by mtoom


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What is the leading cause of disability in Canada?
Stroke
What proportion of strokes are hemorrhagic versus ischemic?
  • Hemorrhagic 15%
  • Ischemic 85%
At what cerebral blood flow (CBF) does tissue become compromised but recoverable, and at what CBF does it become infarcted?
  • 10-20 cc/100g/min: Compromised but recoverable
  • <10 cc/100g/min: Infarcted

Note: It depends not only on CBF but amount of time of exposure
What is penumbra?
  • What is at the center of the penumbra?
  • Why is fast treatment important regarding the penumbra? 
Tissue that has been somewhat oxygen starved
  • At the center of the penumbra there is an ischemic core
  • Fast treatment is important for preventing the penumbra from being dying (the penumbra is recoverable)
What is the primary treatment for stroke?
  • Name 3 other treatments 
IV tPA
  • ASA
  • Stroke unit
  • Hemicraniectomy 
What are the secondary prevention methods for stroke?
  • 2 key preventions
  • 4 other chronic preventative measures
  • Warfarin for atrial fibrillation
  • Carotid endarterectomy
  • HTN Tx
  • Statins
  • Antiplatelets (ASA, clopidogrel)
  • Diabetes Tx
What kind of drug is tPA?
  • What is the mechanism of action?
  • What does it do?
Fibrinolytic
  • Serine protease
  • Converts plasminogen to plasmin
For ischemic strokes, name the causes? (5)
  • Large artery atherosclerosis (20%)
  • Small vessel lacunar stroke (25%)
  • Cardioembolism (20%)
  • Cryptogenic (30%)
  • Others (5%)
What is meant by thrombus versus embolus?
  • Thrombus: Local
  • Embolus: Distant, e.g. originated in heart
What are symptoms of ACA stroke? (3)
  • Leg > arm numbness
  • Leg > arm weakness
  • Abulia (i.e. diminished motivation)
What are symptoms of MCA stroke? (5)
  • Hemiplegia
Cortical features:
  • Aphasia
  • Neglect
  • Visual field deficit
  • Gaze deviation (to side of lesion)
What are symptoms of PCA stroke? (7)

Can affect coordination and vision:
  • Visual field defect
  • Vertigo
  • Diplopia
  • Ataxia
  • Dysphagia
  • Weakness
  • Numbness
With stroke, a hyperdense lesion indicates what?
M1 thrombosis (part of the MCA)
With stroke, a dot sign lesion indicates what? (2)
  • M2 thrombosis
  • M3 thrombosis

(Part of MCA artery)
If you had a right MCA stroke secondary to symptomatic right internal carotid artery stenosis, what strategy would you recommend?
Right carotid endarterectomy

Also:
  • Hypertension
  • Dyslipidemia
  • Smoking cessation
  • Antiplatelets
  • Diabetes control 
What are some cardioembolic sources of emboli?

Atrial fibrillation

Also: 
  • Atrial septal aneurysm
  • Patent foramen ovale
  • Mitral stenosis
  • Mechanical vegetation
  • Cardiomyopathy
  • Myocardial infarction
1 in every 6 strokes caused by what?
Atrial fibrillation
What is the outcome of 1st ischemic stroke?
  • 20% okay
  • 60% disabling
  • 20% fatal
In atrial fibrillation, what is effect of warfarin?
  • Effect of antiplatelet? 
Warfarin reduces stroke risk by 64%
  • Antiplatelet reduces stroke by 22%
Let's say a patient has a stroke and they have purely motor or purely sensory defect with NORMAL CT head and NORMAL CTA
  •  Localization?
Lacunar stroke (affecting small vessels to deep structures in brain)

Can also present as:
  • Mixed sensorimotor
  • Dysarthria clumsy
  • Ataxia hemiparesis 
What is the role of anticoagulation (i.e. warfarin) in non-cardioembolic stroke?
There is no role!
For antiplatelets ASA and clopidogrel:
  • Which drug is better?
  • When do you prescribe ASA & clopidogrel together?
  • When do you combine ASA or clopidogrel with an anticoagulant? 
  • Clopidogrel is slightly better
  • Never prescribe ASA and clopidogrel together
  • Never combine ASA or clopidogrel with an anti-coagulant
For ASA and dabigatran (DB):
  • Is ASA + DB > ASA alone?
  • Is ASA + DB > clopidogrel? 
  • ASA + DB better than ASA alone
  • ASA + DB not better than clopidogrel
How long is treatment with anti-platelet?
Long term
Hypertension has what effect on brain?
Causes brain disease:
  • Symptomatic stroke
  • Silent stroke
  • White matter disease 
These lead to cognitive dysfunction!
What proportion of strokes are attributed to poorly controlled hypertension?
  • Treating HTN does what for stroke risk? 
2/3
  • Reduces number of strokes by 38%
Benefits in stroke prevention achieved by reduction in blood pressure of what?
Reduction of 10/5 mmHg
What is significance of TIA with regard to stroke?
  • High risk of recurrent stroke following a TIA
  • Urgent investigation and management are important 
How does cholesterol affect stroke risk?
  • What class of drugs is associated with risk reduction in stroke? 
Increased cholesterol means increased risk
  • Statins are effective therapy to prevent stroke
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