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Stroke (cerebrovascular accident, CVA) 3 years ago

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Stroke (cerebrovascular accident, CVA)
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Stroke (cerebrovascular accident, CVA)

This is a brief video on strokes, covering pathophysiology, presentation, as well as acute and chronic management/treatments. I created this presentation with Google Slides. Images were created or adapted from Wikimedia Commons. ADDITIONAL TAGS: Stroke cerebrovascular accident (CVA) By Blausen Medical Communications, Inc. - see ticket for details, CC BY 3.0, https://commons.wikimedia.org/w/index... Overview & pathophys Cause / risk factors Presentation Initial workup Chronic therapy / prevention Overview / pathophys Stroke/cerebrovascular accident (CVA) is #3 cause of death in USA #1 cause of neurologic disability Ischemic Thrombotic vs Embolic Hemorrhagic Subarachnoid hemorrhage (btwn arachnoid mater and pia mater) vs Intracranial hemorrhage (into parenchymal or ventricular space) By Manu5 - http://www.scientificanimations.com/w..., CC BY-SA 4.0, https://commons.wikimedia.org/w/index... By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia .org/w/index.php?curid=11414174 By Blausen Medical Communications, Inc. - see ticket for details, CC BY 3.0, https://commons.wikimedia.org/w/index... By ElinorHunt - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index... Ischemic (85%) Similar to heart attack but in the brain: Embolic: clot forms (on damaged heart valves, during afib, carotid stenosis, (or DVT→PFO)), thrown to smaller vessel, gets lodged, occludes blood Thrombotic: atherosclerosis. Risk factors include diabetes, hypertension, hyperlipidemia, obesity, smoking, age Others: smaller arteries (lacunar), vasospasm/migraine, drug abuse, dissection, arteritis Younger pts: hypercoag states, like OCPs; protein C/S deficiencies; cocaine, amphetamines; p vera, sickle cell Cause / risk factors Hemorrhagic (15%) Subarachnoid hemorrhage (btwn arachnoid mater and pia mater) vs Intracranial hemorrhage (into parenchymal or ventricular space) Worst prognosis (50% 30-d mortality) Cause: blood vessel or aneurysm rupture Risks: hypertension, trauma, anticoagulant therapy Overview & pathophys SAH most common ruptures Thunderclap → SAH +/- neck stiff, vomiting Xanthochromia: ACA: paralysis of legs and feet, confusion, urinary incontinence MCA: paralysis of face and arms, aphasia (speech), contralateral sensory, homonymous hemianopsia PCA: vision, ipsilateral sensory of face, contralateral sensory of limps, ACA MCA Locked in syndrome Syncope Cerebellar: dysdiadokinesia, ataxia, discoordination By William Laborde, MD, Brandon Mong, MD, and Joel Mosley, MD - William Laborde, MD, Brandon Mong, MD, and Joel Mosley, MD (2019-06-24). The Bloody CSF Tap – Pearls and Pitfalls. emDocs.net.- "emDocs is licensed under a Creative Commons Attribution 4.0 International License.", CC BY 4.0, https://commons.wikimedia.org/w/index... By File:1421 Sensory Homunculus.jpg: OpenStax Collegederivative work: Popadius - This file was derived from: 1421 Sensory Homunculus.jpg:, CC BY 3.0, https://commons.wikimedia.org/w/index... By Rhcastilhos - Gray519.png, Public Domain, https://commons.wikimedia.org/w/index... Initial workup First test: CT scan w/o contrast If blood → hemorrhagic stroke (15%) → consult neurosurg to coil clip bleed, reduce BP 150, give FFP, prevent hydrocephalus with shunt or LPs or craniotomy, seizure prophylaxis with anticonvulsants, prevent vasospasm with CCB Next consider tPA (tissue plasminogen activator) to break clot, save penumbra If pt presents within 3 (4.5) hrs of definite symptom onset AND no head trauma AND no surgery within 21 days AND never had a brain bleed Later workup: BP → permissive hypertension with ischemic stroke.(unless tPA) EKG → if afib, give anticoagulation (warfarin (without Hep bridge) or NOACs (apixaban, dabigatran, rivaroxaban, and edoxaban)) Echo → check cardiac valves and afib for source of embolism Carotid duplex ultrasound if 80% stenosis or 70%+symptoms → stent or carotid endarterectomy Chronic therapy (for future stroke prevention) BP → Chronic: maintain 140/80 with ACEi, diuretics, other agents Hyperlipidemia → high intensity statin (atorvastatin 40, 80 OR resuva 20, 40) Diabetes → maintain A1c 7% with metformin, other oral agents, insulin Smoking cessation Antiplatelet for life → aspirin (or clopidogrel) +/- dipyridamole Anticoagulation for life → warfarin or NOAC; CHA2DS2-VASc score gets +2 Congestive heart failure Hypertension Age = 75 Diabetes type 2 Stroke or TIA or thromboembolism (2) Vascular dz (PAD, MI) Age 65-74 Sex category (female)

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