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neuro > A17. Diagnostic procedures in cerebrovascular disorders > Flashcards

A17. Diagnostic procedures in cerebrovascular disorders Flashcards

1
Q

Cerebrovascular disorders epidemiology

A

are the third most common causes of death in the western world, after heart disease and cancer.

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2
Q

Cerebrovascular disorders include

A
  • all disorders in which an area of the brain is temporarily or permanently affected by ischemia or hemorrhage , and
  • one or more of the cerebral blood vessels are involved in the pathological process
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3
Q

Stroke types

A

Ischemic stroke (85%)
● Thrombotic (atherosclerotic)
● Embolic
● Haemodynamic
● Lacunar

Hemorrhagic stroke (15%)
● Subarachnoid (SAH)
● Intracerebral (ICH)

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4
Q

which stroke is more common

A

85% of strokes are ischemic, and
only 15% are hemorrhagic

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5
Q

List ischemic strokes

A

● Thrombotic (atherosclerotic)
● Embolic
● Haemodynamic
● Lacunar

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6
Q

List Hemorrhagic strokes

A

● Subarachnoid (SAH)
● Intracerebral (ICH)

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7
Q

Diagnostic procedures done in all patients suspected of cerebrovascular disorders

A

● Neuroimaging (CT or MRI)

● ECG (should not delay imaging or thrombolysis)

● Lab tests:
blood count,
INR,
serum electrolytes,
blood glucose,
CRP,
hepatic and renal functions

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8
Q

Neuroimaging incase of suspected cerebrovascular disorders.

A

(CT or MRI

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9
Q

Stroke protocol
what to do If suspected stroke patient

A
  1. ABCDE (remember glucose - hypoglycemia can mimic acute stroke!)
  2. Blood samples (urgent: Glucose, INR) and blood pressure is taken
  3. GCS, NIHSS: neurological screening assessment
  4. ECG (should not delay CT/MRI)
    (Point 1-4 is usually performed simultaneously (nurses, doctors, neurologist work at same time)
  5. CT or MRI (should be interpreted within 45 minutes)
  6. Thrombolysis (rtPA) considered if within therapeutic window (e-learning: 6 hours, internet: 4,5
    hours) and no contraindications
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10
Q

why do we check glucose in suspected stroke patient

A

hypoglycemia can mimic acute stroke

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11
Q

what do CT or MRI exclude

A
  • Primarily to exclude hemorrhage, but
  • also to visualize intracranial large vessel occlusion
  • and extent of irreversible damage

○ Hemorrhage: consult neurosurgeon
○ Ischemia: candidate for thrombolysis (exclude contraindications)

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12
Q

what to do incase patient who has hemorrhage stroke

A

consult neurosurgeon

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13
Q

what to do incase patient who has ischemic stroke

A

candidate for thrombolysis (exclude contraindications

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14
Q

therapeutic window of stroke thrombolysis (rtPA)

A

e-learning: 6 hours, internet: 4,5
hours)

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15
Q

rtPA stands for

A

Recombinant tissue plasminogen activators

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16
Q

what is mandatory to image within the therapeutic time window

A

■ Brain parenchyma (non-contrast CT or MRI)

■ Extra- and intracranial vessels ( CT- or MR angiography)

● If CTA or MRA cannot be performed, Doppler US might be a solution in order to detect intracranial vessel occlusion

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17
Q

brain parenchyma can be imaged by

A

■ Brain parenchyma
(non-contrast CT or MRI)

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18
Q

Extra- and intracranial vessels can be imaged by

A

( CT- or MR angiography)

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19
Q

what imaging can be used to detect intracranial vessel occlusion
If CTA or MRA cannot be performed

A

Doppler US might be a solution in order to detect intracranial vessel occlusion

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20
Q

what to do If unsure about therapeutic window - e.g in wake-up-strokes

A

■ DWI-FLAIR mismatch: if ischemia is seen on DWI, but not on FLAIR, it means that the stroke still is in the therapeutic window and can receive thrombolytic
therapy.
■ DWI-PWI mismatch: DWI shows infarct core, while PWI shows hypoperfused
tissue, and hence this mismatch shows the salvageable tissue (penumbra)

21
Q

In DWI-FLAIR mismatch what does it mean if ischemia is seen on DWI, but NOT on FLAIR,

A

it means that the stroke still is in the therapeutic window and can receive thrombolytic therapy.

Fluid attenuated inversion recovery

22
Q

In DWI-PWI mismatch: what does it mean when DWI shows infarct core, while PWI shows hypoperfused
tissue

A

hence this mismatch shows the salvageable tissue (penumbra)

23
Q

what is mandatory before thrombolysis

A

● Hypoglycemia (glucose): can mimic acute stroke
● Coagulopathies (INR): CI of thrombolysis (should be under 1,7 to perform)
● Blood pressure (BP): hypertension increase hemorrhagic risk of thrombolysis
○ Hemorrhagic stroke: should be under 140 mmHg
○ Ischemic stroke:
■ Hyperacute phase: treat only if above 220 mmHg
■ If thrombolysis performed: treat if above 185 mmHg

24
Q

before thrombolysis in hemorrhagic stroke blood pressure should be

A

under 140 mmHg

25
Q

when do we treat hypertension in ischemic stroke

A

■ Hyperacute phase: treat only if above 220 mmHg

■ If thrombolysis performed: treat if above 185 mmHg

26
Q

what should be done Urgently, but should not delay thrombolysis

A

● ECG
● Blood count with plt (severe thrombocytopenia/anemia are CI for thrombolysis)
● Electrolytes

27
Q

Diagnostic considerations in cerebrovascular diseases

A

● Presence of clinical signs (WHO)
● Hemorrhagic vs. ischemic (CT, MRI)
● Pathomechanism (thrombotic, embolic, hemodynamic, small vessel disease)
● Duration of signs
● Brain region (hemisphere, cerebellum, brainstem; territorial-borderzone)
● Anterior-Posterior
● Supplying vessel (carotid artery, vertebrobasilar, lacunar, ACA, MCA, PCA)

● Prognostic by signs (Bamford – OCSP)
○ TACI, PACI, POCI, LACI

● Etiology - TOAST
○ Large vessel atherosclerosis
○ Small vessel occlusion (lacuna)
○ Cardioembolism
○ Other determined cause
○ Unknown cause

28
Q

4 questions to think/ask about in cerebrovascular diseases

A
  1. Is it a neurological disease?
  2. If yes, where is the lesion?
  3. What pathological conditions may cause a lesion at this site?
  4. In this patient, which of these conditions are most likely to be present?
29
Q

list examination done incase of suspected Hemorrhagic stroke

A

● CT and possibly CT angio
● CSF examination if strong suspicion, but normal CT
● TCD (transcranial doppler) can detect and monitor vasospasms in SAH
● Test for coagulopathies (must be corrected with antidotes) and blood pressure (must be kept
under 140 mmHg)

30
Q

TCD (transcranial doppler) what is it used for

A

can detect and monitor vasospasms in SAH

31
Q

diagnostics In TIA patients or patients with fast recovery

A

● Diagnostic work-up, especially urgent vascular imaging
● Ultrasound
● CTA or MR

32
Q

Etiology of ischemic strokes

A
  • Cerebral embolism
  • Thrombus
  • Small vessel occlusion (lipohyalinosis)
  • Systemic hypoperfusion
33
Q

etiology of intracerebral hemorhage

A
  • Ruptured cerebral artery or microaneurysm
  • Trauma
  • Reperfusion injury after ischemic stroke
34
Q

etiology of SAH

A
  • Ruptured berry aneurysm
  • Arteriovenous malformation
    Trauma (see “Traumatic brain injury”)
35
Q

Ischemic stroke risk factors

A

Age > 65 years
Hypertension
Atrial fibrillation
Diabetes mellitus
Carotid artery stenosis

36
Q

Intracerebral hemorrhage risk factors

A

Age > 65 years
Hypertension
Vasculitis
Malignancy
Ischemic stroke

37
Q

risk factors of Subarachnoid hemorrhage

A

Hypertension
Tobacco use
Family history

38
Q

Ischemic stroke clinical features

A

Sudden onset of focal neurologic deficits

Embolic stroke: possibly, spectacular shrinking deficit

39
Q

Intracerebral hemorrhage clinical features

A

Headache, confusion, nausea
Sudden onset of focal neurologic deficits

40
Q

Subarachnoid hemorrhage clinical signs

A

Rapid onset of severe headache
Meningeal signs
Sudden onset of focal neurologic deficits

41
Q

when is Lumbar puncture
done and in which type of stroke

A

Subarachnoid hemorrhage

If imaging is negative but suspicion for SAH remains high.

CSF may show xanthochromia. (the yellow discoloration of cerebrospinal fluid (CSF) caused by hemoglobin catabolism)

42
Q

treatment of ischemic stroke

A
  • tPA (if within < 4.5 hours of onset of symptoms)
  • Intra-arterial thrombolysis
  • Thrombectomy
  • Aspirin or clopidogrel for secondary prevention
43
Q

treatment of intracerebral hemorrhage

A
  • Reversal of coagulopathy
  • Blood pressure management
  • Surgical intervention if there are signs of herniation or increased ICP
44
Q

treatment of SAH

A
  • Reversal of coagulopathy
  • Blood pressure management
  • Prevention of vasospasm
  • Surgical clipping
  • Endovascular coiling
45
Q

when is Surgical intervention done in intracerebral hemorrhage

A

if there are signs of herniation or increased ICP

46
Q

pathology of ischemic stroke

A

Pale infarct → liquefactive necrosis and glial scarring

47
Q

pathology of hemorrhagic stroke

A

Hematoma surrounded by pale infarct and edema → hemosiderin-lined cavity with glial scarring

48
Q

For both ischemic and hemorrhagic strokes:
* most important nonmodifiable risk factor and
* the most important modifiable risk factor.

A

nonmodifiable risk factor: age

the most important modifiable risk factor: arterial hypertension

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