3-Ischemia Flashcards
Define ischemic stroke
acute infarction ischemic injury to brain –> persistent focal neuro defect at 24 hrs
Define TIA
ischemic neurological (focal brain or retinal ischemic) deficits completely resolve within 1 hr
Large vessel ischemic stroke deficits correspond with
arterial region supplied by blocked artery
middle cerebral artery stroke causes what?
hemiparesis
hemisensory loss
hemianopsia
ALL CONTRALATERAL TO SIDE OF OCCLUSION
aphasia (dominant)
neglect (non-dominant)
small vessel strokes have what kind of deficits?
mechanism of why?
isolated on one side of body such as isolated motor or sensory loss
occlusion of small penetrating arteries that penetrate brain –> lacunar infarcts
ruptured intracranial aneurysm
most common nontrauamatic cause of ___
subarachnoid hemorrhage
ruptured intracranial aneurysm
presents with
1 o Cataclysmic onset, like a fire cracker
2 o Sudden onset neurological deficits
3 o Headache – “worst headache of my life”
4 o Nausea and vomiting
5 o Depressed level of consciousness
intracerebral (intraparenchymal) hemorrhage
often due to?
commonly occur where?
progresses over how long
hypertension and age
basal ganglia
thalamus
pons
cerebellum
also can have lobar hemorrhage near cortex
progress over few hrs
intracerebral (intraparenchymal) hemorrhage
presents with
1) begin with mild HA
2) some deficit/nausea
3) decr consciousness –> coma
4) hemiparesis –> hemiplegia
subdural hemorrhage
usu due to?
bleed btwn what 2 layers
typically arterial or venous bleed
appearance n imaging
more common at what age?
due to trauma but not always
btwn dura and arachnoid
venous from tearing of bridging veins = low pressure, slow
crescent shape
elderly due to atrophy
subdural hemorrhage
presents with
1) HA, n, v
2) decr eye, verbal, motor responses
3) confusion, LOC, localized weakness
4) speech/vision changes
5) seizures
Epidural hemorrhage
usu due to?
bleed btwn what 2 layers
typically arterial or venous
appearance on imaging
trauma
btwn dura and skull
arterial (fractures –> tear middle meningeal) = high pressure
lens shaped
Epidural hemorrhage
presents with
1) brief decr consciousness or LOC –> coma
2) then lucid interval –> LOC d/t incr ICP
3) N/V/HA
4) seizures
Non-atherosclerotic causes of stroke in young patients
Vasculopathy mechanism
types
Non-inflamm, non-athero hyperplasia of arteries –> weakening
1) fibromuscular dysplasia
2) moyamoya
3) arterial dissection
describe fibromuscular dysplasia
mechanism
assoc with
hypertrophy of arterial media –> segmental occlusion
assoc with saccular aneurysms and arterial dissection
describe moyamoya
mechanism
assoc with
hyperplasia of arterial intima, usu proximal middle cerebral artery and distal internal carotid artery
assoc with saccular aneurysms and arterial dissection
describe arterial dissection
mechanism
assoc with
blood dissect btwn what 2 layers
tear in endothelial lining of artery
assoc with CVD (FMD, marfans)
btwn endothelium and adventitia
Non-atherosclerotic causes of stroke in young patients
hematological = hypercoaglulable states
1) deficiency in prot C, S, antithrombin
2) factor V leiden and prothrombin gene 20210 (decr anticoag products)
3) malignancies
4) sickle cell
5) hyperviscosity (incr prot, HCT, thrombocytopenia)
6) OCT esp smokers
7) antiphospholipid antibodies
Non-atherosclerotic causes of stroke in young patients
inflamm
vasculitis secondary to CNS infections
Non-atherosclerotic causes of stroke in young patients
migraines
via vasospasm or incr platelet aggreg
Non-atherosclerotic causes of stroke in young patients
venous infarction
dehydration –> hypercoag state
Non-atherosclerotic causes of stroke in young patients
vasospasm
1) sympathomimetic drugs
2) severe HTN
3) vessel irritation
most strokes due to
atherosclerotic or thrombotic/embolic occlusion of vessels
major risk factors for atheroscleortic strokes
1) age
2) HTN
3) lipid disorders
4) incr homocysteine
5) smoking
6) obesity
7) DM
8) physical inactivity
9) alcohol abuse
10) cocaine
11) congenital hearts 12) PFO/ASD/VSD
12) CHF, valvular, A-fib, myxoma
how to prevent thrombus formation as way to decr stroke risk or after suffer thrombus ischemic stroke
what is used primarily for small vessel infarcts and also large vessel occlusion or embolization
antiplatelet agents
1) aspirin
2) ticlodipine/clopidogrel/prasugrel
3) ASA/dipyridamole
4) ASA/clopidogrel
anticoag used
what is used for patients with afib or mech heart valve or short term thrombus in artery/dissection to decr risk of stroke
warfarin
procedure to reduce risk in patients with stenosis
carotid endarectomy
what happens in ED for ischemic strokes?
TPA
maintain fluids
maximize cardiac output
maintain BP
treat hypoglycemia
what patients will benefit from tpa and which won’t
benefit = thrombus/embolus
not benefit = vasospastic, vasculopathic, inflamm
basic principles of emergency treatment of ischemic stroke or hemorrhage
1) TPA
2) keep fluids up
3) maximize cardiac ouptut
4) resist temptation to lower BP
how to treat diff factors of stroke
• hypertension -
• hyperlipidemia –
• high homocysteine levels –
- Smoking –
- Obesity –
- Physical inactivity –
- Alcohol abuse
1) HTN = many drugs
2) hyperlipidemia = statins
3) high homocysteine = folate B6, B12
4) smoking = stop
5) obesity = dietary/lifestyle
6) physical inactivity = lifestyle mod
7) alcohol abuse = stop
how to treat • Lumen stenosis – • Cardiac issues – • Atrial septal defects - • Atrial Myxomas – cardiac tumors can increase risk of embolus –
- Lumen stenosis – can be repaired surgically or via IV catheter
- Cardiac issues – A-fib, CHF, valve disorders increase risk of embolus - treat with warfarin
- Atrial septal defects – can be repaired or treated medically to prevent embolus
- Atrial Myxomas – cardiac tumors can increase risk of embolus – remove
do you take asa after a stroke
no because can’t tell if ischemic or hemorrhagic stroke
deep vs lobar intracerebral hemorrhage
locations
deep = basal ganglia, thalamus, pons, cerebellar
lobar = frontal > parietal > occipital > temporal
deep vs lobar intracerebral hemorrhage
major causes
deep = HTN, age lobar = amyloid angiopathy, age, dementia, coagulopathy (HTN 1/3)
deep vs lobar intracerebral hemorrhage
outcomes
deep = poor lobar = well tolerated
pontine intracerebral hemorrhage assoc with
locked in syndrome
cortex is preserved so cognition
but relay in pons destroyed —> quadriplegic
and no facial but still have vertical eye reflex
most common cause of subarachnoid hemorrrhage
trauma
describe brain aneurysm
difference btwn saccular and fusiform aneurysm
weak bulge in brain artery –> wall thinner and swells outward
saccular = branch points fusiform = less likely to rupture
most common sites of brain aneurysm
ACom
PCom
subarachnoid hemorrhage
symptoms
sudden severe HA
sometimes focal deficit
altered LOC
–> arterial bleed = can dissect into brain tissue but usu no deficit
risk factors for subarachnoid hemorrhage
smoking HTN --> risk for aneurysm formation women FHx aneurysm/SAH ADPKD Ehlers, danlos marfan fibromuscular dysplasia
complications of SAH
1) rebleed
2) hydrocephalus
3) vasospasm 94-14 d)
4) cerebral salt wasting
arteriovenous malformation
define
risk for what type hemorrhage
presentation
1) abnormal connection btwn artery and vein w/o capill bed
2) IVH, SAH
3) hemorrhage, incidental, seizure
risk factors for AVM
1) age
2) prior hem
3) deep
4) exclusive deep drainage
5) size doesn’t predict
causes of small vs large vessel stroke
small = lipohyalinosis large = embolic
etiology of stroke
pipes
pump
passengers
vessels
heart
platelets
young stroke patient think of what?
dissection of artery –> occlusion or creating embolus to brain
legs (numbness, weakness); no pain; sudden onset
numbness and weakness (more in arms and face than legs usu symm); gaze preferences and aphasia
vision loss and Wernicke’s aphasia
high chance of causing coma
ACA
MCA
PCA
basilar
Gerstmann’s syndrome features
acalculia
left-right disorientation
finger agnosia
agraphia
CT negative neuro deficits
sudden onset, slow improve sudden onset, rapid improve minute onset, rapid improve sudden onset, slow improve, LOC slow onset,
sudden onset, slow improve = stroke
sudden onset, rapid improve = TIA
minute onset, rapid improve = migraine
sudden onset, slow improve, LOC = seizure
slow onset = MS
symptoms of small vessel strokes
hemiparesis
hemisensory loss
subcortical or lacunar stroke symptoms
1) pure motor hemiparesis
2) hemi sensory loss
3) mixed motor sensory
4) clumsy hand dysarthria
5) ataxia hemiparesis (should not have but cerebellar fibers cross twice)
face + arm + leg symm
acute onset
common features of vasculopathies
young age female lesion any portion of vessel pseudoaneurysm saccular aneurysm 10% familial
symptoms started 1 hr ago
tpa used in acute stroke for 3-4.5 hrs
intraarterial treatment
IA = tPA
or mech retrieval for PENUMBRA or Merci
after given tPA NIHSS high what else to do
MERCI or penumbra or solitaire (stent retriever)
