pain in face, nose, or eye Numbness and weakness of face (involved
side) Gait disturbances Dysphagia Dysarthria (motor speech)
Internal carotid artery Contralateral paralysis (arm, leg, face) Contralateral sensory deficits Aphasia (dominant hemisphere involvement) Apraxia (motor task), Agnosia (obj. recognition), Unilateral neglect (non-dominant hemisphere
involvement) Homonymous hemianopia
Neurological Hyperthermia Neglect syndrome Seizures Agnosias (familiar
obj)
Communication deficits Aphasia (expressive,
receptive, global) Agraphia
Visual deficits Homonymous
hemianopia Diplopia Decreased acuity Decreased blink reflex
Neurological (cont.) Cognitive changes
Memory loss Short attention
span Poor judgment Disorientation Poor problem-
solving ability
Behavioral changes Emotional
lability Loss of
inhibitions Fear Hostility
Musculoskeletal Hemiplegia or
hemiparesis Contractures Bony ankylosis Disuse atrophy Dysarthria - word
formation Dysphagia – swallow Apraxia – complex
movements Flaccidity/spasticity
GU Incontinence Frequency Urgency Urinary retention Renal calculi
Integument Pressure ulcers
Respiratory Respiratory center damage Airway obstruction Decreased cough ability
GI Dysphagia Constipation Stool impaction
Neurological assessment Call “Stroke Alert” Code Ensure patient airway Vital signs IV access Maintain BP within parameters Position head midline CT Brain Anticipate thrombolytic therapy for
ischemic stroke
Tests for the Emergent Evaluation of the Patient with Acute Ischemic Stroke
CT head (-) Electrocardiogram Chest x-ray Hematologic studies (complete blood count,
platelet count, prothrombin time, partial thromboplastin time)
Serum electrolytes Blood glucose Renal and hepatic chemical analyses
BP Factor VII, Vit K,
FFP ICP
Sedation Hyperventilation Paralytics
Fluid management Seizure prophylaxis Sedation Body temperature DVT prophylaxis
ISCHEMIC HEMORRHAGIC
Medical management
TpA Endovascular
Carotid endarectomy Merci clot removal
Medical management
Decompression Craniotomy Craniectomy
REHABILITATION
Anti-coagulants – A fib & TIA Antithrombotics Calcium channel blockers – Nimotop (nimodipine) Diuretics – Mannitol, Lasix (Furosemide) Anticonvulsants – Dilantin (phenytoin) or Cerebyx
(Fosphenytoin Sodium Injection) Thrombolytics - tPA (recombinant tissue
plasminogen activator)