1. Complete the following:

G7 p.1010:100mm

a. Cerebral blood flow (CBF) less than_____mL per 100 g of tissue per minute is associated with ischemia.

20 mL

b. If prolonged, it will result in_____.

cell death

2. Electroencephalography (EEG) becomes flat line at CBF of_____mL/100 g/min.

16 to 18

G7 p.1010:150mm

3. Complete the following about strokes in general:

G7 p.1010:163mm

a. What is the range of cerebral perfusion pressure in which cerebral blood flow is maintained constant despite changes in cerebrovascular resistance?

50 to 150 mm Hg

b. This is called_____.

autoregulation

4. Complete the following about strokes in general:

G7 p.1010:175mm

a. CMRO₂ stands for_____and

cerebral metabolic rate of oxygen consumption

b. averages_____.

3.0 to 3.8 mL/100 g of tissue per minute

5. Complete the following regarding abrupt onset of new focal deficit caused by:

G7 p.1011:60mm

a. tumor/seizure_____%

5%

b. ischemic infarct_____%

85%

c. hemorrhagic infarct_____%

15%

d. mortality_____%

25%

e. nursing home_____%

25%

f. home_____%

50%

6. True or False. The following is a cause of ischemic infarcts:

G7 p.1011:75mm

a. lacune

true

b. large artery embolism

true

c. cardiogenic embolism

true

d. aortic arch plaques

true

7. Modifiable risk factors for stroke include

G7 p.1011:120mm

a. c_____

cigarettes

b. a_____

alcohol

c. h_____

hypertension

d. l_____

lipids

e. a_____

antiplatelets

8. Computed tomographic (CT) scan signs of early ischemia include

G7 p.1012:110mm

a. i_____

insular ribbon lost

b. s_____

shift of midline day 1 to 25

c. c_____

calcification almost never 1 to 2%

d. h_____

hyperdense artery sign

e. e_____

effacement of cerebral sulci

f. m_____

mass effect

g. i_____

interface of gray-white lost

h. c_____

contrast CT should be included on at least one occasion

9. True or False. The following can be early CT findings of ischemic strokes:

G7 p.1012:125mm

a. midline shift

true

b. loss of gray-white interface

true

c. hyperdensity of lentiform nucleus

false (Attenuation of the lentiform nucleus may be seen.)

d. enhancement of ischemic area

true (One third of ischemic strokes may enhance early.)

e. normal CT

true

f. hyperdense artery sign

true (usually MCA)

G7 p.1013:40mm

10. Is there CT enhancement with intravenous (IV) contrast in cerebrovascular accidents (CVAs) in the presence of mass effect?

no (As a rule of thumb there should not be.)

G7 p.1013:55mm

11. MRI sequences in stroke are

G7 p.1013:160mm

a._____ represents dead tissue.

DWI

b._____ represents penumbra.

PWI

c. Penumbra is potentially s_____tissue.

salvageable

12. Components of luxury perfusion are

G7 p.1014:35mm

Hint: ischemia

a. i_____

ischemia

b. “s”_____

“s” idosis (acidosis)

c. c_____

CO₂ rises

d. h_____

hyperemia

e. e_____

enlargement (dilation) of vessels

f. m_____

mechanism of luxury perfusion

g. i_____

increase blood flow

h. a_____

accelerated circulation adjacent to an infarct

13. Explain the mechanism of luxury perfusion.

G7 p.1014:40mm

a. Ischemia produces_____,

acidosis

b. which causes an_____in PCO₂.

increase

c. What does this do to regulation?

loss of autoregulation

d. It results in_____vessels

dilated

e. and blood flow_____called _____.

excess; hyperemia

f. What happens to blood flow adjacent to an infarct?

it becomes accelerated

14. t-PA works by

G7 p.1016:145mm

a. converting p_____

plasminogen

b. to the fibrinolytic compound_____.

plasmin

c. The primary agent is a_____.

alteplase

15. Complete the following regarding the use of recombinant tissue plasminogen activator (rt-PA) compared with control groups:

G7 p.1016:175mm

a. reduction in stroke_____%

30%

b. recurrent stroke rate_____%

5%—same in both groups

c. mortality_____ vs_____%

17 vs 21%

d. hemorrhage (NINDS study)_____ vs _____%

6.4 vs 0.6%

e. hemorrhage ECASSII study_____ vs _____%

8.8 vs 3.4%

f. benefit at 90 days in mortality_____ _____

no difference

16. Facts learned from the ECASS-3 study of t-PA include

G7 p.1017:16mm

a. Extended the window of IV treatment to_____ hours

4.5

b. Improved outcome at 90 days by_____%

7.2%

c.

     i. Incidence of hemorrhage _____%

7.9%

     ii. And_____% for placebo

3.5%

d.

     i. Yet no increase in death rate t-PA _____%

7.7%

     ii. Placebo_____%

8.4%

e. For every 100 patients treated with t-PA

     i._____ will benefit

32

     ii. _____ will be harmed

3

17. True or False. The following would exclude a patient with ischemic stroke from treatment with tissue plasminogen activator (t-PA):

G7 p.1017:70mm

a. systolic blood pressure (SBP) 180 mm Hg

false (SBP above 185 disqualifies.)

b. gastrointestinal (GI) bleed 6 months ago requiring transfusion

false (GI bleed within 21 days disqualifies.)

c. platelet count 120,000/mm³

false (Below 100,000 disqualifies.)

d. hip arthroplasty 10 days ago

true (Major surgery within 14 days of an ischemic stroke is a contraindication for t-PA treatment.)

e. blood glucose 250 mg%

false (Above 400 mg% disqualifies.)

18. Complete the following about the management of post-t-PA intracerebral hemorrhage:

G7 p.1018:15mm

a. Stop_____.

t-PA

b. Obtain stat_____.

CT

c. Send labs for PT, PTT, platelet and _____.

fibrinogen

d. Prepare to administer

     i. 6 to 8 units of c_____

cryoprecipitate

     ii. 6 to 8 units of p_____

platelets

e. Consider use of_____ _____.

factor VII

19. Intra-arterial t-PA may be used up to_____hours after stroke onset.

6

G7 p.1018:48mm

20. Merci retriever

G7 p.1018:48mm

a. stands for mechanical embolus removal in_____.

cerebral ischemia

b. It can be used for up to_____hours.

8

c. It has a recanalization rate of_____%.

48%

21. Complete the following about strokes in general:

G7 p.1018:165mm

a. After a stroke you must monitor electrocardiography (EKG) because

     i. _____% have EKG changes

5 to 10%

     ii. _____% have myocardial infarction (MI)

2 to 3%

b. You must avoid hyperglycemia because hyperglycemia

     i. _____ the ischemia zone, also known as the

extends

     ii. _____.

penumbra

22. Complete the following regarding hypertension treatment:

G7 p.1019:120mm

a. If diastolic blood pressure (DBP) is above_____ it is called malignant hypertension.

140 mm Hg

b. Decreasing by_____% to DBP of_____is desirable.

20 to 30% (112 to 98 mm Hg)

c. If SBP is above 230 or DBP is above 120 decrease to SBP of_____or DBP of_____.

180; 110

d. For SBP of 180 to 230 or DBP of 105 to 120 decrease n_____n_____e_____.

not needed emergently

e. For SBP of less than_____or DBP of less than_____ antihypertensive treatment is not needed.

180; 105

f. Approximately_____ /_____ is acceptable.

180/100

g. Add_____if there is a history of hypertension.

5

23. Complete the following:

G7 p.1020:40mm

a. Incidence of recurrent ischemic strokes in the week following a CVA is _____%.

2.2%

b. Is it any less if you use heparin?

no

     i. except in_____

cardiogenic emboli

c. Complication rate of heparin

     i. symptomatic intracerebral hemorrhage (ICH) occurs in_____%

1 to 8%

     ii. conversion of pale to hemorrhagic CVA_____%

2 to 5%

     iii. other bleeding complications_____%

3 to 12%

d. On balance is it justified to use heparin after an ischemic CVA?

no

     i. The American Heart Association states that the_____decides.

doctor

24. Complete the following regarding the use of anticoagulants (heparin or warfarin):

G7 p.1020:40mm

a. True or False. They are effective in the prevention of embolic strokes caused by cardiogenic embolism.

true

b. True or False. They are effective in ischemic strokes.

false

c. They have a risk of hemorrhage of_____% per year.

1 to 8%

d. They will convert pale to hemorrhagic CVA in_____%.

2 to 5%

25. CVA and anticoagulation are generally used for

G7 p.1020:115mm

a. c_____ e_____.

cardiogenic emboli

b. c_____ d_____.

carotid dissection

c. Complications are worse if the patient has_____.

hypertension

d. How do you start the drugs? (heparin/warfarin)

simultaneously

     i. Why? Because of initial_____.

hypercoagulability

e. Stop warfarin after_____.

6 months

f. Why?

reduced benefits, increased risks

26. True or False. Regarding cerebellar infarction:

G7 p.1021:30mm

a. Hydrocephalus may occur.

true

b. Surgery is appropriate even if patient is in coma.

true (Patient may respond even if in deep coma.)

c. Steroids should be used.

true (Steroids are suggested for cerebellar stroke.)

G7 p.1020:145mm

d. Ventricular drainage should be used.

false (Is to be avoided; it might cause upward herniation.)

e. Incidence of cerebellar infarction is less than 1%.

true (It is seen on 0.6% of all CT scans.)

27. Cerebellar infarction of the

G7 p1021:30mm

a. tonsil implicates the_____

PICA

b. inferior vermis implicates the_____

PICA

c. superior hemisphere implicates the_____

SCA

d. superior vermis implicates the_____

SCA

28. True or False. The following may be a late finding in patients with cerebellar infarctions that may prompt surgical decompression:

G7 p.1021:105mm

a. sixth nerve palsy

true

b. seventh nerve palsy

true

c. worsening headache

true

d. Horner syndrome

false (The late findings in a cerebellar infarction are from hydrocephalus or brain stem compression. Horner syndrome is typically seen with lateral medullary syndrome and is due to an intrinsic brain stem lesion and is not an indication for surgery.)

e. decreased level of consciousness

true

29. Surgical decompression is appropriate if patient develops:

G7 p.1021:105mm

a. True or False. Coma

true

b. True or False. Ataxic respiration

true

c. Loss of lateral gaze implicates_____nerve.

sixth

d. Paresis of face implicates_____ _____.

facial colliculus

e. Confusion and somnolence implicates_____ _____.

hydrocephalus

30. With MCA infarction, consider hemicraniectomy if

G7 p.1022:85mm

a. distribution of infarct is in the_____territory

middle cerebral artery (MCA)

b. age of the patient is_____

under age 70

c. if CVA is on the_____side

right (nondominant)

d. it may reduce mortality from_____to_____%

80 to 30%

31. Demographics of cardiogenic stroke include

G7 p.1022:140mm

a. incidence of_____

1 in every 6 strokes (i.e., ˜17%)

b. after MI_____% in 2 weeks

2.5%

c. anterior wall_____%

6%

d. inferior wall_____%

1%

e. atrial fibrillation_____% per year without treatment

4.5%

f. especially if patient has_____ventriculomegaly

left

g. due to_____ _____

atrial thrombosis

G7 p.1022:165mm

h. heart valve prostheses with anticoagulation

     i. mitral_____% per year

3%

     ii. aortic_____%

1.5%

     iii. without anticoagulation_____% per year

2 to 4%

32. Complete the following about paradoxical embolus:

G7 p.1023:55mm

a. Population incidence of patent foramen ovale is _____%.

10 to 18%

b. In patients with unexplained CVA, the incidence is _____%.

56%

33. Complete the following about a cardiogenic brain embolism:

G7 p.1023:100mm

a. Transformation from bland to hemorrhagic infarct may occur within_____.

2 days (48 hours)

b. Based on what three-step mechanism?

     i. i_____

ischemia

     ii. c_____ l_____

clot lysis

     iii. r_____

reperfusion of the infarcted brain

c. If transformation occurs you can surmise that indeed this large infarction can be attributed to a_____ _____.

cardiac cause

34. Complete the following:

G7 p.1023:145mm

a. What is the only stroke for which anticoagulation is beneficial?

cardiogenic brain embolism

b. What does anticoagulation accomplish regarding further CVAs?

reduces the incidence

c. The natural risk without treatment is_____%.

12%

d. If used, when should anticoagulation be instituted?

not before 48 hours

e. The size of the infarct should be_____.

not a large one

f. Aim for an international normalized ratio (INR) of_____.

2 to 3

g. Coumadin reduces stroke risk in atrial fibrillation by_____%.

66 to 86%

35. True or False. Anticoagulation should be initiated immediately after detection of stroke caused by cardiogenic embolism.

false (After 48 hours is the proper time. Hemorrhagic conversion is more likely to occur with cardiogenic embolic strokes and is most likely to occur within 48 hours of the stroke. A CT scan should be obtained 48 hours after the stroke and before the initiation of anticoagulation.)

G7 p.1023:165mm