SCRN study guide: hyperacute care Questions and Answers 2023

SCRN study guide: hyperacute care Questions and Answers 2023 Communicate effectively with pre-hospital personnel. When stroke victim activates EMS the time to imaging , neuro exam, ED MD evaluation is shorter. This should be emphasized in the community. The greatest time delay is from symptom onset to ED arrival. EMS alerts the hospital, advance notification by EMS has shown to increase the use of TpA EMS evaluation primary goals Obtain last seen normal Obtain blood glucose ABCD score A: age B: blood C: clinical features D: Duration of TIA symptoms Establish ABC's Airway -Breathing: O2 for SpO2 94% Circulation: ECG, BP assessment & IV/Labs (√BG) D (Neuro): NIHSS or Canadian Neurological Scale (CNS), Neuro Exam & Neuro MD Posterior stroke There are important differences between posterior and anterior circulation stroke. The differences include the value of screening instruments, optimum diagnostic modalities, and clinical features. The face arm speech test (FAST), a widely used prehospital stroke recognition screening instrument, is less sensitive for detecting posterior circulation stroke than for anterior circulation stroke Symptoms of Posterior Circulation Stroke Motor deficits (weakness, clumsiness, or paralysis of any combination of arms and legs, up to quadriplegia, sometimes changing from one side to another in different attacks) "Crossed" syndromes, consisting of ipsilateral cranial nerve dysfunction and contralateral long motor or sensory tract dysfunction are highly characteristic of posterior circulation stroke Sensory deficits (numbness, including loss of sensation or paraesthesia in any combination of extremities, sometimes including all four limbs or both sides of the face or mouth) Homonymous hemianopia—a visual field defect affecting either the two right or the two left halves of the visual fields of both eyes Ataxia, imbalance, unsteadiness, or disequilibrium Vertigo, with or without nausea and vomiting Diplopia as a result of ophthalmoplegia Dysphagia or dysarthria Isolated reduced level of consciousness is not a typical stroke symptom but can result from bilateral thalamic or brainstem ischaemia (especially from rostral basilar artery occlusion) Posterior stroke: Lateral medulla (intracranial vertebral artery infarct, also known as Wallenberg syndrome) Nystagmus, vertigo, ipsilateral Horner's syndrome, ipsilateral facial sensory loss, dysarthria, hoarseness, and dysphagia Contralateral hemisensory loss in the trunk and limb—pain and temperature posterior stroke: Medial medulla Ipsilateral tongue weakness and later hemiatrophy of the tongue Contralateral hemiparesis of the arm and leg Hemisensory loss—touch and proprioception posterior stroke: Pons Hemiparesis or hemisensory loss, ataxic hemiparesis, dysarthria, horizontal gaze palsy Complete infarction causes "locked-in syndrome" with quadriparesis, loss of speech, but preserved awareness and cognition, and sometimes preserved eye movements posterior stroke:Top of the basilar (distal basilar occlusion) Somnolence, confusion (from thalamic infarction) Bilateral loss of vision, unawareness or denial of blindness (from bilateral occipital infarction) posterior stroke: Posterior inferior cerebellar artery Truncal ataxia, vertigo (limb ataxia may occur, especially if the inferior cerebellar peduncle is affected) posterior stroke: Posterior cerebral artery Contralateral homonymous hemianopia (from occipital infarction) Hemisensory loss—all modalities (from thalamic infarction) Hemi-body pain—pain (usually with a burning quality) down one side of the body (face, arm, and leg) as a result of thalamic infarction If bilateral, may have poor visual-motor coordination, inability to understand visual objects Symptoms of Anterior Circulation Stroke Patients typically present with sudden onset of focal neurological symptoms. Anterior Circulation Stroke: Left hemisphere (ie, dominant) • Right hemiparesis - Variable involvement of face and upper and lower extremity • Right-sided sensory loss in a pattern similar to that of the motor deficit - Usually involves all modalities, decreased stereognosis, and graphesthesia • Right homonymous hemianopia • Dysarthria • Aphasia, fluent and nonfluent • Alexia • Agraphia • Acalculia • Apraxia Anterior Circulation Stroke: Right hemisphere (ie, nondominant) • Left hemiparesis - Same pattern as on right • Left-sided sensory loss - Similar pattern that of the motor deficit • Left homonymous hemianopia - Same pattern as on right • Dysarthria • Neglect of the left side of environment • Anosognosia • Asomatognosia • Loss of prosody of speech • Flat affect Anterior Circulation Stroke: Cortical and subcortical ACA territory: • Crural paresis arm paresis • Frontal signs (eg, abulia) anterior choroidal artery territory: • Hemiparesis • Hemianesthesia • Homonymous hemianopia Anterior Circulation Stroke: Lacunar syndromes (pure motor) • Contralateral - Usually affects the face and upper and lower extremities equally • Also associated with dysarthria • No sensory or visual loss • No cognitive impairment Anterior Circulation Stroke: Lacunar syndromes (pure sensory) • Contralateral loss of all sensory modalities - Equally affects the face and upper and lower extremities • No motor signs, dysarthria, visual loss, or cognitive impairment Anterior Circulation Stroke: Lacunar syndromes (Dysarthria-clumsy hand syndrome) • Dysarthria • Dysphagia • Contralateral tongue and facial weakness and paresis • Clumsiness of the contralateral arm and hand Anterior Circulation Stroke: Lacunar syndromes (Homolateral ataxia and crural paresis) • Paresis of the contralateral leg and side of the face • Prominent ataxia of the contralateral leg and arm Anterior Circulation Stroke: Lacunar syndromes (Isolated motor/sensory stroke) • Paralysis and sensory loss of the contralateral leg, arm, and face • No visual loss or cognitive impairment Symptoms of hemorrhagic stroke: Intracerebral Hemorrhage Symptoms of an intracerebral, or parenchymal, hemorrhage typically begin very suddenly and evolve over several hours and include: Headache Nausea and vomiting Altered mental states Seizures Symptoms of hemorrhagic stroke: Subarachnoid Hemorrhage. When the hemorrhage is a subarachnoid type, warning signs may occur from the leaky blood vessel a few days to a month before the aneurysm fully develops and ruptures. Warning signs may include: Abrupt headaches Nausea and vomiting Sensitivity to light Various neurologic abnormalities. Seizures, for example, occur in about 8% of patients. When the aneurysm ruptures, the stroke victim may experience: A terrible headache Neck stiffness Vomiting Altered states of consciousness Eyes may become fixed in one direction or lose vision Stupor, rigidity, and coma National Institutes of Health Stroke Scale The National Institutes of Health Stroke Scale (NIHSS) measures neurologic impairment using a 15 item scale The NIHSS is both reliable and valid, and has become a standard stroke impairment scale for use in both clinical trials and as part of clinical care. In addition, the baseline NIHSS score is predictive of long-term outcome after acute stroke An important limitation of the NIHSS is that it does not capture all stroke-related impairments, particularly with infarction involving the vertebrobasilar circulation. This is also true for modified, shortened versions of the scale. Hunt and Hess grading system The grading system proposed by Hunt and Hess in 1968 is one of the most widely used. The scale was intended as an index of surgical risk. The initial clinical grade correlates with the severity of hemorrhage. ●Grade 1: Asymptomatic or mild headache and slight nuchal rigidity ●Grade 2: Moderate to severe headache, stiff neck, no neurologic deficit except cranial nerve palsy ●Grade 3: Drowsy or confused, mild focal neurologic deficit ●Grade 4: Stupor, moderate or severe hemiparesis ●Grade 5: Deep coma, decerebrate posturing ●The grade is advanced one level for the presence of serious systemic disease (hypertension, diabetes, severe arteriosclerosis, chronic pulmonary disease) or vasospasm on angiography Although the Hunt and Hess scale is easy to administer, the classifications are arbitrary, some of the terms are vague (eg, drowsy, stupor, and deep coma) and some patients may present with initial features that defy placement within a single grade Glasgow Coma Scale The Glasgow Coma Scale (GCS) was devised in the early 1970s. The GCS is not a true SAH grading scale, but is rather a standardized method for evaluating the level of consciousness in a number of neurologic conditions including SAH. The GCS assigns points based on three parameters of neurologic function: ●Eye opening (spontaneous = 4, response to verbal command = 3, response to pain = 2, no eye opening = 1) ●Best verbal response (oriented = 5, confused = 4, inappropriate words = 3, incomprehensible sounds = 2, no verbal response = 1) ●Best motor response (obeys commands = 6, localizing response to pain = 5, withdrawal response to pain = 4, flexion to pain = 3, extension to pain = 2, no motor response = 1)