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Neurology Part 2 (Stroke/TIA (hemorrhagic (management (HTN - aggressively…

- - - - ABCD^2 score if > 3 (admit for inpatient workup)
  - - - large vessel
        
        carotid, MCA, PCA, cerebral
        
        mono-ocular blindness
        
        carotid
        
        treatment
        
        Carotid revascularization, preferably within 14 days from the index event, is indicated for nondisabling strokes or TIAs in patients with symptomatic extracranial internal carotid artery stenosis in the range of 70% to 99% and can be performed with endarterectomy or angioplasty-stenting.
      - small vessel
        
        internal capsule, lacunar, basal ganglia
        
        lacunar - medial longitundial fasciculus (INO - cannot convege ipsilateral (adduction weakness) - If old. If young then think multiple sclerosis, but can converge
        
        symptoms
        
        pure motor, clumpsy hand, ataxic hemiparesis
        
        mechanism
        
        lipohyalonis
        
        main risk factor
        
        hypertension
      - cardioembolic (20%)
      - Cryptogenic
  - - - main risk factor/location
        
        basal ganglia, pons, and cerebellum (HTN)
    - - main risk
        
        rupture of anyeursm
      - what to order
        
        CT, if negative then LP (for xanthochromia), gold standard cerebral angiogram
      - vasospasm prevention
        
        Oral nimodipine improves neurologic outcomes in patients with aneurysmal SAH and is recommended in all patients with SAH for the first 21 days or until hospital discharge
      - primary vascular clipping
        
        Surgical treatment with clipping or endovascular coiling can be considered in patients with aneurysms of 7 mm or greater in the posterior circulation (posterior communicating and basilar arteries) or 12 mm or greater in the anterior circulation.
    - - crosses suture lines concave (venous), will have ruffle
    - - HTN - aggressively treat with nicardipine
      - ETOH, tobacco
      - oral nimodipine
      - BP management
      - aspiration precautions
      - DVT prophylaxis
    - - Cerebellar stroke (posterior fossa - prevention of herniation of the 4th ventricle)
        
        1 cm from the surface
        
        with greater 30 cc lobar blood
        
        life threatening
    - - cannot suture lines (arterial), expands inside the brain - get neurosurgery, convex
  - - - arcurate fasiculus
  - - - " my DAD is Very Loving & Honest "
        
        D ~ Dysphagia
        
        A ~ Ataxia (wid tendency to fall to the involved side)
        
        D ~ Dysphonia
        
        V ~ Vertigo,Nausea, Vomiting
        
        L ~ Loss of pain & temperature sensation on same side of face & contralateral side of limbs.
        
        H ~ Horner's syndrome.
  - - - indication for thrombolytics
        
        Intravenous thrombolysis in ischemic stroke is indicated within 3 - 4.5 hours in patients with a measurable deficit who do not meet any of the exclusion
        
        BP requirement
        
        Blood pressure should be less than 185/110 mm Hg before thrombolysis,
        
        BP requirement after
        thrombolytics
        
        180/105 mm Hg and to detect signs of symptomatic ICH
        
        two types of treatment that you can use up to 6 hours
        
        intra-arterial tpa
        
        clot retrieval
    - - embolic - treat with anticoagulation
        
        who can get anticoagulation prior to discharge
        
        infarcts but no petechial hemorrhage, as determined by neuroimaging, or with involvement of less than one third of the middle cerebral artery distribution
      - carotid stenosis 70% (End arterectomy)
      - intracranial - medical management
    - - BP management
        
        CT scan pending - if the BP > 220/120 treat it irrespective
        CT scan - hemorrhage - <140 CT scan - ischemic - TPA - **185/110** CT scan - ischemic - status post TPA - **180/105** in 24-48 allow permissive HTN at >220/120
      - stent, PVD
        
        add Plavix 75 mg to the ASA 81 mg
      - DAPT
        
        high-risk TIA (ABCD2 score ≥ 4) or minor ischemic stroke (National Institute of Health Stroke Scale score ≤ 3), a 21-day course of combination aspirin and clopidogrel followed by clopidogrel monotherapy for a total of 90 days reduced the risk of subsequent stroke when administered within 24 hours of onset compared with aspirin monotherapy.
      - what med avoided
        
        nitrates (increase intracranial pressure)
- - - - which artery
        
        vertebrobasilar
    - - ACA
    - - language
    - - Occipital/ PCA
  - - - CN III, IV
        
        double vision
    - - CN 5-8
        
        numbness/weakness of face, hearing loss
    - - CN 9-12
        
        dysarthria/dysphagia, weak shoulder/neck