Cerebrovascular

Question 1

Name the components of the CHA2DS2-VASc Risk Score.

Answer 1

CHF (1 pt)
HTN (1 pt)
Age >/= 75 years (2 pt)
DM (1 pt)
Stroke hx (2 pt)
Vascular disease (1 pt)
Age 65-74 years (1 pt)
Sex category (1 pt for female)

Anticoagulation recommended for:
- males with score of >/=2
- females with score of >/=3

Question 2

If a patient presenting as a CODE STROKE has a history of multiple TIA’s, what are the most important follow-up questions to ask when gathering the history?

Answer 2

Were the symptoms the same each time? (single vascular territory)
How many TIA’s did the patient have in the last 2 weeks? (if 3+, this suggests unstable plaque)

Question 3

When should you be concerned about an unstable plaque in a patient being evaluated for stroke?

Answer 3

A) 3+ TIA’s within 2 weeks of presentation involving the same vascular territory
B) stuttering symptoms

Question 4

What substances may precipitate a stroke?

Answer 4

Cocaine
Amphetamines
Chronic marijuana use

Question 5

What family history is important in stroke patients?

Answer 5

Family history of dementia, migraines, venous thrombosis, premature atherosclerosis, stroke/MI, diabetes should be obtained to assess for potential heritable risk factors for ischemic stroke

Question 6

These elements in the history should raise concern for cervical arterial dissection.

Answer 6

head or neck trauma
high-velocity chiropractic neck manipulation

Question 7

What percentage of strokes will score a 0 on the NIHSS?

Answer 7

Nearly 5% of strokes, mostly lacunar and infratentorial

Question 8

What percentage of acute ischemic strokes are DWI negative?

Answer 8

Nearly 7%! This is 5x more likely in posterior circulation strokes than anterior circulation strokes

Question 9

What features of plaque vulnerability can be identified on vessel-wall imaging using MRI?

Answer 9

intraplaque hemorrhage, a lipid-rich necrotic core, and thinning of the fibrous cap

Question 10

Define ESUS.

Answer 10

“Embolic Stroke of Undetermined Source” – a non-lacunar stroke that is not associated with LVD or obvious cardioembolic disease

Question 11

List the monogenetic stroke syndromes.

Answer 11

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL)
Cerebral Autosomal Recessive Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CARASIL)
Pontine Autosomal Dominant Microangiopathy and Leukoencephalopathy (PADMAL)
Fabry disease
Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes (MELAS)
type Iv collagen disorders (i.e. COL4A1 or COL4A2 mutations)

Question 12

What cerebrovascular complications are associated with Sickle Cell Disease?

Answer 12

ischemic stroke
hemorrhagic stroke
moyamoya vasculopathy

Question 13

How should children and adolescents with Sickle Cell Disease be screened for signs of an emerging vasculopathy/increased risk of stroke?

Answer 13

transcranial Doppler of the MCA looking for elevated blood flow velocities which may indicate need for exchange transfusion

Question 14

What patients should be screened for thrombophilia?

Answer 14

Young patients with cryptogenic strokes
Patients with aseptic CVST

Question 15

What were the findings of the Antiphospholipid Antibody and Stroke Study (APASS)?

Answer 15

The presence of antiphospholipid antibodies did not predict increased stroke risk or a differential response to treatment (warfarin or ASA)

Question 16

What is the diagnostic criteria for Antiphospholipid Antibody Syndrome?

Answer 16

persistently positive (for 12 or more weeks) lupus anticoagulant, anti-beta2 glycoprotein I, or anticardiolipin antibodies associated with recurrent thromboses and pregnancy complications