2c. Cerebrovascular Accidents (CVA) / Stroke Flashcards
What is a CVA or stroke?
Cerebrovascular accident = a focal neurological disorder of abrupt development due to the obstruction of an artery > the brain will be deprived from oxygen and nutrients > leading to irreversible brain damage/cell death
Wat does FAST mean?
Face drooping
Arm/leg weakness
Speech difficulty
Time for 112
What 2 types of strokes are there and what are causing them?
- Obstructive/ischemic stroke (iCVA) = caused by a narrowing or blockage of the blood vessels in the brain
- Hemorrhagic stroke (hCVA) = caused by a rupture of a weakened blood vessel in the brain
What 2 types of blood clots are there and where are they formed?
- Thrombus = blood clot that forms in a healthy artery in the brain
- Embolism = blood clot that forms elsewhere in the body
What are causes of weakened blood vessels (causing hCVA)? (2x explained, 4x extra)
- Hypertension = longtime exposure to high blood pressure (50%)
- Arteriovenous malformation = poorly formed blood vessels
- Brain tumors
- Inflammation
- Coagulation disorders
- Trauma
Ischemia
What is a stenosis?
Due to the process of atherosclerosis a gradual build-up of fat deposits forms. It occurs mostly in the smaller, deeper perforating arteries.
Ischemia
What is an embolism?
A bloodclot that loges a narrowed artery.
Ischemia
What is thrombolysis?
This is injecting a powerful drug into the bloodstream to disperse a bloot clot in a blood vessel. It is performed fast after an infarct.
Reversible conditions after embolism
What is a ‘Transient Ischemic Attack’ (TIA)?
If the neurological deficits dissapear within a short period of time (usually less than 45 min). There is no evidence of infarction on a CT scan.
Reversible conditions after embolism
What is a ‘Cerebral Infarction with Transient Signs’ (CITS)?
Here, the symptoms last longer than 45 min, but compared to a full stroke, less than 24 hours. Here, there is evidence of recent infarction on a CT scan
What is a deep intracerebral hemorrhage?
This type occurs in the area of the basal nuclei, usually as a result of the rupture of smaller arteries caused by the effect of longtime exposure to high blood pressure.
It’s the most common hemorrhage.
What is a lobar intracerebral hemorrhage?
This type we see more in the elderly, and is far more superficial, caused by amyloid angiopathy.
What is a subarachnoid hemorrhage (SAH)?
This type does occur in the space between the meninges surrounding the brain, mostly caused by a rupture (aneurysm) at or near the circle of Willis.
It causes a sudden and extremely severe headache followed by neck stifness (some patients are traumatized by this)
What is a hemorrhagic infarct?
A combination of infarction and bleeding, associated with a very high mortality rate.
What is an aneurysm?
A weak area in a vessel wall which eventually causes a balloon shaped belch that can rupture.
What is diaschisis?
A disturbance or loss of function in one part of the brain due to a localized injury in another part.
What are the cognitive alterations mainly related to in a hemorrhage?
Cognitive problems are mainly related to the resulting hematoma that leads to intercranial pressure and edema (swelling), so SIZE and SECONDARY effects
When the hematoma has dissapeared, a bit of normal functioning may be restored
What are the cognitive alterations mainly related to in an ischemia?
Impairment is primarily caused by the infarct itself, so here, LOCATION is of major importance. Also, damage to more remote areas is possible and this is the result of “diaschisis” > the connection with the remote area can be broken
What arteries form the circle of Willis? (3x)
- Carotid arteries
- Vertebral arteries
- Basilar arteries
What is collateral circulation?
When one of the main arteries is occluded, the distal smaller arteries can still receive blood from the other arteries
Where does the arteria cerebri anterior (ACA) supplies blood to? (3x)
Frontal lobe
Frontal-basal structures
Part of the parietal lobe
Where does the arteria cerebri media (MCA) supplies blood to?
Temporal lobe
Larger part of the parietal lobe
Basal ganglia
Part of the frontal lobe
80% of the cases an infarct affects this artery
Where does the arteria cerebri posterior (PCA) supplies blood to?
Occipital lobe
Posterior part of the temporal lobe
Thalamus
Most mentioned cognitive changes…
Right-side? (3x)
Left-side? (3x)
Right-side: hyperemotionality, more listless, more self-centered
Left-side: hyperemotionality, impairment in memory, mental slowness
What are the 3 general cognitive domains that are impaired in patients with a CVA?
- Memory
- Attention
- EF
General cognitive impairments CVA: Memory
When impairment?
And what is mostly affected?
When?
Mostly after infarct of the MCA, when the medial temporal lobe is affected (hippocampus) and more apparent when on the left-side.
What?
- Declarative/explicit memory mainly affected, procedural/implicit memory remains quite unaffected.
General cognitive impairments CVA: Attention
What is mostly affected?
Mostly mental slowness and loss of concentration
- Basic attentional processes: attention cannot be hold when not stimulated, patients wander off or fall asleep. Also, problems in arousal.
Where? These basic functions originate in the subcortical structures - Complex attentional processes: difficulties with focusing for a longer period of time, easily distracted, difficulties doing 2 things at a time.
Where? Parietal temporal lobes and prefrontal cortex
General cognitive impairments CVA: EF
When impairment?
What is mostly affected?
When?
Mostly after infarct of the ACA (prefrontal cortex), but also the cerebellum plays an important role
What?
EF largely determines the patients ability to learn and function independently > so difficulties in initiating behavior, maintaining orders in EF tasks, monitoring own behavior, and problems of awareness of their illness
What are common impairments in a left hemisphere CVA?
- Physical/neurological
- Cognitive
- Behavioral
- Hemianopsia and hemiparesis on the right side
- Language disorders are most marked in this area
- Patients often feel handicapped and behave generally carefull and cautious, also catastrophic reactions, depression
Impairments left CVA
What is mixed/global aphasia?
Inability to speak or understand others (combi of Wernicke’s and Broca’s aphasia) > MCA
Impairments left CVA
What is transcortical aphasia?
Patients are unable to communicate verbally or process written language > infarct of the ACA > communication between Broca and Wernicke is prevented
Impairments left CVA
What is (ideomotor) apraxia?
The concept of movements and motor/sensory abilities are intact, but inability to make meaningful movements, e.g. using a fork and knife during dinner (MCA)
Impairments left CVA
What is alexia?
Inability to comprehend written words
Impairments left CVA
What is agraphia?
Inability to write
Impairments left CVA
What is acalculia?
Inability to perfrom arithmetic operations
Impairments left CVA
What is agnosia?
Inability to recognize/understand visual stimuli (PCA)
What are common impairments in a right hemisphere CVA?
- Physical/neurological
- Cognitive
- Behavioral
- Hemianopsia and hemiparesis on the left side
- Visual and spatial problems are far more prominent
- Left sided CVA patients have more prominent cognitive disturbances, but they often do better at daily functioning than right sided patients
Impairments right CVA
What cognitive disorders? (6x)
- Agnosia (PCA)
- Prosopagnosia (PCA)
- Neglect (MCA)
- Spatial/visuoconstructive tasks
- Aprosodia
- Problems with body perception
Impairments right CVA
What is aprosodia?
Inability to express or understand the emotive content of spoken language
Impairments right CVA
What is finger agnosia?
Incapable of naming/recognizing fingers of your own hand (parietal lobe)
Impairments right CVA
What behavioral disorders? (4x)
- Social cognition
- Anosognosia
- Anosodiaphoria
- Impulsivity
Impairments right CVA
What is anosognosia?
Lacking awareness of your condition
Impairments right CVA
What is anosodiaphoria?
Failure to appreciate the significance of the condition (indifference towards the condition)
Impairments right CVA
What are problems in social cognition?
Problems with recognition of emotions, impairment of understanding social situations
Anosognosia vs. denial: name 3 differences
- Anosognosia is a neurological condition caused by a brain lesion, denial is more a psychological process.
- Patients with anosognosia often show perplexity or indifference when given feedback, in denial often resistance and angry reactions.
- Patients with anosognosia are more stable in their manifestations, denial patients are less stable.
Other consequences of CVA? (2x)
- Fatigue: in more than 50%
2. Depression: 1/3 suffer from depression
It’s not always easy to recognize depression after stroke, because … (3x)
- Patients do not always have the ability to express themselves properly.
- Apathy, less initiative, and problems in emotion regulation can also be direct consequences of a stroke.
- There is much debate as to whether depression is caused by stroke itself (vascular depresson) or a reaction to a life-threathening event (reactive depression)
