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stroke define
rapidly developing disturbance of cerebral fx lasting longer than 24 h
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define TIA
acute episodes of focal loss of cerebral fx lasting <24 h
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2 most common pathologic processes that result in stroke
- 1. occlusive
- large vessel
- small vessel
- emblic
- inadequate blood flow
- 2. hemorrhagic
- hypertensive
- SAH
- AVM
- henorrhagic metastises
- venous infarction
- arteritis
- bleeding diastheses
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risk factors for stroke
- age
- hypertension
- diabetes
- smoking
- afib/cardiomyopathy/valve dz
- cad/hyperlipidemia
- obesity/inactivity
- OCP use
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history in suspected stroke
o- when did it start
p- what was pt doing
q- what sxs developed
r-
s- symptoms associated, headache, chest pain, palpitations, vision changes, weakness, numbness, swollowing or speech problems, involuntary movements, loc, incontinence
t-
- pmh- recent surgeries, trauma, infections
- meds
- drug use
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physical exam in suspected stroke
- vs- often occur in setting of hypotensiona nd hypertension
- heent- temporal artery tenderness may be present in elderly w temporal arteritis
- neck- nuchal rigidity, caritid bruit
- heart- arrhythmia, murmur
- lung-
- extremities- stigmata of endocarditis(splinter hemorrhages,janeway lesions, osler nodes), hemorrhagic diasthesis, and/or vasculitis
- neuro-
- MS-level of consciousness, orientation, memory, naming, speech, understanding, reading, writing, copying
- CN- including fundiscopic and visual field impairment
- Motor- strength and pronator drift
- DTR-initially hypoactive then hyperactive, babinski
- sensory- pain, temp, light touch, sharp, proprioception(rhomberg)
- cerebellar-balance, heel to shin, finger to nose and gait
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useful tests in strokes
blood glucose
cbc, lytes, pt/ptt,
uhcg
cxr- eval for infiltrates, cardiomegaly, signs of malignancy
EKG- arrhythmia,cardiomegaly, ischemia, (both SAH and ischemic stroke can cause peaked t waves, st segment changes, qt interval changes)
NonContrast CT- primarily to r/o hemorrhage or mass effect. ischemia will not usually show up for 24-48 hours. repeat imaging in 7-10 days may furhter define. sensitivity for SAH is 95% if in doubt do LP.
MRI-perferred over CT for brain stem stroke, subacute hematoma, demyelinating diseases, AVMs.
- optional tests
- ESR-manditory in those > 50 w HA or transient vision loss
- LP-if meningitis or SAH suspected
- carotiod doppler
- echocardiography
- angiography
- MRA
- RPR,LYME,toxicology, antithrombinIII, protein c, protein s, anticardiolipin antibody, blood cultures(endocarditis)
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Treatment of Acute Stroke
ABC- oxygen, IV, Monitor
do not lower bp unless >220 systolic in hemorrhagic stroke or >120 diastolic in in occlusive stroke. >180 systolic in SAH.
get neurology/neurosurgery consult/transfer early
do frequent neuro checks
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