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1. Clin Med III > 3- Cerebrovascular Disease > Flashcards

3- Cerebrovascular Disease Flashcards

1
Q

What is the leading cause of disability and 5th leading cause of death in the US?

A

CVA

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2
Q

A stroke is the acute neurologic injury that occurs as a result of one of which 2 pathologic processes?

A

Hemorrhage

Ischemia (more common)

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3
Q

What are the 3 causes of brain ischemia?

A

Thrombosis, embolism (ex. a fib, carotid artery plaques), hypoperfusion

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4
Q

Pt presents with sxs of brain dysfunction that are diffuse and nonfocal, bilateral neurologic signs, and evidence of circulatory compromise with hypotension. You are concerned for ischemic stroke caused by what?

A

Hypoperfusion

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5
Q

What type of CVA is secondary to low flow states from vessel overlap or systemic hypotension?

A

Watershed infarcts

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6
Q

What type of hemorrhage is bleeding directly into brain tissue?

A

Intracerebral

(aka parenchymal)

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7
Q

What type of hemorrhage is bleeding into the CSF that surrounds the brain and spinal cord?

A

Subarachnoid

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8
Q

CT of pt with suspected CVA shows a hypodense (darker) area of brain tissue. Are you concerned for hemorrhagic or ischemic stroke?

A

Ischemic

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9
Q

CT of pt with suspected CVA shows a radiopaque/white area. Are you concerned for hemorrhagic or ischemic stroke?

A

Hemorrhagic

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10
Q

A large vessel stroke can be within either the anterior circulation or posterior circulation. What vessels contribute to the anterior circulation? (4)

A
  • Carotid arteries (extra/ intracranial)
  • Middle cerebral artery (MCA)
  • Anterior cerebral artery (ACA)
  • Anterior communicating artery (AComm)
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11
Q

A large vessel stroke can be within either the anterior circulation or posterior circulation. What vessels contribute to the posterior circulation? (4)

A
  • Vertebral arteries (extra/ intracranial)
  • Posterior cerebral artery (PCA)
  • Posterior inferior cerebellar artery (PICA)
  • Basilar artery
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12
Q

What is the most common affected vessel in a CVA?

A

Middle cerebral artery

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13
Q

Pt presents with contralateral hemiplegia/ hemianaesthesia (weakness/ numbness) of the face + arm > leg. You note contralateral homonymous hemianopia and a faze preference to the ipsilateral side. Where are you concerned for CVA?

A

Middle cerebral artery (MCA)- affects frontal, temporal, parietal lobes

(large vessel, anterior circulation)

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14
Q

What will be noted if dominant vs non-dominant hemisphere is involved in CVA of MCA? (large vessel, anterior circulation)

A

Dominant: global aphasia

Non-dominant: hemineglect

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15
Q

Pt presents with contralateral hemiplegia/ hemianaesthesia (weakness/ numbness) of the leg > arm. You note profound abulia or perseverating speech. Where are you concerned for CVA?

(abulia- delay in verbal/ motor response)

A

Anterior cerebral artery (ACA)- affects frontal pole/ lobe

(large vessel, anterior circulation)

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16
Q

Pt presents with visual field defects due to impingement of cranial nerves. Where are you concerned for CVA?

A

Anterior communicating artery (AComm)

(large vessel, anterior circulation)

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17
Q

Pt presents with contralateral homonymous hemianopia and reduced light touch/ pinprick sensation. Where are you concerned for CVA and why is this type of CVA concerning?

A

Posterior cerebral artery (PCA)- affects occipital cortex

Concerning b/c may go unnoticed by pt due to minimal motor involvement

(large vessel, posterior circulation)

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18
Q

Pt presents with ipsilateral loss of facial pain/ temp sensation with contralateral loss of these senses over the body +/- vertigo, vomiting, nystagumus, ipsilateral ataxia, hoarseness, dysarthria, dysphagia, hiccupts, and ipsilateral Horner’s syndrome. Where are you concerned for CVA?

(Horner’s- ptosis/ miosis w/o anhidrosis)

A

Posterior inferior cerebellar artery (PICA)- affects lateral medulla

(Wallenberg’s/ lateral medullary syndrome)

(large vessel, posterior circulation)

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19
Q

Pt presents with quadriplegia and facial/ mouth/ tongue weakness, preserved consciousness, and preservation of vertical eye movements/ blinking. Where are you concerned for CVA?

A

Basilar artery

(sxs = “locked-in syndrome”)

(large vessel, posterior circulation)

20
Q

What type of CVA is due to occlusion of one of the small, penetrating branches of the Circle of Willis, middle cerebral artery stem, or vertebral/ basilar arteries and is commonly a/w chronic HTN?

A

Small vessel (“Lacunar”) stroke

21
Q

What may be necessary during initial assessment in CVA due to increased ICP?

A

Intubation

(if decreased respiratory drive/ decreased level of consciousness)

22
Q

What is usually elevated in patients with acute stroke and often represents an appropriate response to maintain brain perfusion?

A

MAP

23
Q

When should you start treating BP for ischemic stroke?

A

> 220/120

24
Q

What are the BP guidelines for hemorrhagic stroke?

A

Keep < 160/ 90, but systolic > 140

25
Q

What is the most important hx question when evaluating for CVA?

A

When did the sxs start?

(should also r/o problems that could mimic stroke, ex. hypoglycemia)

26
Q

What is the 1st dx test in the assessment of stroke?

A

Non-contrast CT brain

27
Q

Does a CT for a hemorrhagic or ischemic CVA have the potential to be normal?

A

Ischemic (takes time to be evident on CT)

28
Q

When would an ischemic CVA be clinically diagnosed?

A

Sxs present for < 6 hrs

Affected area is small

Located in area of brain not well seen on CT

29
Q

In addition to ICU admission, what is the tx for ischemic CVA if brain CT returns showing no bleed?

A

Full dose aspirin w/i 48 hrs

tPA w/i 60 minutes- if sx onset < 4.5 hours and BP must be ≤ 185/110

30
Q

If CT of pt with suspected ischemic CVA shows ischemia (acute hypodensities), what tx is contraindicated?

A

tPA- sxs have been going on too long

31
Q

What tx might be utilized for patients with acute ischemic stroke caused by an intracranial large artery occlusioin in the proximal anterior circulation?

A

Mechanical thromebectomy (if w/i 6 hrs of sxs onset)

32
Q

In addition to ICU admission and immediate neurosurgery consult, what is the tx for hemorrhagic CVA?

A

D/c + reverse anticoagulants/ antiplatelet drugs

Lower ICP

Control BP (~160/90)

Antiepileptics (prn)

(methods for lowering ICP: elevate head of bed, analgesia, sedation, osmotic diuretics, drain CSF (bolt), NM blockade, hyperventilation)

33
Q

In the management of hemorrhagic CVA, what are the indications for immediate surgical consult/ removal of hemorrhage?

A

Cerebellar hemorrhages > 3cm

Deteriorating/ brain stem compression

Hydrocephalus

34
Q

What is included in secondary prevention of CVA?

A

Tx underlying + antiplatelets for ischemic

35
Q

TIA is defined as a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia WITHOUT what?

(sxs do not have to be focal)

A

Acute infarction (tissue damage)

36
Q

TIA places pt at increased risk for stroke. What testing/ therapy lessens this risk?

A

Hospital admission, EKG, carotid US, lipid lowering/ antihypertensive meds, diet/ lifestyle mod, start daily aspirin therapy +/- CTA of head and neck

37
Q

If a pt is on a daily aspirin + meds for controllable RFs and still suffers a TIA, discussion with neurology might indicate addition of what?

A

Clopidogrel or aspirin-extended-release dipyridamole

38
Q

Pt w/ no hx of HAs presents with sudden onset (“thunderclap”) worst HA of their life (WHOL) and has become somnolent. What are you concerned for and what urgent imaging is indicated?

A

Subarachnoid hemorrhage (SAH)

Non-contrast brain CT

39
Q

Most SAHs are caused by what?

A

Ruptured saccular aneurysms

(although most aneurysms do not rupture)

40
Q

What are 2 more important RFs a/w SAH?

A

Hx of polycystic kidney disease

Smoking (biggest preventable RF)

41
Q

What is the pathogenesis of SAH?

A

Rupture of aneurysm releases blood into CSF leading to increased ICP

42
Q

What are the common complications a/w SAH that contribute to mortality?

A

Re-bleeding (w/i 1st day)

Vasospasm (no earlier than day 3 and peaks at day 7)

43
Q

If RBCs are present in CSF, there is either true SAH or traumatic tap. How are these differentiated?

A

True SAH- RBC #’s stay the same from 1st - 4th tube

Traumatic tap- RBC #’s decreased from 1st - 4th tube

44
Q

What is the most sensitive indicator of SAH?

A

Xanthochromia- pink or yellow tint of CSF

(compare vial of CSF with vial of plain water)

45
Q

Pt with suspected SAH has normal non-contrast CT brain results. What should be your next step?

A

LP +/- CTA of COW

46
Q

In addition to ICU admission, control of ICP, seizure prophylaxis, and d/c blood thinners, what is the management for SAH?

A

Analgesia (prevent rebleeding)

Transcranial doppler (TCD) US (monitor for vasospasm)

IV fluids + nimodipine (prevent vasospasm)

Definitive: surgical clipping or endovascular coiling

47
Q

Are the consequences of traumatic SAH or spontaneous SAH generally more severe?

A

Spontaneous

1. Clin Med III (29 decks)

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