WEBVTT 1 00:00:01.600 --> 00:00:03.720 All right, so this podcast is going to be on stroke. I have 2 00:00:03.759 --> 00:00:06.120 a few pnemonics in there to help you remember the things you need to know 3 00:00:06.200 --> 00:00:08.599 for your exam, and of course I'll try to keep it as brief as 4 00:00:08.599 --> 00:00:11.119 I can, just to focus on the things you really need to know for 5 00:00:11.199 --> 00:00:14.240 your exam questions. As always, thank you so much for all of the 6 00:00:14.279 --> 00:00:17.239 really nice comments. I truly do appreciate that, so thank you for that. 7 00:00:17.480 --> 00:00:20.000 Let's go ahead and get started with stroke. We'll start with our TIA, 8 00:00:20.039 --> 00:00:23.600 our transient a schemic attack. Keep this part brief. There's not a 9 00:00:23.600 --> 00:00:27.039 lot of high yield stuff from TIA, just a few things that you need 10 00:00:27.079 --> 00:00:29.719 to know of. So first, what is a TIA. SO TIA is 11 00:00:29.760 --> 00:00:35.079 a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or 12 00:00:35.079 --> 00:00:41.119 retinal schemia without acute infarction. That's the official definition from the American Heart Association 13 00:00:41.439 --> 00:00:45.840 and the American Stroke Association. So a TIA it's a clinical diagnosis. It's 14 00:00:46.000 --> 00:00:50.439 often not the easiest diagnosis to make because the presentation can be highly variable. 15 00:00:50.679 --> 00:00:54.000 There's many differentials to consider, and often by the time the patient presents to 16 00:00:54.000 --> 00:00:58.119 you their symptoms are already gone. But essentially a TIA looks exactly like a 17 00:00:58.159 --> 00:01:00.840 stroke and presentation. But this resolved, they get better. That's the key. 18 00:01:00.840 --> 00:01:04.120 There's no tissue infarction, there's no tissue injury. So to put it 19 00:01:04.159 --> 00:01:08.000 really simply, tia, there's a clot in a vessel, causes some transient 20 00:01:08.040 --> 00:01:12.280 symptoms, but it dissolved fast enough. Clot dissolve fast enough that it didn't 21 00:01:12.359 --> 00:01:15.519 lead to the death of brain tissue. I wanted to talk a little bit 22 00:01:15.680 --> 00:01:19.480 about the time based tia. So you may have heard that a TIA is 23 00:01:21.280 --> 00:01:26.560 described as a focal neurologic signs or symptoms lasting less than twenty four hours. 24 00:01:26.560 --> 00:01:30.159 You may still hear about that in clinical as your preceptor. It's something that 25 00:01:30.200 --> 00:01:34.120 we used to use a while ago before we had MRI neuroimaging. The d 26 00:01:34.280 --> 00:01:40.400 emphasis really came after multiple studies showed that up to half of classically defined time 27 00:01:40.400 --> 00:01:44.640 based tias showed brain injury on MRI. So you had these patients, They're 28 00:01:44.680 --> 00:01:48.519 symptoms resolved in less than twenty four hours, so time based definition of a 29 00:01:48.560 --> 00:01:52.120 TIA, But then when they actually had an MRI done, they showed stroke 30 00:01:52.159 --> 00:01:55.879 on their MRI and in FARCT, so just be aware of that kind of 31 00:01:55.879 --> 00:01:59.560 try to get that time based definition out of your head. Focus on the 32 00:01:59.599 --> 00:02:02.760 tissue you based definition of a TIA, which is lack of tissue and farction. 33 00:02:04.159 --> 00:02:07.560 Visualize on neuroimaging m R, etc. Now history and exam with the 34 00:02:07.680 --> 00:02:10.800 tia. Usually the symptoms are really brief. They're only going to last a 35 00:02:10.840 --> 00:02:14.520 few minutes, maybe up to a half hour, an hour or so, 36 00:02:14.639 --> 00:02:16.479 and often by the time these patients get to your office or the year to 37 00:02:16.479 --> 00:02:20.039 see you, the symptoms are already gone. So a lot of the actual 38 00:02:20.080 --> 00:02:23.639 exam is getting a good history. We'll talk more about the specific symptoms when 39 00:02:23.680 --> 00:02:25.719 we talk about stroke in a minute, but for tia, there's really two 40 00:02:25.759 --> 00:02:30.439 things you should be familiar with that always seem to come up on exam questions, 41 00:02:30.479 --> 00:02:34.800 and that's amaurosis few gas and corodi brewy so amurosis few gas. It's 42 00:02:34.800 --> 00:02:38.560 a transient monocular vision loss. This one's really big. It always seems to 43 00:02:38.599 --> 00:02:42.560 come up on exam questions when we're talking about TIA's. There's obviously other causes, 44 00:02:42.560 --> 00:02:44.680 but if you see an exam question right away, be thinking of a 45 00:02:44.759 --> 00:02:50.240 tia. So what happens is you have an occlusion or stenosis of the internal 46 00:02:50.280 --> 00:02:55.919 crodd artery circulation. This leads to hypoperfusion of the ocular arterial circulation. So 47 00:02:55.960 --> 00:03:00.400 basically your crodids are clogged, your eyes aren't get perfuse, and this temporarily 48 00:03:00.400 --> 00:03:04.560 shuts off the lights. That's am rosis, feu gacks, and the vignette. 49 00:03:04.560 --> 00:03:07.360 The way you'll see it described is as a curtain coming down in front 50 00:03:07.360 --> 00:03:10.719 of their eyes that generalize darkening or shadow in one eye. It can last 51 00:03:10.759 --> 00:03:14.000 a few seconds up to around thirty minutes. If you see it on a 52 00:03:14.080 --> 00:03:16.919 vignette right away, be thinking of a tia. The other thing karadd brewing. 53 00:03:17.400 --> 00:03:21.240 So on physical exam you oscill tate the karateds. You hear this turbulent 54 00:03:21.240 --> 00:03:24.439 flow through the karads and this is due to after asclerotic plaque in the charatic 55 00:03:24.520 --> 00:03:29.599 arteries causing stenosis, and it can be a major cause of not only just 56 00:03:29.639 --> 00:03:32.439 a tia, but also in a schemic stroke. All right, now, 57 00:03:32.520 --> 00:03:37.000 let's talk about diagnosis. I'm going to briefly run through the diagnostic tests because 58 00:03:37.000 --> 00:03:38.680 the thing is the workup. It's very much the same as in stroke, 59 00:03:38.719 --> 00:03:44.000 which I'm gonna go over next to more detail. The idea is though with 60 00:03:44.039 --> 00:03:47.560 the TIA is you start with your neuroimaging and suspect the TIA patients, so 61 00:03:47.759 --> 00:03:53.240 MRI CT, so early brain imaging with MRI or CT is indicated for all 62 00:03:53.319 --> 00:03:58.879 patients with suspected TIA. MRI does have greater sensitivity than CT. But the 63 00:03:58.879 --> 00:04:02.560 problem with MRI is it time consuming, it's expensive, there's contraindications, so 64 00:04:02.680 --> 00:04:09.400 t CT is often used more often than MRI. But if MRI is available, 65 00:04:09.439 --> 00:04:12.960 it is the better test of the two. So that's your that's your 66 00:04:12.960 --> 00:04:16.560 brain imaging. Then we talk about neurovascular imaging, so MRA CCA crodi ultrasound. 67 00:04:16.839 --> 00:04:20.199 It's really important in patients with a TIA to rule out in an obstructive 68 00:04:20.319 --> 00:04:25.319 lesion in a large artery supplying the affected territory. So you image the vessels 69 00:04:25.319 --> 00:04:28.439 of the brain, the neck. You're looking for your source essentially, do 70 00:04:28.480 --> 00:04:32.279 you have an intracranial afterosclerotic disease? Do you have crodo stenosis? Because once 71 00:04:32.319 --> 00:04:36.959 you find your source, you can direct your secondary prevention at that afterrosclerotic disease, 72 00:04:38.079 --> 00:04:41.639 or you can intervene even with like a crowded and art directomy for instance. 73 00:04:42.000 --> 00:04:45.680 So that's really the cornerstone of your diagnostic workup for TIA. That's what 74 00:04:45.720 --> 00:04:50.199 i'd memorize. Your neuroimaging with CTR MRI and your neurovascular imaging MRA ct e 75 00:04:50.319 --> 00:04:54.480 CE. You also have your ancillary test. These aren't as important, but 76 00:04:54.519 --> 00:04:56.920 I'm going to talk about them. Just you have an idea, so ec 77 00:04:57.560 --> 00:05:00.160 ECG to roull out, say a fib eco cardio gram where you're looking for 78 00:05:00.199 --> 00:05:04.279 your cardio embolic source for the TIA. Lab tests to rule out metabolic and 79 00:05:04.319 --> 00:05:09.639 hematologic causes. But the main workup is going to be your brain imaging, 80 00:05:09.680 --> 00:05:13.360 your neurovascular imaging, so focus on those, but be aware of the EKG, 81 00:05:13.800 --> 00:05:16.720 the echo, the lab testing and rule out low blood sugar in those 82 00:05:16.720 --> 00:05:19.439 types of things. Now, treatment, there's a few things that you need 83 00:05:19.480 --> 00:05:24.480 to know. So anti platelet treatment this one's really important. So aspirin or 84 00:05:24.480 --> 00:05:29.439 a combination of aspirin and clopidogril. This is probably the most important intervention to 85 00:05:29.480 --> 00:05:33.120 remember for TIA. So for almost all patients with the TIA who do not 86 00:05:33.319 --> 00:05:38.000 have a known cardio embolic source, so this isn't from like a fib throwing 87 00:05:38.040 --> 00:05:41.839 a clot. We start with anti platelet therapy, so this can be aspirin 88 00:05:41.959 --> 00:05:47.040 is monotherapy or dual anti platelet therapy asprein and clopiedigril. You decide that depending 89 00:05:47.079 --> 00:05:50.439 on the on the risk score, which we'll talk about in a little bit. 90 00:05:50.480 --> 00:05:55.480 So remember that anti platelet treatment for almost all TIA patients. Now, 91 00:05:55.480 --> 00:05:58.680 if they have a cardio embolic source, you're going to use anti coagulation. 92 00:05:58.839 --> 00:06:00.879 So if they have I said before they have a FIB, you're going to 93 00:06:00.920 --> 00:06:06.279 start them on oral anti coagulation with warfarin or a direct oral anti coagulant to 94 00:06:06.319 --> 00:06:10.879 prevent future emboli. So if it's a cardiomobolic source, your treatments a little 95 00:06:10.879 --> 00:06:15.439 bit different. And then you have your a little bit more invasive treatment, 96 00:06:15.480 --> 00:06:19.279 so crowded end artirectomy or crowded artery stentting. So if you see a neurovascular 97 00:06:19.319 --> 00:06:25.360 imaging the patient has significant crowded artery stenosis. Specifically, what we're looking for 98 00:06:25.519 --> 00:06:30.319 is internal crowded artery stenosis fifty to ninety nine percent. You're going to intervene 99 00:06:30.360 --> 00:06:33.240 with revascularization of the crowd is, which can be done via an end ardirectomy. 100 00:06:33.360 --> 00:06:38.879 Or credit artery stentting, so you're looking for stenosis fifteen to ninety nine 101 00:06:38.920 --> 00:06:42.319 percent. And then also in the guidelines it says patients should have a life 102 00:06:42.360 --> 00:06:46.600 expectancy of over five years. All an end ardirectomy is is you basically cut 103 00:06:46.639 --> 00:06:49.079 open that crowded artery that has the stenosis in it, you pull out the 104 00:06:49.120 --> 00:06:53.079 plaque, you suit, youre a backup. That's what an end ardirectomy is, 105 00:06:53.199 --> 00:06:58.240 or you have the options with stenting as well. Then finally for treatment 106 00:06:58.279 --> 00:07:02.399 this is important too. So you're intense risk factor management hyperlipidemia, hypertension, 107 00:07:02.439 --> 00:07:06.600 diabetes, smoking, cessation. So the big thing with the TIA is the 108 00:07:06.680 --> 00:07:10.800 patient got a warning sign. Not everybody's going to get that lucky. So 109 00:07:10.839 --> 00:07:15.279 these patients need to make some significant lifestyle changes to prevent recurrence. So effectively 110 00:07:15.319 --> 00:07:19.759 treating their hypertension, getting started on high intensity statin therapy to lower their LDL, 111 00:07:19.879 --> 00:07:25.879 smoking cessation, limiting alcohol consumption if they're diabetic, improving their glycimic control, 112 00:07:26.279 --> 00:07:30.560 reducing their modifiable risk factors to help reduce their future stroke risk. I 113 00:07:30.600 --> 00:07:33.199 don't necessarily think that'll be an exam question because it's kind of hard to ask 114 00:07:33.240 --> 00:07:35.600 that, but in generally you need to be aware of that because that's really 115 00:07:35.600 --> 00:07:40.519 important for treating these patients. So for treatment overall, the two most important 116 00:07:40.519 --> 00:07:45.120 things to remember is your anti platelet treatment, so that's a sprinklopedograp that's going 117 00:07:45.160 --> 00:07:47.360 to be most of your patients with the TIA. And then remember reduce those 118 00:07:47.399 --> 00:07:53.480 modifiable risk factors. That's the cornerstone of TIA long term management. Let's talk 119 00:07:53.519 --> 00:07:58.519 about one last thing for TIA. So there's something for your stroke risk called 120 00:07:58.519 --> 00:08:03.759 your ABCD square and I'm quoting up to date here, but up to Date 121 00:08:03.800 --> 00:08:09.120 calls the ABCD square AT score a simple but suboptimal assessment tool. So the 122 00:08:09.160 --> 00:08:11.519 test is far from perfect, but it's still being used. You'll likely hear 123 00:08:11.519 --> 00:08:15.480 about it. So let's go over what it is, what it's designed to 124 00:08:15.519 --> 00:08:18.360 be used for. So the ABCD square IT score helps you determine a few 125 00:08:18.439 --> 00:08:22.120 things. So a patient that has a TIA is at a much higher risk 126 00:08:22.279 --> 00:08:26.920 for stroke in the future, so this calculator helps you to determine one how 127 00:08:28.000 --> 00:08:31.120 high the risk is for stroke in the near future. This test also helps 128 00:08:31.120 --> 00:08:35.480 determine how aggressive the treatment needs to be in these patients. So, for 129 00:08:35.519 --> 00:08:37.679 instance, It helps determine whether or not we're going to use just monotherapy with 130 00:08:37.759 --> 00:08:41.759 just aspirin or dual a type platelet therapy with aspirin and clop pedigreal, all 131 00:08:41.759 --> 00:08:46.519 depending on their score. And then finally helps you determine is the patient that's 132 00:08:46.600 --> 00:08:50.200 present in your office to day and the er going to get the full million 133 00:08:50.200 --> 00:08:54.200 dollar TIA work up or do they maybe just have complicated migraine and maybe we 134 00:08:54.200 --> 00:08:56.600 don't need to do every diagnostic test in the book. So how high is 135 00:08:56.639 --> 00:09:00.879 their risk? So this calculator helps guide you with these types of things. 136 00:09:01.080 --> 00:09:03.440 So again, the assessment tool is known as the abc D square tool. 137 00:09:03.919 --> 00:09:09.000 Do not memorize it. Just be aware that it exists for stroke risk ratification. 138 00:09:09.240 --> 00:09:11.639 And then I'm going to briefly go over it. But again I repeat, 139 00:09:11.679 --> 00:09:13.039 don't memorize this, just be aware of it. So if it comes 140 00:09:13.080 --> 00:09:16.840 up your preceptor mentions this, you kind of have an idea of what it 141 00:09:16.919 --> 00:09:18.879 is, like, oh, yeah, that's the stroke risk assessment tool, 142 00:09:18.960 --> 00:09:22.279 So just be aware of it. I'm going to briefly go over it. 143 00:09:22.600 --> 00:09:26.720 So ABCD square it stands for age sixty or over. That gives you one 144 00:09:26.759 --> 00:09:33.159 point blood pressure one forty systolic or a ninety or higher diastolic. That's another 145 00:09:33.159 --> 00:09:35.679 point. Clinical features, depending on what their features are, unilateral weaknesses two 146 00:09:35.679 --> 00:09:41.320 points, isolated speech disturbances one point. The duration of your tia symptoms all 147 00:09:41.360 --> 00:09:43.519 gives you more or less points. And then if they have diabetes, that 148 00:09:43.519 --> 00:09:46.919 also gives you another point. How high their score is the higher risk of 149 00:09:48.240 --> 00:09:50.000 their two day stroke risk. You know, and you can look all those 150 00:09:50.039 --> 00:09:52.159 things up if you want the specifics. Again, I don't think you need 151 00:09:52.200 --> 00:09:54.559 to memorize that, but just be aware of it. What do you need 152 00:09:54.600 --> 00:09:58.159 to know if your tia? There's three things I would say to take away. 153 00:09:58.159 --> 00:10:00.679 If you're going to forget everything else, remember what it's tia is. 154 00:10:00.840 --> 00:10:05.679 It's a transient episode of neurologic dysfunction caused by a schemia without acute infarction. 155 00:10:07.000 --> 00:10:11.399 Remember Amurosi's few backs. That's probably the most important clinical manifestation. And then 156 00:10:11.440 --> 00:10:13.360 for treatment, I'd say the one thing you should definitely remember is your anti 157 00:10:13.360 --> 00:10:16.519 play lit treatment with aspirin. All right, So that's your tia. Let's 158 00:10:16.519 --> 00:10:20.120 move on to a stroke, all right. So for stroke, there's two 159 00:10:20.200 --> 00:10:24.840 types of stroke. There's a schemic and hemorrhagic. So a schemic that's going 160 00:10:24.840 --> 00:10:28.120 to be your most common type, around seventy five to eighty percent of all 161 00:10:28.200 --> 00:10:31.120 strokes. And that's the one that will really focus on as most of your 162 00:10:31.200 --> 00:10:33.759 questions are going to come from this hemorrhagic. Like I said, it's much 163 00:10:33.799 --> 00:10:35.879 less common. We'll touch on that at the end. So a schemic stroke, 164 00:10:35.960 --> 00:10:39.039 let's start with the schemic strokes. This is the one you need to 165 00:10:39.080 --> 00:10:43.399 focus on. An aeschemic stroke is a sudden loss of blood circulation to an 166 00:10:43.440 --> 00:10:46.559 area of the brain, leading to death of tissue and loss of neurologic function. 167 00:10:48.399 --> 00:10:52.519 A schemic stroke is a compromised blood vessel leading to decreased profusion resulting in 168 00:10:52.720 --> 00:10:56.759 death of brain tissue. So remember in a tia, the clot dissolve fast 169 00:10:56.840 --> 00:11:00.679 enough so there was no brain death and stroke that's not the case. We 170 00:11:00.759 --> 00:11:03.480 have death of brain tissue. That's the key. Now, there's two types 171 00:11:03.840 --> 00:11:09.000 of a schemic stroke. There's thrombodic and there's embolic. So thrombodic is going 172 00:11:09.039 --> 00:11:11.879 to be by far, you're most common, So most common type. And 173 00:11:11.000 --> 00:11:15.399 what happens is you have a thrombus that forms in the artery walls. And 174 00:11:15.519 --> 00:11:18.799 this generally happens when you have athrosclerosis in the vessel. So you have a 175 00:11:18.799 --> 00:11:24.840 plaque in the vessel. Something causes the fibrous cap of the plaque to shear 176 00:11:24.879 --> 00:11:28.240 off, so it opens up. And then once this happens, platelets come 177 00:11:28.279 --> 00:11:31.120 in to plug up that little fibrous cap that popped off. And when that 178 00:11:31.159 --> 00:11:35.360 happens, all the platelets come in to plug it up and a thrombus forms 179 00:11:35.360 --> 00:11:37.440 around the plaque. This leads to inclusion of the blood flow distal to this 180 00:11:37.519 --> 00:11:41.639 area, which leads to the stroke. Second type is embolic, So embolic 181 00:11:41.720 --> 00:11:45.320 means the clock came from somewhere else in the body. It travels from a 182 00:11:45.360 --> 00:11:48.799 distal site, got lodged in the vessel of the brain and included the vessel. 183 00:11:48.440 --> 00:11:52.720 Common cause of embolic stroke as a fib patient, as a fib throws, 184 00:11:52.720 --> 00:11:56.159 a clot from the heart clock gets lodged in the vessels of the brain, 185 00:11:56.320 --> 00:11:58.440 leaving you to stroke. If you ever forget which is which, like 186 00:11:58.639 --> 00:12:01.919 is a rombiotic or embolic the one where the clout traveling from somewhere else. 187 00:12:01.919 --> 00:12:07.240 The way that I remember that is embolic starts with an EE stands for elsewhere, 188 00:12:07.320 --> 00:12:09.919 aka, the clout came from elsewhere in the body. Just a little 189 00:12:09.919 --> 00:12:15.240 tip to remember which is which clinical manifestations. All right, So different arteries 190 00:12:15.279 --> 00:12:18.399 supply blood to different parts of the brain. Different parts of the brain, 191 00:12:18.440 --> 00:12:20.240 as we know, control different parts of the body. So you need to 192 00:12:20.279 --> 00:12:24.519 have a very basic understanding of aclusion, of which vessel is going to lead 193 00:12:24.519 --> 00:12:28.759 to a deficit in which part of the body. This is important because it's 194 00:12:28.759 --> 00:12:31.159 likely going to come up. I had this on Anosky question and I had 195 00:12:31.360 --> 00:12:33.480 an exam question. They're going to give you the patient presentation. Maybe they'll 196 00:12:33.519 --> 00:12:37.360 give you a left lower leg weakness, and then they're going to ask you 197 00:12:37.440 --> 00:12:39.440 which type of stroke is this, middle cerebral, anterior, cerebral, et 198 00:12:39.440 --> 00:12:41.960 cetera. I do have a couple of tricks for you to remember this. 199 00:12:43.519 --> 00:12:46.919 I'm not going to list every single symptom or deficit for each different artery. 200 00:12:46.919 --> 00:12:48.879 I'm going to stick to just the very basics enough for you to pick it 201 00:12:48.879 --> 00:12:54.960 out in a vignette. So let's talk about first our anterior cerebral artery stroke. 202 00:12:58.240 --> 00:13:01.240 All right, With an anterior cerebral artery stroke, There's one thing you 203 00:13:01.240 --> 00:13:05.600 need to be looking for, and that's contralateral involvement of the feet and legs. 204 00:13:05.000 --> 00:13:09.159 This is the most common area to be involved contralateral meaning if it's the 205 00:13:09.240 --> 00:13:13.360 left anterior cerebral artery involved, the right leg or right foot will be affected. 206 00:13:13.720 --> 00:13:16.960 There's obviously other possible presentations urinary continence, as possible to have weakness in 207 00:13:16.960 --> 00:13:20.200 the upper extremities, but the most common what's going to be on the vignette 208 00:13:20.200 --> 00:13:24.200 where you need to focus on is some kind of deficit in the lower extremities, 209 00:13:24.200 --> 00:13:28.919 so paralysis and sensory loss and the contralateral leg and foot. So how 210 00:13:28.919 --> 00:13:33.600 do you remember that antior cerebral artery stroke. As soon as you see antiior 211 00:13:33.639 --> 00:13:35.480 cerebral artery stroke, I want you to think of the first three letters, 212 00:13:35.480 --> 00:13:39.320 which is ANT, and I want you to think of an ant. What 213 00:13:39.399 --> 00:13:41.919 do you do when you see an ANT on the floor, You lift your 214 00:13:41.000 --> 00:13:46.200 leg and you step on it with your foot. Anterior cerebral artery stroke most 215 00:13:46.200 --> 00:13:50.720 commonly affects the contralateral leg and foot. So when you see ant tior cerebral 216 00:13:50.759 --> 00:13:52.960 artery stroke, think of an ANT on the floor, lifting your legs, 217 00:13:54.000 --> 00:13:58.000 stepping it on with your foot. Most commonly affects the contralateral leg and foot. 218 00:13:58.039 --> 00:14:01.279 That's how you remember the most common presentation of anterior cerebral artery stroke. 219 00:14:01.320 --> 00:14:05.399 Think of an ant stepping up with lifting up your leg, stepping in up 220 00:14:05.440 --> 00:14:09.080 with your foot, that's anterior cerebral artery stroke. Let's move on to middle 221 00:14:09.120 --> 00:14:13.200 cerebral artery stroke. Now, middle cerebral artery stroke is the most common artery 222 00:14:13.240 --> 00:14:16.720 to be involved in an eschemic stroke. The way that you remember that is 223 00:14:16.759 --> 00:14:22.120 middle cerebral artery. MCA also stands for most common artery, so that's how 224 00:14:22.159 --> 00:14:26.159 you remember the MCA. The middle cerebral artery is most common artery to be 225 00:14:26.200 --> 00:14:31.879 involved in an eschemic stroke. While you're looking for in the vignette is contralateral 226 00:14:31.000 --> 00:14:35.600 face in arm involvement as well as a phasia, So paralysis and sensory loss 227 00:14:35.679 --> 00:14:41.120 is going to be createst on the contralateral side of the face and the arm 228 00:14:41.240 --> 00:14:45.039 verse the lower extremities, and you also may see a phasia and middle cerebral 229 00:14:45.120 --> 00:14:48.919 artery stroke. A phasia, remember, is difficulty producing or understanding speech. 230 00:14:48.360 --> 00:14:54.720 The way that I always remember this was instead of remembering middle cerebral artery MD 231 00:14:54.399 --> 00:15:00.639 D L E instead of middle cerebral artery. I remembered mattle cerebral artery aka 232 00:15:00.879 --> 00:15:05.440 m A D D d L. I'm sorry, m A D D L 233 00:15:05.519 --> 00:15:09.799 E cerebral artery strokes instead of middle cerebral artery. Think of mad maddele cerebral 234 00:15:09.879 --> 00:15:13.879 artery. And think of somebody that's very mad. Think of like that cartoon 235 00:15:13.919 --> 00:15:16.840 image. Whenever you think of like a cartoon character being mad, what do 236 00:15:16.840 --> 00:15:20.559 they do? Their face gets all red. They raise their arms up in 237 00:15:20.559 --> 00:15:22.320 the air and like shake it and then they like scream. They're like, 238 00:15:22.440 --> 00:15:26.600 ah, So that's what I want you to think of middle cerebral artery. 239 00:15:26.639 --> 00:15:31.039 Think of mad dule cerebral artery. I think of that cartoon character. His 240 00:15:31.159 --> 00:15:35.759 face is red and his face is red because remembering and commonly involves the face, 241 00:15:35.799 --> 00:15:37.600 the controlatero side of the face. That helps you remember that and then 242 00:15:37.679 --> 00:15:41.039 remember the arms are up in the air. They're shaking their arms up in 243 00:15:41.039 --> 00:15:43.840 the air. Remember most commonly affects the contralateral arm. That's their arms and 244 00:15:43.879 --> 00:15:48.120 their face being red. And then they're yelling, they're screaming because they're so 245 00:15:48.240 --> 00:15:50.759 mad, And that helps you remember not necessarily that the patient with middle cerebral 246 00:15:50.799 --> 00:15:54.080 artery stroke is gonna be yelling, but it helps you remember, okay, 247 00:15:54.120 --> 00:15:56.799 the voice is involved, and then helps you remember a pass remember middle cerebral 248 00:15:56.840 --> 00:16:00.960 artery stroke. Think of madle cerebral ar restroke. Somebody's very mad. Arms 249 00:16:00.960 --> 00:16:03.000 are up in the air, shaking them up in the air. That helps 250 00:16:03.000 --> 00:16:07.879 you remember the contralateral arm involvement. Their face is all red because they're angry. 251 00:16:07.919 --> 00:16:10.559 That helps remember the contra lateral side of the face. And then they're 252 00:16:10.639 --> 00:16:14.120 yelling, they're screaming. That helps you remember the aphasia the voice involvement. 253 00:16:14.919 --> 00:16:18.320 All right, So let's move on to our post serial circulation, specifically the 254 00:16:18.360 --> 00:16:22.960 post sious cerebral artery and the vertebra basler artery in general. If they mentioned 255 00:16:23.080 --> 00:16:27.039 any kind of visual changes, you should be thinking posterior circulation. I wanted 256 00:16:27.039 --> 00:16:30.879 to break it down a little bit further though each individual vessel, and we'll 257 00:16:30.919 --> 00:16:34.919 discuss the unique presentation scene with each. So let's start with our posterior cerebral 258 00:16:36.039 --> 00:16:38.759 artery stroke. So two common things in a pc A stroke that you should 259 00:16:38.759 --> 00:16:45.559 be aware for the exam. First one is homonymous hemianopia, so that normally 260 00:16:45.600 --> 00:16:49.399 spares the macula because the macula is perfused from collateral flow from the middle cerebral 261 00:16:49.480 --> 00:16:56.240 artery, so again homonymous hemianopia. So what this is. You can also 262 00:16:56.240 --> 00:16:59.279 see this in an MCA stroke, just an fyi, but it's much more 263 00:16:59.279 --> 00:17:03.200 common in a pc A stroke. So it's a visual defect involving the contralateral 264 00:17:03.279 --> 00:17:07.160 side, so either the two right or the two left halves of the visual 265 00:17:07.200 --> 00:17:11.519 fields of the eye. So basically half of the visual field is not being 266 00:17:11.519 --> 00:17:14.839 processed. You can just think of like half of the vision on one eye 267 00:17:15.319 --> 00:17:18.400 is just completely blacked out, so the visual field is blacked out on the 268 00:17:18.440 --> 00:17:22.440 contralateral side. That is homonymous, I mean enopia. And remember that for 269 00:17:22.640 --> 00:17:26.880 your PCA stroke they may mention that it spares the macula again because remember that's 270 00:17:26.160 --> 00:17:30.440 perfused from the middle cerebral artery. The second thing that you need to know 271 00:17:30.519 --> 00:17:33.680 for your PCA stroke is something known as alexia without a graphia, which means 272 00:17:34.160 --> 00:17:38.960 they cannot read, but they can write. So they cannot read but they 273 00:17:40.079 --> 00:17:42.119 can write, so they can write out a whole story, but they can't 274 00:17:42.119 --> 00:17:45.880 read it back to you. And the way that I used to remember these 275 00:17:45.880 --> 00:17:48.359 two. Let's talk about that. So the first thing is this works much 276 00:17:48.400 --> 00:17:51.119 better with a visual like I have on YouTube, but I'll try to explain 277 00:17:51.160 --> 00:17:56.000 it. So basically, when you think of your posterious cerebral artery stroke, 278 00:17:56.039 --> 00:17:57.920 I when you think of like a P on its side, and if you 279 00:17:57.920 --> 00:18:00.680 think of a P on its side, it kind of looks like glasses. 280 00:18:02.039 --> 00:18:04.039 And I have a picture of this. It obviously works, it makes much 281 00:18:04.039 --> 00:18:07.720 easier. But if you think of two peas on their sides, they basically 282 00:18:07.759 --> 00:18:10.680 look like glasses, and that always helps for me. Remember, I just 283 00:18:10.720 --> 00:18:14.799 have this visual of two peas on their sides like glasses that it involves the 284 00:18:14.839 --> 00:18:19.920 eyes, the homonymous hemianopia that helps me remember two pieces glasses. Posterior starts 285 00:18:19.920 --> 00:18:25.079 with the P post serious cerebra auttery. And then the second thing is alexia 286 00:18:25.160 --> 00:18:29.400 without a graphia the way that I used to remember that is posterior cerebral artery 287 00:18:29.519 --> 00:18:34.599 PCA. Alexia is your personal personal computer assistant, because Alexia sounds like Alexa, 288 00:18:34.720 --> 00:18:40.400 like Amazon Alexa and Amazon Alexa as a person personal computer assistant. So 289 00:18:40.440 --> 00:18:45.279 Alexia is your personal computer assistant that helps me remember Alexia without a graphia. 290 00:18:45.559 --> 00:18:47.640 All right, So I know those aren't the best pneumonics, but that's the 291 00:18:47.680 --> 00:18:48.839 way that I used to remember it. Let's move on to the last thing, 292 00:18:48.839 --> 00:18:52.079 which is going to be our vertebral basil or artery stroke. Now, 293 00:18:52.119 --> 00:18:56.079 the good thing about vertebro basel or attery stroke is most of the things you'll 294 00:18:56.079 --> 00:19:00.359 see in a vignette, most of the clinical manifestations all start with the V, 295 00:19:00.079 --> 00:19:03.000 and vertebro based lare auttery stroke also starts with the VS. So as 296 00:19:03.000 --> 00:19:07.039 soon as you see fortebro based law auttery stroke, think of all of your 297 00:19:07.119 --> 00:19:11.680 V clinical manifestations. That's going to be vertigo, visual changes like diplopia, 298 00:19:11.880 --> 00:19:15.000 vomiting, and then the last one I kind of made this up on my 299 00:19:15.039 --> 00:19:21.960 own, but vibrating eyes because nice stagmus is another possible presentation of vertebral based 300 00:19:22.000 --> 00:19:23.799 law auttery stroke. And if you ever look at nice stagmus, basically the 301 00:19:23.839 --> 00:19:26.400 eyes are like shaking and vibrating off to the side. So that's how I 302 00:19:26.480 --> 00:19:30.720 remember that vertigo, visual changes, vomiting, vibrating eyes, vertebro based lore 303 00:19:30.720 --> 00:19:34.160 attery stroke. Remember they all start with VS. Those are clinical manifestations. 304 00:19:34.160 --> 00:19:37.519 If you remember that, you'll likely be able to pick it out on a 305 00:19:37.599 --> 00:19:41.000 vignette. Let's talk about diagnosis. So this is obviously going to be pretty 306 00:19:41.000 --> 00:19:45.599 similar to the TIA workup, going a little bit more depth though, So 307 00:19:45.640 --> 00:19:48.720 when making the diagnosis in a patient with suspected stroke, the initial test, 308 00:19:48.799 --> 00:19:51.920 like right when they come in the door, that's going to include a finger 309 00:19:51.960 --> 00:19:56.400 stick, blood glucose, oxygen saturation, and a non contrast CT. Those 310 00:19:56.440 --> 00:20:00.319 are the main diagnostic tests to guide acute therapy. The finger stick it's important 311 00:20:00.359 --> 00:20:04.960 because you want to make sure the presentation isn't due to hypoglycemia. Hypoglycemia can 312 00:20:06.000 --> 00:20:10.440 cause focal neurologic deficits that mimic a stroke so much. You must roll that 313 00:20:10.440 --> 00:20:12.440 out right away because that's really important to make sure this patient you think has 314 00:20:12.440 --> 00:20:15.720 a stroke doesn't just have low blood sugar. So that's important as well. 315 00:20:15.880 --> 00:20:19.480 All right, let's talk about your CT head non contrast, so CT of 316 00:20:19.480 --> 00:20:23.880 the head non contrast. You're gonna do a CT of the head in any 317 00:20:23.920 --> 00:20:27.960 patient you suspect a stroke. This is your initial test of choice. Now, 318 00:20:29.119 --> 00:20:32.160 is a CT of the head used to make the diagnosis of an ischemic 319 00:20:32.200 --> 00:20:36.880 stroke. It's actually not and that's a common misconception. The main purpose of 320 00:20:36.880 --> 00:20:40.640 a non contrast CT is basically to tell us one thing, is their blood. 321 00:20:41.000 --> 00:20:42.920 Is there no blood? Is this a hemorrhagic stroke or is it not? 322 00:20:44.039 --> 00:20:47.519 Because if there's blood present and this is a hemorrhagic stroke, we know 323 00:20:47.599 --> 00:20:52.759 that reperfusion therapy with intravenous thrombolysis like TPA, it's off the table. So 324 00:20:52.799 --> 00:20:56.720 again CT initial test of choice use basically to guide treatment in regards to TPA 325 00:20:56.759 --> 00:21:00.680 and let us know whether or not this is a hemorrhagic stroke. It can 326 00:21:00.680 --> 00:21:03.440 pick up some early signs of acute schemic stroke, but really the best way 327 00:21:03.759 --> 00:21:06.960 to look for a cute schemic stroke is going to be with an MRI, 328 00:21:07.119 --> 00:21:10.799 like I talked about before, when you're talking about our TIA. So MRI 329 00:21:11.000 --> 00:21:12.400 is a better test than a CT. It does a much better job at 330 00:21:12.400 --> 00:21:18.920 determining acute infarction. But the reason why we use CT compared to MRI more 331 00:21:18.920 --> 00:21:23.279 commonly is because MRI's time consuming. CT just takes a few minutes. MRI 332 00:21:23.400 --> 00:21:26.799 is not available at every institution, MRI has a bunch of contraindications. So 333 00:21:26.920 --> 00:21:30.319 basically, again like over before, TIA MRI is a better test, but 334 00:21:30.319 --> 00:21:33.920 it's not used as often. Most of the time, non contrast CT it's 335 00:21:33.960 --> 00:21:37.599 going to be your answer. That's why you'll probably use in real life. 336 00:21:37.960 --> 00:21:40.839 All Right, So once you've done your neuroimaging, you've done a finger stick, 337 00:21:40.880 --> 00:21:44.720 make sure this patient's presentation isn't due to see your hypoglycemia. You have 338 00:21:44.799 --> 00:21:48.480 some additional tests as part of your work up. So let's first talk about 339 00:21:48.480 --> 00:21:51.720 your EKG. So you get an EKG because you want to know does this 340 00:21:51.839 --> 00:21:55.200 patient have an arrhythmia, do they have a fib A flutter which may have 341 00:21:55.240 --> 00:21:59.839 been the cause of an embolic stroke, and is this patient going to be 342 00:22:00.039 --> 00:22:04.079 are it on anti coagulation to prevent future strokes from this cardio embolic source. 343 00:22:04.400 --> 00:22:07.960 Another thing you're going to use as your ancillary testing is an echo, so 344 00:22:08.039 --> 00:22:12.160 echo cardiogram. So if your echo, you're looking to detect cardiogenic and aortic 345 00:22:12.240 --> 00:22:17.720 sources of cerebral embolism. So basically you're looking, is there another bullet left 346 00:22:17.720 --> 00:22:19.359 in the chamber. Does this patient have another clot in the heart that could 347 00:22:19.400 --> 00:22:23.079 potentially lead to another stroke? Is there vegetations on the hart valves? From 348 00:22:23.160 --> 00:22:27.759 endocardiis, etc. So echo cardiogram is another important test, and then neurovascular 349 00:22:27.799 --> 00:22:32.440 imaging like we talked about before, its CTA MRA. Main thing is you 350 00:22:32.440 --> 00:22:36.640 want to rule out a large artery oclusion. Make sure this patient isn't a 351 00:22:36.759 --> 00:22:38.880 candidate for something called a mechanical thromback to me, which we'll go over in 352 00:22:38.920 --> 00:22:41.720 a minute. So those are your ancillary tests or echo, your KG, 353 00:22:41.839 --> 00:22:47.240 your neurovascular imaging. The main diagnostic test. They'll focus on your non contrast 354 00:22:47.240 --> 00:22:49.400 ct that's going to be the one you get when they first come in treatment 355 00:22:49.920 --> 00:22:53.319 que treatment. There's two things that you need to know TPA that's the really 356 00:22:53.359 --> 00:22:56.680 big one, and then mechanical thrown back to me. All right, let's 357 00:22:56.680 --> 00:23:00.599 start with our thrombolytics. All to place aka TPA. So out of place 358 00:23:00.680 --> 00:23:04.960 is a thrombolytic drug. It's a clopbuster and its first line therapy for acute 359 00:23:06.079 --> 00:23:11.279 eschemic stroke patients. If it's initiated within four point five hours of symptom onset, 360 00:23:11.920 --> 00:23:15.799 and after four point five hours, there's really no point the risks are 361 00:23:15.839 --> 00:23:18.599 actually going to outweigh the benefit of using TPA. There are some exceptions to 362 00:23:18.640 --> 00:23:22.000 the time that I'm going to go over in a minute, but most patients 363 00:23:22.200 --> 00:23:26.240 are going to be within that four point five hours of onset. Then the 364 00:23:26.359 --> 00:23:30.240 other thing is that you want to make sure is that this patient doesn't have 365 00:23:30.279 --> 00:23:34.440 any contraindications to TPA. And there's a whole laundry list. I wouldn't recommend 366 00:23:34.519 --> 00:23:38.000 memorizing them, but if you want to remember a few of the important ones, 367 00:23:38.039 --> 00:23:41.839 they do have a little mnemonic. So instead of remembering TPA, I 368 00:23:41.880 --> 00:23:45.640 want you to add on a couple letters and make it t pain AKA the 369 00:23:45.720 --> 00:23:49.839 rapper may buy you a drink. So remember T pain instead of TPA. 370 00:23:49.880 --> 00:23:53.200 And remember T pain is forty five. That's how you used to remember some 371 00:23:53.279 --> 00:23:59.119 of the main contradications for TPA. So T pain is forty five. What 372 00:23:59.240 --> 00:24:02.359 that stands for. The T stands for trauma to the head in the last 373 00:24:02.359 --> 00:24:04.240 three months, So any kind of severe head trauma in the last three months 374 00:24:04.359 --> 00:24:07.960 is going to be a contradication of TPA. The P stands for plately count 375 00:24:08.039 --> 00:24:12.519 less than one hundred thousand. A stands for active internal bleeding. The I 376 00:24:12.759 --> 00:24:18.119 stands for intracranial hemorrhage. Ever in their lives, the end stands for neurosurgery 377 00:24:18.200 --> 00:24:22.039 in the last three months, so any kind of intracranial or intraspinal surgery. 378 00:24:22.519 --> 00:24:27.720 The I N T pain IS stands for intestinal malignancy or intestinal hemorrhage in the 379 00:24:27.799 --> 00:24:33.039 last twenty one days. The S stands for stroke specifically, we're talking about 380 00:24:33.039 --> 00:24:36.279 an aschemic stroke in the last three months. And then the forty five T 381 00:24:36.440 --> 00:24:38.960 pain IS forty five stands for then four point five hours. Let's talking about 382 00:24:38.960 --> 00:24:42.359 the four point five hours for a minute. So there's a few warnings, 383 00:24:42.839 --> 00:24:47.880 not absolute contradications to the four point five hour window, where you have to 384 00:24:48.759 --> 00:24:52.240 weigh the benefit verse risk. So in certain patients this four point five hour, 385 00:24:52.799 --> 00:24:56.359 it's cautioned that maybe it shouldn't be four point five, but maybe three 386 00:24:56.400 --> 00:25:02.400 in certain patient populations. So these patients saw patients that are over eighty, 387 00:25:02.839 --> 00:25:07.359 patients that have a severe stroke classified by the nih SS score, patients that 388 00:25:07.400 --> 00:25:11.920 are on oral anti coagulants, or patients that have a combination of both previous 389 00:25:11.920 --> 00:25:17.880 ischemic stroke and diabetes molitis. Then generally it's safer to be within three hours, 390 00:25:17.920 --> 00:25:21.440 but not an absolute contraindication. You kind of have to weigh the benefit 391 00:25:21.440 --> 00:25:25.400 first risk, So that's just something to consider. Most patients will be within 392 00:25:25.400 --> 00:25:26.960 that four point five hours. Those other patients you just want to kind of 393 00:25:27.440 --> 00:25:32.079 weigh the benefit verse risk, see maybe should they be within maybe a three 394 00:25:32.079 --> 00:25:34.920 hour window. Second treatment that I wanted to talk about is a mechanical thromback 395 00:25:34.960 --> 00:25:41.319 to me. So a mechanical thromback to me you have in interventional radiologists or 396 00:25:41.359 --> 00:25:45.200 another type of surgeon that goes in and literally just pulls the clot out works 397 00:25:45.240 --> 00:25:48.000 great, can be done in up to twenty four hours compared to four point 398 00:25:48.039 --> 00:25:52.519 five hours. That you know the restriction with TPA, But the problem is 399 00:25:52.559 --> 00:25:56.160 not every hospital's equipped to perform the type of procedure, and it can only 400 00:25:56.160 --> 00:26:02.480 be used in patients that have a large arteryclusion the anterior circulation, so other 401 00:26:02.519 --> 00:26:06.640 patients aren't going to be eligible. It is a great alternative to TPA because 402 00:26:06.640 --> 00:26:11.720 obviously there's way less risk with this to mind only evass procedure. But the 403 00:26:11.759 --> 00:26:14.799 problem is it's not going to work with every patient. You have those exclusions 404 00:26:14.799 --> 00:26:18.200 that I talked about there. Okay, so those are your main treatment options. 405 00:26:18.240 --> 00:26:21.160 Let's talk about blood pressure for a minute, because blood pressure is interesting. 406 00:26:21.519 --> 00:26:25.279 So in patients within a schemic stroke, you don't touch their blood pressure 407 00:26:25.440 --> 00:26:30.079 unless their blood pressure is two O two twenty over one twenty, so either 408 00:26:30.119 --> 00:26:34.039 a systolic over two twenty or a diastolic over one twenty, or if you're 409 00:26:34.079 --> 00:26:38.000 giving them TPA, then you have to make sure you manage their blood pressure 410 00:26:38.039 --> 00:26:41.440 once it reaches a point of one eighty five or higher or one ten or 411 00:26:41.519 --> 00:26:45.160 higher. So I'll talk about that again. So blood pressure and patients with 412 00:26:45.200 --> 00:26:48.920 a schemic stroke, if they're getting TPA, you want their blood pressure less 413 00:26:48.960 --> 00:26:52.160 than or equal to one eighty five, and diastolic blood pressure should be less 414 00:26:52.200 --> 00:26:55.240 than or equal to one ten. That wasn't in dedemonic, so just be 415 00:26:55.279 --> 00:27:00.000 aware of that as well. If they're not getting TPA, you can actually 416 00:27:00.200 --> 00:27:03.279 let their blood pressure ride all the way up to two twenty over one twenty 417 00:27:03.319 --> 00:27:06.599 before you have to intervene. So why is that, Well, let's think 418 00:27:06.599 --> 00:27:10.519 about that. When you have this clogged up cerebral artery, there's not much 419 00:27:10.519 --> 00:27:15.680 blood getting past the secluded area, and profusion pressure distal to that obstructed vessels 420 00:27:15.720 --> 00:27:19.079 actually really low. So this elevation and blood pressure, it's actually helping to 421 00:27:19.160 --> 00:27:23.200 maintain brain profusion past this point in those of schemic areas. So most of 422 00:27:23.240 --> 00:27:26.519 the time you actually don't want to turn down the pressure in an a schemic 423 00:27:26.599 --> 00:27:32.680 stroke. Some of your adjunct and your long term management treatment options, let's 424 00:27:32.680 --> 00:27:34.160 talk about that too. So in addition to TPA, you're thrown back to 425 00:27:34.240 --> 00:27:38.839 me, there's a lot of interventions for schemic stroke that reduces the complications and 426 00:27:38.880 --> 00:27:42.440 it reduces stroke recurrence. So one, just like in our TIA, we 427 00:27:42.480 --> 00:27:48.160 have our anti platelet therapy asprinklopiedigrop. If they didn't get TPA, they need 428 00:27:48.200 --> 00:27:51.240 anti platelets. General it's going to be three hundred and twenty five milligrams of 429 00:27:51.279 --> 00:27:52.880 aspirin. If they had TPA, you have to wait at least twenty four 430 00:27:52.920 --> 00:27:56.319 hours before you give them anti platelets. Also, statin therapy, this one's 431 00:27:56.359 --> 00:28:02.559 really important. There's clear evidence and study is that long term invasive statin therapy 432 00:28:02.680 --> 00:28:06.839 is associated with a reduced risk of recurrent eschemic stroke. And then of course 433 00:28:07.200 --> 00:28:11.240 lifestyle changes smoking cessation, exercise, weight reduction, crolling blood pressure, controlling 434 00:28:11.279 --> 00:28:18.160 diabetes is set to produce to reduce the risk of a future stroke. All 435 00:28:18.240 --> 00:28:21.480 Right, So that was our eschemic stroke. So let's talk a little bit 436 00:28:21.480 --> 00:28:26.319 about our intracranial hemorrhages, our hemorrhagic strokes. I wanted to briefly touch on 437 00:28:26.359 --> 00:28:30.240 some of these intracranial hemorrhages, including some of the causes of our hemorrhagic strokes. 438 00:28:30.559 --> 00:28:33.640 I'm just going to focus on the basics. I'm gonna give you some 439 00:28:33.720 --> 00:28:37.480 demonics. Diagnosis is pretty similar across the board for these with the ctmmost cases, 440 00:28:38.200 --> 00:28:41.920 treatment is generally not going to be tested on. Can range from supportive 441 00:28:41.920 --> 00:28:47.960 measures clips and coils all the way up to craniotomy and severe cases. Okay, 442 00:28:48.000 --> 00:28:52.480 so let's start with epidural hematoma. So, an epidural hematoma is bleeding 443 00:28:52.519 --> 00:28:56.480 between the skull and duram matter. So it's a collection of blood that forms 444 00:28:56.519 --> 00:29:02.039 between your skull and the dura matter middle mini indual artery. So bleeding typically 445 00:29:02.079 --> 00:29:06.039 arises from the middle minigual artery and a lot of times it's associated with a 446 00:29:06.079 --> 00:29:11.880 temporal skull fracture, particularly seen in children. More common lucid interval in the 447 00:29:11.000 --> 00:29:15.480 vignette, and epidural hematoma. They're always going to mention the patient had this 448 00:29:15.640 --> 00:29:18.400 loss of consciousness. Then it was followed by this lucid interval where they had 449 00:29:18.440 --> 00:29:22.640 this transient recovery. So this lucid interval where they got a bit better for 450 00:29:22.680 --> 00:29:26.400 a period of time, that's the key to lookout for the evenend the vignette. 451 00:29:26.400 --> 00:29:30.039 If you see lucid interval right away, be thinking of an epidural hematoma 452 00:29:30.160 --> 00:29:33.440 on your CT. You're going to have a convex shaped bleed, so you're 453 00:29:33.440 --> 00:29:37.759 gonna have this bleeding that the outline or the surface is kind of curved, 454 00:29:37.799 --> 00:29:41.319 like the exterior of a circle or a sphere. It's hard to describe these 455 00:29:41.319 --> 00:29:45.440 things without visuals. So really there's three things that you have to know. 456 00:29:45.599 --> 00:29:49.160 You need to remember your middle minigual artery tear. You have to remember the 457 00:29:49.200 --> 00:29:53.279 convex bleeding on the CT and be able to recognize that on a CT image. 458 00:29:53.400 --> 00:29:56.960 And then you need to remember that lucid interval. The way that you 459 00:29:56.039 --> 00:30:00.920 remember that is when you think of epidural hematoma. I want you to think 460 00:30:00.920 --> 00:30:04.200 about those first three letters in epidural hematoma, so EPI. If you rearrange 461 00:30:04.240 --> 00:30:10.359 those letters, you have the word pie. You can also the second two 462 00:30:10.440 --> 00:30:15.599 letters PI is spelled pie like pi like the mathematical term pie. So however 463 00:30:15.640 --> 00:30:18.440 you get there. As soon as you see epidural hematoma, I want you 464 00:30:18.440 --> 00:30:21.039 to think of a pie, and I want you to think of the sentence 465 00:30:21.480 --> 00:30:26.079 m A Lulu lemon pie, A Lulu lemon pie. So what does that 466 00:30:26.119 --> 00:30:30.440 stands for? So m A. So mm A stands for middle meningual arteries, 467 00:30:30.519 --> 00:30:34.359 so m A. And then Lulu lemon pie. I'm sure you've all 468 00:30:34.400 --> 00:30:37.839 heard of Lulu Lemon. That's like the athletic company that makes the leggings and 469 00:30:37.839 --> 00:30:44.559 stuff, So Lulu lemon. Lulu stands for lucid interval. So Lulu, 470 00:30:44.599 --> 00:30:47.839 as soon as you see Lulu, think of lucid interval that's associated with your 471 00:30:47.839 --> 00:30:52.599 epidural hematoma. And then lemon is actually because and this makes sense when you 472 00:30:52.599 --> 00:30:56.039 look at the CT image, But if you look at a CT image, 473 00:30:56.279 --> 00:31:00.000 you have a convex shaped bleed. It looks exactly like the side of a 474 00:31:00.079 --> 00:31:03.759 lemon. And I have a picture on my YouTube channel and you can see 475 00:31:03.799 --> 00:31:06.720 it. But the bleed. As soon as you see a CT image and 476 00:31:06.759 --> 00:31:10.160 it looks like there's like half a lemon on the CT sticking out, you'll 477 00:31:10.200 --> 00:31:12.319 be thinking of an epidural hematoma. So that's why I have lemon pie. 478 00:31:12.680 --> 00:31:15.559 So as soon as you see epidural hematoma right away, be thinking of pie 479 00:31:15.759 --> 00:31:23.319 epi epi rearranged pie pie epideral hematoma, A lulu, lemon pie, a 480 00:31:23.559 --> 00:31:26.759 middleman, and you'll artery lucid. That's going to be your lulu and then 481 00:31:26.880 --> 00:31:30.960 lemon. Think of your lemon or convex shaped bleed on the CT. All 482 00:31:30.039 --> 00:31:34.160 right, so that is your epidural hematoma. Let's move on to our subdural 483 00:31:34.160 --> 00:31:41.000 hematoma. So this is bleeding that forms between the dora and the arachnoid membranes 484 00:31:41.079 --> 00:31:47.400 overlying the brain bridging veins tear. So an acute subdural hematoma is usually caused 485 00:31:47.400 --> 00:31:52.079 by tearing of the bridging veins located between the arachnoid membranes and the dura, 486 00:31:52.519 --> 00:31:56.039 so bridging veins. Remember that that's really important for subdural hematoma that will likely 487 00:31:56.079 --> 00:32:00.839 come up now as far as the patients are going to see this in elderly 488 00:32:00.000 --> 00:32:04.880 alcoholics. So in a vignette, the patient will likely be elderly or an 489 00:32:04.880 --> 00:32:07.839 alcoholic who had some kind of trauma a fall, a motor vehicle accident. 490 00:32:08.119 --> 00:32:14.400 The reason that we see this more commonly in this patient population is because cerebral 491 00:32:14.480 --> 00:32:17.799 atrophy is common in both older adults and those with the history of chronic alcohol 492 00:32:17.839 --> 00:32:22.680 abuse. Cerebral atrophy results in this larger space between the dural membrane and the 493 00:32:22.680 --> 00:32:27.839 cortical surface of the brain, and that increases tension on these bridging veins. 494 00:32:27.880 --> 00:32:30.400 So in these patients fall they have a traumatic brain injury like in an MVA, 495 00:32:30.519 --> 00:32:36.079 these bridging veins they're more susceptible to tearing because they're stretched and pulled across 496 00:32:36.119 --> 00:32:39.880 this greater distance. On CT, you're gonna have a crescent shaped hematoma, 497 00:32:39.960 --> 00:32:45.160 so crescent shaped appearance because the bleeding follows the contour of the overlying dura and 498 00:32:45.279 --> 00:32:50.039 it looks I'm sure we've all seen a crescent moon, just that little sliver 499 00:32:50.119 --> 00:32:52.599 of moon. That's what it looks like on a CT. So the way 500 00:32:52.599 --> 00:32:54.720 that you remember the things that you need to know for your subdural hematoma is 501 00:32:54.759 --> 00:33:04.759 instead of subdural as in you are so subdural hematoma, I remember subdural hematoma, 502 00:33:04.839 --> 00:33:09.759 So sub d O O r all, so subdor all hematoma. And 503 00:33:09.799 --> 00:33:15.880 then door stands for drunk old overpass because it overpasses another way of saying bridge, 504 00:33:15.920 --> 00:33:20.119 and that helps you remember your bridging veins. And then the R endoor 505 00:33:20.359 --> 00:33:25.880 and indoor is the second letter in crescent, So subdural hematoma drunk old that's 506 00:33:25.880 --> 00:33:30.000 your patients that you'll see it in overpass that's your bridging veins. And then 507 00:33:30.079 --> 00:33:34.519 crescent. The R indor is the second letter in crescent because you have a 508 00:33:34.519 --> 00:33:37.720 crescent shaped hematoma on CT. So that is your subdural hematomas. Let's move 509 00:33:37.720 --> 00:33:40.720 on to our suboracnoin hemorrhage. So a few things you need to know about 510 00:33:40.720 --> 00:33:45.759 suberacto and hemorrhage. So this is going to be an extravasation of blood into 511 00:33:45.799 --> 00:33:50.599 the suborachnoid space between the pia and the arachnoid membrane, so you're bleeding within 512 00:33:50.640 --> 00:33:55.039 the Meninji's into the ventricles. Very aneurism rupture is going to be your most 513 00:33:55.039 --> 00:33:59.319 common cause. So a rupture of a very aneurism, which is also known 514 00:33:59.359 --> 00:34:01.160 as a sac or aneurysm, it's going to be your most common cause of 515 00:34:01.160 --> 00:34:08.440 a suboractoine hemorrhage presentation. This is important severe headache aka worst headache of my 516 00:34:08.519 --> 00:34:14.119 life. So suboracto and hemorrhates has a very specific clinical presentation. I'm sure 517 00:34:14.159 --> 00:34:16.639 most of you have heard of this before, probably even before PA school. 518 00:34:16.679 --> 00:34:22.000 So patient with the suberacto and hemorrhage will often describe having the worst headache of 519 00:34:22.000 --> 00:34:24.400 their life. It's also known as a thunderclap headache because all of a sudden, 520 00:34:24.400 --> 00:34:28.920 when they have this headache, the severe headache, it's not an insidious 521 00:34:29.000 --> 00:34:30.800 onset. It's this patient is feeling completely normal and then all of a sudden, 522 00:34:30.800 --> 00:34:34.360 they have this ten out of ten headache in a matter of minutes. 523 00:34:34.360 --> 00:34:36.760 So the same way like thunder, all of a sudden just hits out of 524 00:34:36.800 --> 00:34:39.199 nowhere. That's the severe headache. It's also known as a thunderclap headache. 525 00:34:39.599 --> 00:34:44.400 Meningual symptoms so this is really important as well, because these patients may have 526 00:34:44.480 --> 00:34:49.639 symptoms of meningeal irritation, which is also known as meningismus. So you look 527 00:34:49.679 --> 00:34:53.960 for nucual rigidity, photophobia, lower back pain. It can occurs in as 528 00:34:54.000 --> 00:35:00.239 many as eighty percent of patients and it's from the breakdown of blood product in 529 00:35:00.239 --> 00:35:05.360 the CSF which leads to this aseptic meningitis. And then finally the diagnosis is 530 00:35:05.599 --> 00:35:07.519 a little bit different with a subarachnoid because we always talked about the CT. 531 00:35:07.679 --> 00:35:12.400 I talked about that earlier. But with a patient with a subarachnoid hemorrhage, 532 00:35:12.440 --> 00:35:15.440 you want to consider a lumbar puncture. Now you're gonna get your CT like 533 00:35:15.440 --> 00:35:17.519 you did in all of your other types we went over, But in a 534 00:35:17.559 --> 00:35:22.719 patient with a negative CT that you really suspect may have a subarachnoid hemorrhage, 535 00:35:22.960 --> 00:35:25.000 you have to go a little bit further. You have to get a lumbar 536 00:35:25.039 --> 00:35:28.559 puncture. And this is going to be on your vignette where you look from 537 00:35:28.599 --> 00:35:34.519 the lumbar puncture is something known as xanthochromia, and it's this yellow tinged CSF 538 00:35:34.880 --> 00:35:38.719 which is from Billy Rubin and the CSF indicating old blood. So if both 539 00:35:38.760 --> 00:35:43.039 the CT and the LP are negative, you've essentially rolled out of suberachnoid. 540 00:35:43.280 --> 00:35:46.480 But you need both to say, definitively in patience with a high clinical suspicion 541 00:35:46.480 --> 00:35:51.519 because this can be fatal, so you don't want to miss it. Into 542 00:35:51.760 --> 00:35:53.679 cerebral hemorrhage is the last one I'll go over. There's very little to know 543 00:35:53.719 --> 00:35:57.960 for this there's not really much unique about it, and most things that don't 544 00:35:57.960 --> 00:36:00.639 have a lot unique about them are to not test it on. But an 545 00:36:00.639 --> 00:36:06.119 interestcrebral hemorrhage. It's bleeding into the brain perencuma. It's the second most common 546 00:36:06.199 --> 00:36:08.440 cause of stroke after a schemic stroke. And then what you need to be 547 00:36:08.440 --> 00:36:13.800 looking for is a patient, an older patient, older age, and hypertensive, 548 00:36:14.199 --> 00:36:19.199 so the risk for interest cerebral hemorrhage increases with advancing age. In addition, 549 00:36:19.199 --> 00:36:22.599 the most common eteology of a spontaneous interest cerebral hemorrhage is hypertension, so 550 00:36:22.679 --> 00:36:27.119 look out for that. So elderly patients hypertension, those are the main ones 551 00:36:27.119 --> 00:36:30.960 you need to know of, and then be aware of some of the other 552 00:36:30.079 --> 00:36:36.760 causes that are also common as well, so amyloid and geopathy, ruptured vascular 553 00:36:36.800 --> 00:36:40.920 malformation, But focus on hypertension. That's the most common eteology. All right, 554 00:36:40.920 --> 00:36:44.400 So that is stroke. Let's do five quick questions. See what you've 555 00:36:44.440 --> 00:36:47.480 retain. So question one. Sixty seven year old male with history of hypertension 556 00:36:47.679 --> 00:36:52.239 and hyperlipidemia arrives to the emergency department accompanied by his wife and daughter. His 557 00:36:52.360 --> 00:36:55.199 family members state he is unable to speak, and he has not been able 558 00:36:55.239 --> 00:36:59.400 to lift his right arm. When you ask the patient to pup out his 559 00:36:59.480 --> 00:37:02.519 cheeks and you know prominent drooping on the right side of the face. This 560 00:37:02.599 --> 00:37:07.239 patient likely has a stroke of which cerebral artery, so that is going to 561 00:37:07.239 --> 00:37:13.079 be your middle cerebral artery, so left sided specifically, as we see contralateral 562 00:37:13.119 --> 00:37:16.760 involvement of the right upper extremities, we see contralateral involvement the right side of 563 00:37:16.800 --> 00:37:21.400 the face, and then aphasia. Remember your middle screbral artery. You're mad, 564 00:37:21.440 --> 00:37:23.000 your mattle cerebral artery. You're raising your arms up in the air. 565 00:37:23.000 --> 00:37:28.119 It's patient has right arm involvement. Your faces read this patient has drooping on 566 00:37:28.159 --> 00:37:30.440 the right side of the face, and then you're yelling. Remember your phasia. 567 00:37:30.480 --> 00:37:35.639 This patient has trouble speaking. So middle cerebral artery left sided specifically in 568 00:37:35.760 --> 00:37:39.559 this patient question two. Sixty three year old Mail presents today to the emergency 569 00:37:39.639 --> 00:37:45.880 department complaining of next stiffness and a sudden onset severe headache. Unlike any other 570 00:37:45.960 --> 00:37:50.840 he has had before. His path medical history includes only hypertension. While speaking 571 00:37:50.840 --> 00:37:52.519 to him, you notice he is squinting his eyes and asks if you can 572 00:37:52.559 --> 00:37:55.559 dim the lights. You enter a CT of the head which is negative, 573 00:37:55.880 --> 00:38:00.559 which additional test should be performed for the suspected diagnosis, So that is going 574 00:38:00.599 --> 00:38:04.440 to be a lumbar puncture. A suspicion has a history of a severe headache 575 00:38:04.639 --> 00:38:07.440 which he describes came on suddenly. That's our thunderclap headache. In addition, 576 00:38:07.440 --> 00:38:10.760 he has meningial symptoms, so photophobia, remember he's asking the doctor to turn 577 00:38:10.800 --> 00:38:15.159 on the lights. Nucle rigidity, that stiffness of the pain of the neck, 578 00:38:15.519 --> 00:38:19.039 no history of migraines, so we should be suspecting a subarachnoid hemorrhage in 579 00:38:19.039 --> 00:38:22.639 this patient. And you start with your non contrast CT. If that's negative, 580 00:38:22.800 --> 00:38:25.239 you have a high degree of suspicion for subarachnoid. You need to also 581 00:38:25.360 --> 00:38:29.639 order your lumbar puncture, which would be looking for again xanto chromia, which 582 00:38:29.679 --> 00:38:32.039 is from the breakdown of the red blood cells. In the CSF question three, 583 00:38:32.639 --> 00:38:36.960 seventy six year old male company by his daughter has been diagnosed with an 584 00:38:36.960 --> 00:38:39.840 acute schemic stroke. His blood pressure is one sixty eight over ninety two, 585 00:38:39.960 --> 00:38:45.360 oxygen saturation ninety six percent pulse eighty eight temperature ninety eight point three. He 586 00:38:45.440 --> 00:38:49.239 was known to be well two hours ago when his daughter spoke to him by 587 00:38:49.239 --> 00:38:52.840 phone. She states he has a history of hypertension, type two diabetes and 588 00:38:52.880 --> 00:38:55.639 Celiac disease. She's very worried about him, as stating, this is his 589 00:38:55.719 --> 00:39:00.119 second schemic stroke in the last three months. With his patient an ideal candidate 590 00:39:00.119 --> 00:39:05.679 for TPA, if not, why so that's going to be no, because 591 00:39:05.679 --> 00:39:07.599 he has a history of a schemic stroke in the last three months. Schemic 592 00:39:07.639 --> 00:39:12.360 stroke in the last three months is part of the exclusion criteria for IV thrombolycens 593 00:39:12.440 --> 00:39:15.400 TPA. It's one of the many. Again, I don't expect to remember 594 00:39:15.440 --> 00:39:16.360 all of them, but this is one of the important ones. And just 595 00:39:16.440 --> 00:39:21.360 remember t pain is forty five, and you can remember the important ones. 596 00:39:21.840 --> 00:39:24.840 Question four, Which artery is the most common to be involved in an ischemic 597 00:39:24.960 --> 00:39:29.599 stroke? So that is going to be your middle cerebral artery member, middle 598 00:39:29.599 --> 00:39:32.440 cerebral artery MCA, most common artery, and that's going to be in around 599 00:39:32.519 --> 00:39:36.039 seventy percent of the cases. It's going to be your MCA that's going to 600 00:39:36.039 --> 00:39:39.000 be involved in an a schemic stroke. Question five patient being treated for a 601 00:39:39.000 --> 00:39:44.239 schemic stroke is greeted by the treating physician who informs him they're going to administer 602 00:39:44.280 --> 00:39:49.280 a medication called nicartapine into his IV to start lowering his blood pressure. Is 603 00:39:49.360 --> 00:39:52.679 unable to receive TPA due to a gastro intestinal malignancy. The blood pressure in 604 00:39:52.719 --> 00:39:59.440 this patient has likely exceeded what systolic and or diastolic level level, so that 605 00:39:59.519 --> 00:40:02.320 is going to be systolic over two twenty and a diastolic over one twenty. 606 00:40:02.760 --> 00:40:06.559 So patients with a schemic stroke, we are not going to be treated with 607 00:40:06.599 --> 00:40:09.000 thrombolytic therapy. We stated this patient is not it's not a candidate due to 608 00:40:09.039 --> 00:40:12.960 the GI malignacy. We don't need to worry about those BP guidelines. But 609 00:40:13.079 --> 00:40:16.559 this patient that's not going to be treated with TPA should not have their blood 610 00:40:16.599 --> 00:40:22.280 pressure treated acutely unless the hypertension is extreme. That's going to be a systolic 611 00:40:22.320 --> 00:40:25.239 blood pressure over two twenty and or diastolic blood pressure over one twenty. So 612 00:40:25.320 --> 00:40:30.119 remember these patients with a schemic stroke, the perfusion pressure distal to the obstructed 613 00:40:30.199 --> 00:40:34.079 vessel is low, so we need to keep that pressure high enough to maintain 614 00:40:34.119 --> 00:40:37.239 brain perfusion. Only if it's systolic over two twenty and or diastolic over one 615 00:40:37.280 --> 00:40:40.599 twenty do we treat like in this patient. All right, So that was 616 00:40:40.639 --> 00:40:44.480 your stroke. Hopefully that was helpful. Thank you so much for listening, 617 00:40:44.800 --> 00:40:46.440 and thank you as always for all of the really nice comments. I do 618 00:40:46.480 --> 00:40:50.920 appreciate it, and good luck in PA school, your pants, your panory, 619 00:40:51.159 --> 00:40:52.000 and your ears