420 Ischemic Stroke Flashcards by Medicine Katorse

decrease in the cerebral blood flow to zero causes death of brain tissue within how many minutes

4-10 mins

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defined as the ischemic but reversibly dysfunctional tissue surrounding a core area of infarction

ischemic penumbra

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goal of revascularization therapies

saving the ischemic penumbra

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two distinct pathway of focal cerebral infarction

necrotic and apoptotic pathway

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what is necrotic pathway

which cellular cytoskeletal breakdown is rapid due to principally to energy failure of the cell

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what is apoptotic pathway

which cells become programmed to die

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how does ischemic lead to necrosis

ischemia produces necrosis by starving neurons of glucose and oxygen which in turn results in failure of mitochondria to produce ATP

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what is the first goal in the management of acute ischemic stroke

the first goal is to prevent or reverse pain injury; ABCs, treat hypoglycemia and hyperthermia

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what is the main 6 treatment modality in the management of acute ischemic stroke

medical support, IV thrombolysis, endovascular revascularization, antithrombotic treatment, neuroprotection, stroke rehabilitation

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conditions wherein blood pressure is lowered in cases of acute ischemic stroke

blood pressure should be reduced if exceed 220/120 mmHg if there is malignant hypertension or concomitant myocardial infarction; of if BP is more than 185/110 mmHg and thrombolytic therapy is anticipated

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true or false. Fever is detrimental in acute ischemic stroke and should be treated with antipyretics and surface cooling

true.

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what is the target serum glucose and how is hyperglycemia managed?

serum glucose should be monitored and kept below 10 mmol or 180 mg/dl and above 3.3 mmol or 60 mg/dl; elevated blood glucose is managed with insulin

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When does cerebral edema peak in ischemic stroke?

edema peaks on the second and third day but can cause mass effect for about 10 days

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True or false. The larger the infarct the greater the likelihood that clinically significant edema will develop

true.

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predictor of deterioration requiring hemicraniectomy

size of the diffusion- weighted imaging volume of brain infarction during the acute stroke

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vertigo, vomiting, neck or head pain should alert physician to what type of stroke

cerebellar stroke

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recommended in patients with cerebellar stroke

suboccipital decompression is recommended in patients with cerebellar infarcts who demonstrate neurological deterioration and should be performed before significant brainstem compression occurs

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how to give rtPA

0.9 mg/kg (max of 90 mg) to give 10% as bolus and the remaining as IV drip over 60 mins

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what is the rtpa dose for Japanese and other Asian countries

0.6 mg/kg

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True or false. Occlusions in such large vessels as the MCA, intracranial internal carotid artery, and the basilar artery may generally involve a large clot volume and often fail to open with IV rtPA alone

true.

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what did the PROACT Trial II say

Trial found benefit in intraarterial prourokinase in acute MCA occlusions up to the sixth hour following onset of stroke

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alternative or adjunctive treatment of acute stroke patient who are ineligible to have contraindication to rTPA

endovascular mechanical thrombectomy

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true or false. Endovascular therapy improved clinical outcomes for internal carotid and MCA occlusions under 6 hours with or withou pre treatment with rTPA

True.

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time of vessel opening associated with good prognosis

vessel opening 1 hour of arrival

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time of vessel opening associated with poor prognosis

vessel opening 6 hours of arrival

when can revascularization beyond 6 hours be of benefit

extending time window beyond 6 hours appears to be effective if the patient has specific imaging findings demonstrating good vascular collaterals

is the only antiplatelet agent that has been proven to be effective for the acute management of ischemic stroke

aspirin

true or false.routine use of heparin or other anticoagulants for patients with atherothrombotic stroke is not warranted

True

concept of providing a treatment that prolongs the brain tolerance to ischemia

neuroprotection

two conditions which should be sought out in acute ischemic stroke as these two conditions have proven secondary prevention strategies

atrial fibrillation and carotid atherosclerosis

responsible for 20% of all ischemic stroke

cardioembolic

embolic from the heart often lodge in which vessels

emboli from the heart often loge in the intracranial internal carotid artery, the MCA, the posterior cerebral artery

most significant cause of cardioembolic stroke in most the world

nonrheumatic or nonvalvular atrial fibrillation

what is the presumed stroke mechanism in atrial fibrillation

thrombus formation in the fibrillating atrium or atrial appendage with subsequent embolization

additional risk factor for formation of atrial thrombi

left atrial enlargement

when does rheumatic heart disease cause stroke

when there is prominent mitral stenosis or atrial fibrillation

true or false. Mitral valve prolapse is not a source of emboli unless the prolapse is severe

True

which type of MI may be a source of emboli

transmural, involving the anteroapical ventricular wall

what is a paradoxical emboli

occurs when a venous thrombus migrate to the arterial circulation via a patent foramen ovale or atrial septal defect

diagnostic test that can show the conduit for paradoxical embolization

bubble contrast echocardiography

how is bubble contrast echocardiography done

IV injection of agitated saline coupled with transthoracic or transesophageal echocardiography

how is artery to artery embolic stroke produced

thrombus formation on atherosclerotic plaques may embolize to intracranial arteries producing an artery to artery embolic stroke

in the carotid artery, where is the most common site of atherosclerosis

atherosclerosis within the carotid artery occurs most frequently within the common carotid bifurcation and proximal internal carotid artery

produces stoke either by an embolic mechanism or by in-situ thrombosis of a diseased vessel. It is more common in patients of Asian and African- American descent

intracranial atherosclerosis

common source of embolic stroke in young age 60 years old and below

dissection of the internal carotid or vertebral arteries or even vessels beyond the circle of Willis

infarction following atherothrombotic or lipohyalonotic occlusion of a small artery in the brain

lacunar infarction or small vessel stroke

what is small vessel stroke

denotes occlusion of such a small penetrating artery

true or false. Small vessel stroke accounts for 50% of all strokes

false. Small vessel stroke accounts for about 20% of all strokes

principal risk factors for small vessel stroke

hypertension and age

Four most common small vessel stroke syndrome

pure motor hemiparesis; pure sensory stroke, ataxic hemiparesis, dysarthria and a clumsy hard

less common cause of stroke. Primarily increase the risk of cortical vein or cerebral venous sinus thrombosis

hypercoagulable state disorders

less common cause of stroke. Occurs as a complication of oral contraceptive use, pregnancy and the postpartum period, IBD

venous sinus thrombosis

common sites of venous sinus thrombosis

lateral or sagittal sinus or of small cortical veins

most common cause of stroke in children

sickle cell anemia (SS disease)

less common cause of stroke. Affects the cervical arteries and occurs mainly in women. Carotid or vertical arteries show mulitple rings of segmental narrowing alternating with dilatation

fibromuscular dysplasia

true or false. Vascular occlusion is usually incomplete in fibromuscular dysplasia

true.

True or false. Renal artery involvement in fibromuscular dysplasia is common and may cause hypertension

true.

less common cause of stroke. Temporal arteries undergo subacute granulomatous inflammation with giant cells

temporal arteritis

True or false. Temporaly arteritis often cause stoke because it leads to internal carotid thrombosis.

False it rarely cause stroke because the internal carotid are not inflammed.

idiopathic giant cell arteritis involving the great vessels arising from the aortic arch that may cause carotid or vertebral thrombosis

Takayas's arteritis

drugs that can leads to stroke

amphetamines and cocaine

how does this drugs lead to stroke

acute hypertension or drug induced vasculopathy

occlusive disease involving large intracranial arteries especially the distal internal carotid artery and the stem of the MCA and ACA. Vascular inflammation in absent. The lenticulostriate arteries develop a rick collateral circulation around the occlussive disease given an impression of puffed smoke on conventional x-ray angiography

Moyamoya disease

occurs as a result of hyperperfusion state where blood pressure exceeds the upper limit of cerebral autoregulation resulting in cerebral edema

posterior reversible encephalopathy syndrome

what is the MRI finding in PRES

edema present in the occipital lobes but can be generalized and do not respect any single vascular territory

refers to multiple small vessel infarcts within the subcortical white matter

leukoaraiosis or periventricular white matter disease

what is the typical MRI findings of periventtricular white matter disease

white matter injury surrounding the ventricles and within the corona radiata

what is the pathophysiology of periventricular white matter disease

lipohyalinosis of small penetrating arteries within the white matter likely produced of chronic hypertension

inherited disorder that presents as small vessel strokes, progressive dementia, and extensive symmetric white matter changes often including the anterior temporal lobes visualized by MRI

cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy (CADASIL)

what is the genetic mutation in CADASIL

mutations in Notch-3

episodes of stroke symptoms that last only briefly duration is less than 24 hours

transient ischemic attack (TIA)

in patients with TIA, when does stoke most commonly occur

most stroke events occur in the first 2 days

what does the POINT study say regarding management of TIA

aspirin plus clopidogrel is better than aspirin alone for 21 days in preventing stroke

most significant risk factor for stroke

hypertension

most effective strategy for primary and secondary stroke prevention

diabetes prevention

irreversibly inhibits formation in platelets of thromboxane A2

aspirin

block ADP receptors on platelets thus prevent the cascade resulting in the activation of glycoprotein IIb/IIIa receptor

clopidogrel and ticlopidine

how was POINT trial done

Clopidogrel 300 mg then clopidogrel 75 mg OD plus aspirin 80 mg OD x 21 days

what does the ARISTOTLE trial say

Apixaban 5 mg BID is non inferior to warfarin in stroke prevention

what does the ROCKET-AF trial say

Rivaroxaban 20 mg OD is non inferior to warfarin in stroke prevention

true or false. Intermittent atrial fibrillation carries the same risk of stroke as chronic atrial fibrillation

true.

what did the WARRS trial show

there is no benefit of warfarin over aspirin for secondary stroke prevention

what is the WASID trial show

no benefit of warfarin over aspirin in patients with symptomatic intracranial athersoclerosis

what did the NASCET trial show

benefit of surgery in patients with carotid stenosis of more than 70%

what do the ACAS and ACST recommend regarding carotid artery disease

asymptomatic carotid disease patients with more than 60% stenosis needs medical treatment with aspirin and carotid endarterectomy

what is the natural history for stroke in patients with carotid artery disease

asymptomatic carotid stenosis have a 2% risk for stroke per year while symptomatic carotid stenosis have a 13% risk of stroke

what did the SAPPHIRE trial show

stenting is at the very least comparable to endartectomy as treatment option for patient at high risk of surgery

what the CREST trial show

carotid endarterectomy and stenting showed relative equivalence of risk between procedures