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Neuro 2 Exam 2 > Atherosclerotic CNS stuff (Pales) > Flashcards

Atherosclerotic CNS stuff (Pales) Flashcards

1
Q

Epidemiology of Stroke

A

Third leading cause of death in the US

very common

deaths: black males> black females> white males> white females

leading cause of long-term disability in the US

high economic burden

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2
Q

Stroke definitions

A

CVA (cerebrovascular accident)

abrupt onset of a neurological deficit that is attributable to a focal vascular cause

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3
Q

2 major types of stroke

A

Hemorrhagic (cerebral hemorrhage)- 15%

Ischemic (cerebral ischemia)- 85%

Ishemia– from Greek. Restriction of Blood

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4
Q

blood in the brain

A

is an irritant, causes swelling (in hemorrhagic stroke, cut a hole to let the brain swell)

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5
Q

Ischemic penumbra

A

brain tissue surrounding the cerebral necrosis that exhibits reversible ischemic changes (salvageable)

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6
Q

causes of ischemic stroke

A

large artery thrombosis

embolism

Lacunar

Other (watershed infarcts, hypercoagulable disorders, vasculitis, vasospasm, dissection of artery, venous thrombosis, Moyamoya disease)

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7
Q

large artery thrombosis

A

plaque with fibrous cap–> cap ruptures–> blood clot forms around the rupture, blocking the artery

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8
Q

Embolic stroke- types of emboli

A

originating from an atherosclerotic plaque

originating from thrombus

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9
Q

Sources of emboli

A

heart
artery to artery
lower extremity DVT with paradoxical emboli

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10
Q

Cardiac emboli sources

A

Atrial: atrial fib/ flutter, atrial eptal aneurism, atrial tumors (myxoma)

Ventricular (cardiomyopathy, MI, ventricular aneurisms)

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11
Q

Atrial septal aneurism

A

weakening and out-pouching of interatrial septum, leading to stasis and thrombus formation (mural)

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12
Q

Atrial myxoma

A

pieces of tumor may tear off and become emboli

associated thrombus can embolize

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13
Q

Ventricular sources of emboli

A

cardiomyopathy

infarction

ventricular aneurisms

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14
Q

cardiomyopathy

A

Weak and dilated ventricle isn’t pumping efficiently leading to blood stasis and thrombus formation

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15
Q

MI (as source of embolus)

A

part of the wall is not moving, creating stasis and leading to mural thrombosis

can be from current or old MI

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16
Q

Cardiac emboli- valvular sources

A

rheumatic miral stenosis
prosthetic valves
infective and non-infective endocarditis
nonbacterial thrombotic (marantic- age-related) endocarditis associated with malignancies and prothrombic states
calcification of valves
bicuspid aortic valves
inflammatory valvulitis (Libman-Sacks, Behcet, Syphilis)

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17
Q

Artery to artery embolic infarcts

A

Carotid artery atherosclerosis/ stenosis- casues 5% of all strokes.
The tighter the stenosis, the higher the risk risk of stroke
May cause embolic or thrombotic type of strokes

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18
Q

Paradoxical emboli

A

originate from the L.E. deep veins

“hole” in the heart between left heart and right heart

(PFO or ASD/ VSD)

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19
Q

Lacunar stroke

A

Infarct forms in ** subcortical** areas of brain supplied by small deep penetrating arteries arising from the big arteries

may be due to atheroemboli or lipohyalinosis (fibrous tissue replacing muscle around the lacunar arteries)

HTN is major factor

frequently asymptomatic (subcortex does very little, but basal ganglia can be affected)

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20
Q

Lipohyalinosis

A

high pressure of large arteries transmitted to small arteries

hyperplasia of small vessel walls

hyalinization of the vessel walls

narrowing and occlusion of the lumen

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21
Q

Autoregulation of cerebral blood flow

A

the organs that are meant to die last when blood pressure falls: Brain and Kidneys. They have autoregulation.

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22
Q

Watershed infarcts

A

Ischemic infarct of the areas farthest from the large arteries

the most sensitive areas when perfusion decreases

Develops with conditions causing hypotension

  • sepsis
  • severe bleeding
  • severe dehydration, etc.
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23
Q

Hypercoagulable disorders

A

Hemostasis system- 3 parts: coagulation system, anticoagulation system, thrombolytic system

hypercoagulable disorders promote coagulation over anticoagulation

most cause venous clotting but some favor arterial

examples:

Factor V Leiden mutation (most common)
Protein C deficiency
Protein S deficiency
Antithrombin deficiency
Plasminogen deficiency
Prothrombin gene mutation
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24
Q

disorders more likely to cause arterial clotting

A

antiphospholipid antibody syndrome .

  • Anticardiolipin antibodies (ACA)
  • Lupus anticoagulants (LA)

Hyperhomocysteinemia

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25
Q

Other hypercoagulable states

A

Cancer (pancreatic, lung)

pregnancy and exogenous estrogen use (including use of oral contraceptive pills-birth control pills)
hormone replacement therapy
prolonged bed rest or immobility, heart attack, stroke and other illnesses that lead to decreased activity
myeloproliferative disorders such as polycythemia vera or essential throbocytosis

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26
Q

vasculitis

A

inflammatory condition –> thickening of arterial wall–> decreased lumen –> CNS restricted blood flow

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27
Q

Vasospasm causes

A
  1. Cocaine (fries both cortices)

2. After intracerebral bleeding (subarachnoid bleeding)

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28
Q

disection

A

often traumatic causes (golf, chiropractic, etc.)

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29
Q

Moyamoya disease

A

= “smoke puff”

poorly understood.
occlusive disease involving large intracranial arteries

30
Q

Venous stroke

A

DVT in one of the venous sinuses
may be ischemic or hemorrhagic
usually associated with severe headaches and neurological symptoms

31
Q

hemiparesis

A

weakness of one side of the body

32
Q

hemiplegia

A

complete paralysis of one side of the body

33
Q

homonymous hemianopsia (hemianopia)

A

loss of vision in the same visual field of both eyes

34
Q

acalculia

A

difficulty to perform simple math tasks

35
Q

agnosia

A

inability to recognize objects, persons, sounds, shapes, or smells

36
Q

aphasia

A

inability to speak (motor or sensory)

37
Q

alexia

A

inability to read

38
Q

agraphia

A

inability to write

39
Q

dysphagia

A

difficulty swallowing

40
Q

dysarthria

A

slurred speech

41
Q

hemispatial neglect

A

inability to attend to one side of the body or visual field

42
Q

apraxia

A

inability to perform a specific task

43
Q

anosognosia

A

unawareness of or denial of the existence of disability

44
Q

anomia

A

difficulty with recalling words or names

45
Q

ataxia

A

unsteady gait

46
Q

MCA Syndrome

A

Contralateral hemiplegia/ sensation loss (sometimes in face and upper extremity only)

contralateral homonymous hemianopsia

Dominant side: aphasia, alexia, agraphia, acalculia, finger agnosia, and right-left confusion

Non-dominant side: unilateral neglect, dressing apraxia, anosognosia, and constructional apraxia

47
Q

ACA syndrome

A

Contralateral sensory and motor loss of lower extremity

48
Q

PCA syndrome

A

Homonymous hemianopsia
alexia without agraphia
visual or color anomia

49
Q

lateral pontine syndrome (Marie-Foix Syndrome)

A

anterior inferior cerebellar artery
ataxia- arm and leg
weakness- upper and lower extremity
hemisensory loss- pain and temp

50
Q

lateral medullary syndrome (Wallenburg)

A 
Posterior inferior cerebellar artery
Facial sensory loss and pain 
Ataxia
Nystagmus
Vertigo
Hoarseness
Dysphagia
Horner syndrome
Hemisensory loss
Hiccups
51
Q

Basilar artery strokes

A

Locked-in Syndrome
- Quadriplegia, bilateral facial paralysis, dysarthria

Lateral pontine syndrome (Marie-Foix Syndrome)

Ventral pontine syndrome (Raymond Syndrome)

  • Lateral gaze weakness
  • Contraletaral hemiplegia

Ventral pontine syndrome (Millard-Gubler Syndrome)

  • contralateral - upper and lower extremity weakness
  • Ipsilateral facial weakness

Ataxic hemiparesis
- Contralateral upper and lower extremityweakness and ataxia

Cortical blindness (Anton Syndrome) 
- (blindness and denial)
52
Q

Other symptoms of stroke

A

headache
nausea/ vomiting
stupor/ coma/ amnesia/ confusion/ delerium

53
Q

amaurosis fugax

A

transient mono-ocular blindness

often warning sign of an impending stroke

several causes:

  • embolic (most often from carotid artery of the same side)
  • hemodynamic
  • ocular
  • neurologic
  • idiopathic
54
Q

opthalmic artery

A

is the first branch of the carotid before it goes to the brain

thus amaurosis fugax is often the first warning sign of impending stroke

55
Q

TIA

A

AKA “mini-stroke)

the same symptoms (and detiology) as with stroke but lasting less than 24 hours

15-45% –> infarcts

patients with TIA have 10% risk of CVA within first 3 months

56
Q

Dx of stroke

A

History: sudden onset, symptoms described previously

Complete neurological and mental status exam

CT of brain (without contrast) is the quickest way- only detects big strokes. to R/O bleed (because we want to treat with blood thinners)– takes 5 minutes

MRI of brain is very sensitive– takes 45 minutes

57
Q

assessing the cause of stroke

A 
History: look for risk factors
lipids, blood glucose, cardiac enzymes
EKG- arrhythmia, MI
Echocardiogram (transthoracic or transesophageal)- intracardiac thrombosis, cardiomyopathy, valvular disorders, ASD
Carotid Doppler- carotid stenosis
MR-A/ CT-A
58
Q

Differential Dx of ischemic stroke

A 
hemorrhagic stroke/ subdural hemorrhages
seizures
complex migraines
CNS tumors
nerves palsy, peripheral neuropathy
encephalitis
toxic metabolic encephalopathy
syncope
vertigo
59
Q

most common cause of mental status change in hospitalized patients

A

toxic metabolic encephalopathy

60
Q

acute treatment of stroke

A

activation of STROKE ALERT TEAM (time is brain)

medications

  • rtPA (intra-venous and catheter-directed intraarterial)
  • antiplatelet agents- ASA, clopidogrel, aggrenox (ASA/ dipiridamole)

IV fluids

heparin- select cases (known visible thrombus, dissection, staggering CVAs) - causes a lot of bleeding

Keep BP sufficient for saving penumbra but not too high- permissive HTN

Swallowing evaluation

Early rehabilitation

61
Q

clot buster rtPA works on

A

plasminogen–> plasmin

62
Q

Stroke risk factors - modifiable

A 
HTN
Arial fib
smoking
diabetes
carotid stenosis (increases risk 2 times if no previous TIA or CVA)
Hyperlipidemia (increases risk 2-2.5 times)
Physical inactivity and obesity
Alcohol and drug abuse
Geographic location 
US South-East has more strokes
Socioeconomic factors
63
Q

stroke prevention

A

Diet- low in sat fat
exercise- aerobic exercises 30-60 minutes/ day, most days

Strict control of Blood Pressures, Blood sugars, blood cholesterol
Quit smoking

meds:
- antiplatelets. Aspirin, clopidogril
- anticoag agents: warfarin, heparin and LMWH, new oral anticoag drugs: dabigtran, rivaroxaban, apixaban, edoxaban

64
Q

treatment options of carotid stenosis

A

depends on degree of stenosis and on h/o CVA

medical treatment (treat risk factors)

surgical treatment with carotid endarterectoy

stents - only for lesions not reachable with surgical approach
- Patients have high surgical risk

65
Q

carotid endarterectomy

A

atherosclerotic plaque removed from carotid artery to restore blood flow to brain

66
Q

Stroke Risk FactorsNon-modifiable

A

Age.
- Risk doubles with each decade after 55

Heredity (Family history)

Race
- African Americans and Hispanics higher than Caucasians

Gender

  • More men has strokes in a given year in each age group
  • More than half of total stroke deaths occur in women

Personal h/o TIA, CVA, MI, any atherosclerosis

67
Q

Ischemic stroke - general

A

extremely common cause of death and disability in the US

There are multiple causes of ischemic stroke; embolic, lacunar and thrombotic being the most common ones

In both TIA and CVA it’s important to know the type of stroke and the source of emboli, as it will determine the acute treatment and the means for secondary prophylaxis

68
Q

Atherosclerosis and Hypertension

A

are major risk factors for strokes.

Hypertension is the main cause of lacunar (small vessel) strokes.

Symptoms of the stroke depends on the location and size of the vessel involved

69
Q

TIA

A

a transient ischemia or small CVA when all symptoms are resolved within 24 hours.
The same patient may have several CVAs of different etiology as the risk factors for different conditions are similar.
Always look at the patient’s symptoms and match them with the stroke location on MRI

70
Q

If location of stroke is in the territory of more than one particular artery, think

A

embolic and think about the source upstream

It’s always important to consider differential diagnosis

71
Q

CT of the brain

A

is used for diagnosing large strokes and to r/o bleeding for tPA administration, but may miss early strokes, especially if it’s small or in posterior circulation.

72
Q

tPA

A

is a one of the major treatment of the ischemic stroke, but full of complexities and controversies

Neuro 2 Exam 2 (19 decks)

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