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Vascular Neurology Masterclass > CAPLAN CH8: POST CIRC > Flashcards

CAPLAN CH8: POST CIRC Flashcards

1
Q

T/F. Most patients with subclavian artery disease are asymptomatic.

A

TRUE. Though some present with fatigue, aching after exercise and coolness

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2
Q

In patients with subclavian stenosis, neurological symptoms are NOT common unless ___.

A

There is accompanying carotid artery disease.

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3
Q

A. What is the most frequent symptom of SUBCLAVIAN ARTERY DISEASE?
B. What is the most frequent NEUROLOGICAL symptom of SUBCLAVIAN ARTERY DISEASE?

A

A. Those related with ipsilateral arm and hand (eg coolness, weakness and pain)
B. Dizziness (that is spinning or vertiginous in character)

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4
Q

Characteristic pulse of patients with SUBCLAVIAN occlusion.

A

smaller volume, and delayed relative to the contralateral arm,

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5
Q

bruit from ECVA stenosis WITHOUT subclavian artery narrowing, inflating a BP cuff above systolic BP may ___ the bruit.

A

AUGMENT (by directing more blood into the ECVA)

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6
Q

When a bruit is caused by SUBCLAVIAN or INNOMINATE artery stenosis, inflating the cuff, ___.

A

REDUCES flow into the arm, hence the bruit becomes SOFTER.

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7
Q

Where can you find most SUBCLAVIAN ARTERY STENOSIS?

A

Left more than the right.

Proximal to the VA more often involved.

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8
Q

Professions at risk for INNOMINATE and SUBCLAVIAN ARTERY disease:

A

Baseball pitchers

Cricket Howlers

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9
Q

Identify which blood vessel involved:

ipsilateral arm and eye ischemia
anterior or posterior circulation (or both) ischemia

A

INNOMINATE ARTERY DISEASE

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10
Q

Why is the RIGHT SUBCLAVIAN more problematic than the left?

A

The proximal right subclavian artery makes a posterolateral curve.

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11
Q

Why is it important to obtain delayed films of ECVA when angiography is performed?

A

Retrograde phase of flow might be missed.

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12
Q

When is repair indicated in subclavian artery occlusions?

A
  1. Patient is incapacitated by arm ischemia
  2. Affects the right innominate or subclavian, serious carotid, territory infarction can ensue.

Otherwise, watchful waitiing

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13
Q

The most frequent location for atherosclerotic disease of the ECVA is at___.

A

Their origin from the subclavian arteries.

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14
Q

Patients with VA occlusion are indistinguishable from patients with subclavian steal EXCEPT FOR___.

A

ECVA- origin TIAs are not precipitated by effort or by arm exertion.

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15
Q

ECVA occlusion can be a good differential in patients with ____ dizziness.

A

repeated, unaccompanied dizziness

Remember that BPPV is only present on rising and retiring

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16
Q

Description of ECVA lesions:

A

fibrous and smooth; seldom ulcerate

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17
Q

Why are there only scant pathologic data on ECVA-origin lesions?

A

Endarterectomy is not often performed, so the vessel is not available for pathological examination.

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18
Q

Differentiate ECVA and ICA in terms of origin:

A

ECVA: arises at nearly 90 degrees
ICA: a direct 180 degree extension

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19
Q

Most important presentation of ECVA-origin disease

A

Embolization of white platelet-fibrin and red erythrocyte-fibrin thrombi from atherostenotic occlusive lesions

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20
Q

Give TWO reasons why ECVA- origin lesions seldom cause chronic, hemodynamically significant low flow to the vertebrobasilar system:

A

1, VA are paired uniting to form a single basilar artery (rare atresia of a VA)
2. ECVA gives off numerous muscular and other branches as it ascends (remember ICA has no nuchal branches)

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21
Q

In patients with proximal ECVA disease, a bruit can often be heard over the ___.

A

SUPRACLAVICULAR REGION. Physicians should auscultate by moving the stethoscope bell to listen over the POSTERIOR CERVICAL MUSCLES, MASTOID.

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22
Q

Most effective means of monitoring ECVA blood flow?

A

CW Doppler insonation in the low neck and at the C2 region

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23
Q

Restenosis rate of angioplasty and stenting of ECVA?

A

9-10% within one year

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24
Q

Which part of the vertebral artery is within the intervertebral foramina?

A

V2 portion

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25
Q

Trial that demonstrated ECVAs treated with stenting developiing restenosis more than 50% at 6 months follow-up.

A

SSYLVIA TRIAL

Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries

26
Q

Treatment for patients with proximal ECVA disease?

A

Not established yet.

LRC chooses warfarin; JSK uses aspirin + clopidogrel

27
Q

Usual locations of vertebral artery dissections?

A

V1- proximal portion of the ECVA

V3- distal extracranial portion, MOST COMMON

28
Q

Pain is a common presentation of verebral artery dissection? YES OR NO.

A

YES. Remember that pain in the posterior neck, occiput, and generalized headache is common. Usually hours, rarely weeks.

29
Q

Typical duplex scan findings of the ECVAs that suggest dilatation:

A

Increased arterial diameter
Decreased pulsatility
Intravascular abnormal echoes
hemodynamic evidence of decreased flow

30
Q

Features predictive of a good prognosis for a VAD?

A

Pain as presentation

No or minor neurological siigns

31
Q

TIAs are less common in ECVA dissections than in ICA dissections? YES or NO.

A

YES.

32
Q

Commonest patterns of ischemic brain damage from VAD?

A

Cerebellar infarction in the PICA territory distribution and

Lateral medullary infarction

33
Q

How can ECVA dissections cause cervical root pain?

A

When an aneurysmal dilatation of the ECVA adjacent to nerve roots causes the radicular pain and can lead to radicular distribution motor, sensory and reflex abnormalities.

34
Q

What is still the optimal method of imaging the extracranial vertebral arteries in patients suspected of having VAD?

A

dye-contrast catheter cerebral angiography

35
Q

What is the most common vascular lesion explaining the lateral medullary syndrome?

A

occlusion of the proximal or middle portion of the ICVA

36
Q

Describe the nystagmus of patients with lateral medullary syndrome?

A

with coarse rotatory movement
when looking at the ipsilateral side- SMALL- AMPLITUDE
when looking at the contralateral side- LARGE- AMPLITUDE

sometimes, there is ocular lateral pulsion

37
Q

Describe the sensory loss in LATERAL MEDULLARY SYNDROME?

A

In the limbs, it is ANALGESIA- CONTRALATERAL.
The leg is worse than the arm. (It is because sacral area– leg– trunk– arm are arranged from superficial to medial).

LOSS OF VIBRATION SENSE IS- IPSILATERAL
Associated with caudal lesions extending dorsomedially involving dorsal column or decussating lemniscal fibers.

38
Q

Differentiate ROSTRAL vs CAUDAL medullary infarctions?

A

ROSTRAL- more associated with distal artery atherosclerotic disease (ventral paramedian area affected)
Hence, dysphagia, dysarthria, contralateral trigeminal sensory loss, and facial palsy.

CAUDAL- laterally located.
Hence, more severe gait ataxia, more lower extremity involvement due to spinocerebellar tract

39
Q

Lateral Medullary Syndromes usually have good prognosis EXCEPT for:

A
  1. If extended and affects ipsilateral cerebellum
  2. If respiratory centers are affected (hence sudden death)
  3. If both ICVAs are occluded
40
Q

Mechanism of a hemimedullary infarction?

A

Long occlusion of the distal ICVA (that spares the PICA)

41
Q

Territory of SCA and PICA/AICA is separated by what?

A

The horizontal fissure (above is SCA, below is PICA/AICA)

42
Q

Important PICA symptoms:

A

alteration of posture
gait ataxia
limb hypotonia

(note that ipsilateral limbs do not show a cerebellar type of rhythmic intention tremor)

43
Q

What is the general rule in ICVA disease?

A

The more distal it is along the path from the proximal subclavian-vertebral junction to the distal basilar artery, the more likely it is to cause infarction.

The more proximal, the more benign.

44
Q

What are the most common symptoms of an AICA infarct?

A

dysarthria, limb dysmetria and intention tremor

45
Q

What do you call eyelid retraction. Common in patients with lesions at the midbrain-thalamic junction.

A

Collier sign.

46
Q

In how many percent, the basilar communicating artery is hypoplastic?

A

30%

47
Q

What is the most common mechanism of infarction in PCA strokes?

A

embolism from a proximal occlusive lesion within the vertebrobasilar system

48
Q

When intrinsic atherosclerosis of the PCA is present, the clinical presentation usually consists of ___.

A

transient hemianopic visual symptoms, sometimes accompanied by transient hemisensory symptoms on the same side.

49
Q

Describe the headaches caused by PCA disease?

A

Found retro-orbital or above the eye

- reflecting the fact that the upper surface of the tentorium is innervated by the first division of the CNV

50
Q

Affected in SUPERIOR QUADTRANTONOPIA?

A

Lingual gyrus

51
Q

Describe the optokinetic nystagmus in patients with occipital lobe infarcts?

A

NORMAL

52
Q

Hemisensory loss + Hemianopia and NO PARALYSIS

A

Think of PCA territory

Lesion is within the PCA (before the thalamogeniculate branches to the lateral thalamus)

53
Q

Lateral thalamus is infarcted and midbrain is spared. What is the presentation?

A

Hemisensory loss + hemiataxia, chorea and dystonic movements on the same side of hemisensory loss

ATAXIA- interruption of cerebellofugal fibers from SCP and RN that synapse in the VL of thalamus

CHOREA and DYSTONIA- interruption of extrapyramidal fibers from ansa leticularis to VL and VA thalamic nuclei

54
Q

ALEXIA without AGRAPHIA

A

left PCA territory infarct

- Right occipital lobe can read the left hemi-space, but since the corpus callosum has been damaged, cannot be processed

55
Q

Gerstmann Syndrome. Where is the lesion?

A

angular gyrus

56
Q

R PCA infarction are accompanied by what symptom:

A

Prosopagnosia- difficulty in recognizing familiar faces

57
Q

Syndrome wherein the patient may not recognize their visual deficit, and do not admit that they cannot see

A

Anton syndrome or visual anosognosia

58
Q

How can a posterior circulation stroke present with behavioral change?

A

If hippocampus, fusiform, lingual gyri are infarcted, they can be confused with delirium tremens

59
Q

Where data vs What data in occipital lobe processing?

A

Where data– goes to parietal and frontal regions
What data- middle and inferior temporal gyri, medial temporal limbic structures, amygdaloid nucleus hippocampus, ventrolateral frontal lobe cortex

60
Q

If ventral pathway (lower banks of calcarine fissure) affected, major findings are:

A

prosopagnosia and defective color vision

61
Q

If dorsal pathway is affected, what is the

A

Vascular Neurology Masterclass (6 decks)

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