Lp Stroke Non Hemoragik Pdf Downloadl
The patient also may develop a stroke of the posterior cerebral artery distribution. In approximately 5% of cases, the hemiparesis may be ipsilateral to the dilated pupil. This phenomenon is called the Kernohan notch syndrome and results when uncal herniation forces the midbrain to shift so that the contralateral cerebral peduncle is forced against the contralateral tentorial incisura.
Some chronic subdural hematomas may be derived from subdural hygromas. Brain atrophy or loss of brain tissue due to any cause, such as alcoholism, or stroke, may provide either an increased space between the dura and the brain surface where a subdural hygroma can form (see the image below) or traction on bridging veins that span the gap between the cortical surface and dura or venous sinuses.
A stroke, or cerebrovascular accident, is an emergency medical condition characterized by an acute compromise of the cerebral perfusion or vasculature. The leading cause of ischemic stroke is hypertension whereas clotting disorders, carotid dissection, and illicit drug abuse are common causes in the younger populations. A quick diagnosis followed by prompt management needs to be set in motion by the interprofessional team members to improve outcomes for those with stroke. This activity reviews the etiology, presentation, evaluation, and management of cerebrovascular disease and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition.
Objectives:Summarize the risk factors for a cerebrovascular accident.Describe the presentation of a patient with a stroke, and the appropriate examination process, including diagnostic imaging if indicated.Review the treatment and management of stroke.Outline the value of collaboration and communication among the interprofessional team members to promptly identify the type of stroke (embolic or hemorrhagic) and institute thrombolytic treatment accordingly to decrease morbidity and mortality in those affected.Access free multiple choice questions on this topic.
A stroke or cerebrovascular accident (CVA) is an acute compromise of the cerebral perfusion or vasculature. Approximately 85% of strokes are ischemic and rest are hemorrhagic. In this discussion, we mainly confine to ischemic strokes. Over the past several decades, the incidence of stroke and mortality is decreasing. Stroke is the leading cause of adult disability worldwide. It is thus critical to recognize stroke early and treat it rapidly to prevent or minimize morbidity and mortality. There are many causes of stroke. Hypertension is the leading cause of ischemic stroke. In the younger population, there are numerous causes of stroke including clotting disorders, carotid dissection, and illicit drug abuse. In the acute setting, a quick history and examination to be performed. As \"time is brain\", it is very important not to waste any time. As acute stroke management is evolving rapidly, one must consider patients for intravenous tissue plasminogen activator (IV tPA) up to 4.5 hours and mechanical thrombectomy for up to 6 hours. The recent DAWN trial showed that one can extend the window for mechanical thrombectomy up to 24 hours in selected cases of large vessel occlusion.
Ischemic etiologies can further be divided into embolic, thrombotic, and lacunar. In general, the common risk factors for stroke include hypertension, diabetes, smoking, obesity, atrial fibrillation, and drug use. Of all the risk factors, hypertension is the most common modifiable risk factor for stroke. Hypertension is most prevalent in African-Americans and also occurs earlier in life. According to JNC8, the recommended blood pressure targets in patients with stroke should be less than 140/90 mm Hg. Chronic uncontrolled hypertension causes small vessel strokes mainly in the internal capsule, thalamus, pons, and cerebellum. Lifestyle measures such as weight loss, salt restriction, taking more fruits and vegetables (such as the Mediterranean diet) are helpful in decreasing the blood pressure. Every 10 mm Hg reduction in blood pressure is associated with a 1/3rd reduction in stroke risk in primary prevention. One-third of the adults in the USA have elevated low-density lipoprotein (LDL), leading to plaque formation in the intracerebral vasculature. Eventually, due to the excessive plaque build-up thrombotic strokes occur. In the older population, the risk of cardioembolic stroke increases mainly due to atrial fibrillation. The rest 20% of strokes are hemorrhagic in nature. Hemorrhagic etiologies can be from hypertension, aneurysm rupture, arteriovenous malformations, venous angiomas, bleeding due to illicit drugs like cocaine, hemorrhagic metastasis, amyloid angiopathy, and other obscure etiologies.
Lacunar strokes contribute up about 20% of all ischemic strokes and result from occlusion of the small penetrating branches of the middle cerebral artery, vertebral or basilar artery or the lenticulostriate vessels. Typical causes of lacunar strokes include microemboli, fibrinoid necrosis secondary to vasculitis or hypertension, amyloid angiopathy, and hyaline arteriosclerosis.
Stroke is the fifth leading cause of death in the US. The incidence of stroke is around 800,000 people annually. Stroke is the leading cause of disability. The incidence of stroke has declined, but the morbidity has increased. Due to longer life expectancy, the lifetime risk of stroke is higher in women. Globally, at least 5 million people die from strokes and millions of others remain disabled.
The most important piece of historical information that the clinician should obtain is the time of symptoms onset or time last seen normal. This is critical because it determines the eligibility to receive rtPA or endovascular intervention for stroke.  Other important information to obtain is risk factors for arteriosclerosis and cardiovascular disease, diabetes, smoking, atrial fibrillations drug abuse, migraine, seizures, infection, trauma or pregnancy.
The PCA mainly supplies occipital lobe, thalamus and some portion of the temporal lobe. The classic presentation of PCA stroke is homonymous hemianopsia. Apart from this hypersomnolence, cognitive issues, the hemisensory loss can be seen when the deep PCA is involved. Some times there is bilateral infarction of distal PCAs producing cortical blindness and the patient is unaware of the blindness and denies it. This is called Anton-Babinski syndrome.
Lacunar strokes are due to occlusion of small perforating vessels and can be a pure motor, pure sensory and ataxic hemiparetic strokes. In general, these strokes don't impair memory, cognition, level of consciousness or speech.
The initial workup of a stroke patient involves stabilizing the Airway, Breathing, and Circulation (ABC). This is followed by a rapid, concise, history and exam such as the NIHSS which is administered simultaneously as the patient gets IV access, telemetry, and labs were drawn. The patient should then get a stat non-contrasted head computed tomogram (CT) or a combination of head CT, CT Angiography, and perfusion imaging. \"Time is brain,\" and so we should not waste any time at all. Ideally, rtPA should be prepared as imaging is occurring, and as soon as the non-contrasted head CT can be visualized, and a bleed is excluded, rtPA should be administered after discussing the risks and benefits, and excluding rtPA contraindications. Time is critical, as only patients who get all the required studies within 4.5 hours qualify for potentially lifesaving thrombolysis. After IV rtPA, the CT angiography should be reviewed to determine if the patient qualifies for endovascular therapy as well.
In recent years there are significant advancements in acute stroke care. Multiple stroke trials in 2015 showed that endovascular thrombectomy in the first six hours is much better than standard medical care in patients with large vessel occlusion in the arteries of the proximal anterior circulation. These benefits sustained irrespective of geographical location and patient characteristics.
Again in 2018, a significant paradigm shift happened in stroke care. DAWN trial showed significant benefits of endovascular thrombectomy in patients with large vessel occlusion in the arteries of the proximal anterior circulation. This trial extended the stroke window up to 24 hours in selected patients using perfusion imaging. Due to this, we can treat more patients even up to 24 hours.
All patients should be treated with an antiplatelet agent and a statin, and be admitted for full stroke evaluation. Hypertension is often seen in acute stroke. This should not be aggressively treated. A baseline electrocardiogram is recommended. The following labs would be indicated when a diagnosis of stroke is entertained:
Acute ischemic stroke patients who meet the criteria for rtPA and do not have any contraindications should receive IV rtPA. Patients who have large vessel occlusions should be evaluated for possible endovascular intervention. All patients suspected of having an acute ischemic stroke should be admitted for a full neurological workup. Neurology consultation should be obtained. The workup of acute ischemic stroke includes a search for a source of thrombus, which includes carotid artery evaluation by ultrasound, CTA, MRA, or conventional angiography. A transthoracic echocardiogram is obtained to ascertain for low ejection fraction, the cardiac source of the clot, or patent foramen ovale. EKG and telemetry are obtained to ascertain for rhythms predisposing to stroke such as atrial fibrillation. Labs such as a fasting lipid panel, and hemoglobin A1C, are obtained to ascertain for modifiable risk factors for stroke. Other labs such as a hypercoagulable panel in young patients or B12 and syphilis testing in selected patients is also obtained. Antiplatelet and statins remain the mainstay of medical management of stroke.
Aspirin is recommended within 24-48 hours after stroke onset. Its administration can be delayed for 24 hours in patients treated with IV tPA. Mono/dual antiplatelet therapy is not a contraindication for receiving rtPA. 153554b96e