Cerebrovascular Disease Flashcards
Vascular territories:
Anterior cerebral artery issues affect what?
Deficits: Upper motor neuron-type weakness & cortical-type sensory loss; contralateral hemiplegia initially
- Contralateral leg (more common than arm or face)
- “Alien hand” syndrome: Semiautomatic movements of the contralateral arm not under voluntary control
Vascular territories:
Posterior cerebral artery issues affect what?
Contralateral homonymous hemianopia
Vascular territories:
Middle cerebral artery issues affect what?
This is most commonly the site of issue
Deficits: Aphasia, hemineglect (lack of awareness to half of body), hemianopia, face-arm or face-arm-leg sensorimotor loss
- Gaze preference toward side of lesion
- Lacunes: Small, deep infarcts involving penetrating branches of MCA or other vessels
What are the 3 categories of cerebrovascular diseases?
- Thrombosis
- Embolism
- Hemorrhage
What is the difference between a transient ischemic attack and a stroke?
Both: Clinical designation
TIA: Symptoms disappear within 24h
Stroke: Acute onset and persist beyond 24h
Infarction is the resultant lesion on the brain parenchyma
What are the 4 most common cerebrovascular disorders?
- Global ischemia (Blood pressure issues, strangulation, carbon monoxide, etc)
- Embolism
- Hypertensive intraparenchymal hemorrhage
- Ruptures aneurysm
What are watershed infarcts?
Region between two vessels that is most susceptible to ischemia & infarction
- Damage to this region produces a sickle-shaped band of necrosis over the cerebral convexity a few centimeters lateral to the interhemispheric fissure
Can have secondary hemorrhagic transformation
What symptoms happen with infarct to the ACA-MCA watershed area?
Occlusion of the internal carotid artery, hypotension in pt w carotid stenosis
- Proximal arm & leg weakness
- Transcortical aphasia: (language issues)
What symptoms happen with infarct to the PCA-MCA watershed area?
Higher-order visual processing
Assortment of info about carotid stenosis
Where do thrombi formed here go if they embolize?
- Atherosclerosis commonly leads to stenosis of internal carotid artery just beyond bifurcation
- Carotid bruit continues into diastole
- Thrombi formed here can embolize distally, esp to MCA, ACA, and ophthalmic artery
What are symptoms of carotid stenosis?
What can be done about stenosis?
Contralateral face-arm of face-arm-leg weakness, contralateral sensory changes, contralateral visual field defects, aphasia or neglect
Angioplasty or stenting or endarterectomy
Where are 3 primary sites of thrombosis?
- Carotid bifurcation
- Origin of MCA
- Either end of basilar artery
Often d/t atherosclerosis
What are 6 common sources of emboli in cardioembolic infarcts?
- Atrial fibrillation (Left atrial appendage)
- Myocardial infarction (Hypokinetic or akinetic areas)
- Valvular disease
- Artery-to-artery emboli (Emboli from stenosed internal carotid artery, vertebral stenosis)
- Dissection: Carotid or vertebral (atherosclerosis of aortic arch)
- PFO (bypasses lungs and goes straight to brain; paradoxical embolus)
What are 4 sources of emboli that are not blood clots?
- Air emboli
- Septic emboli
- Fat or cholesterol emboli
- Marantic emboli (non-bacterial) from hypercoagulable states like advanced malignancy, amniotic fluid emboli, etc
What artery is most often affect by embolic infarction?
MCA
- Emboli lodge where blood vessel branch or pre-existing areas of luminal stenosis
What are shower emboli?
Fat after a long bone fracture
Name 7 hypercoagulable states
- Heritable coag factor disorders
- Dehydration
- Adenocarcinoma/malignancies
- Surgery, trauma, childbirth
- DIC
- Hematologic disorders
- Vasculitis
What are symptoms of TIAs?
Positive or negative (doing something you don’t want or not doing something you do want) in motor, somatosensory, visual, auditory, olfactory, kinesthetic, emotional, cognitive
Common causes of TIA
Previous TIA, migraines, seizures, non-neurologic conditions like arrhythmias or hypoglycemia
What do TIAs indicate?
- Warning sign for potentially larger ischemic injury to the brain
- Neurological emergency even when symptoms cease
What are the 2 different types of stroke? Are they associated with emboli or thrombi?
Hemorrhagic (red)
- Emboli associated
- Hemorrhage secondary to reperfusion of damages vessels
Ischemic (pale)
- Thrombus associated
- Can have secondary hemorrhage
Hypertensive cerebrovascular disease:
Lacunar infarcts. What are they, what do they commonly affect?
Deep penetrating arteries & arterioles develop arteriolar sclerosis
- Lenticulostriate arteries
- Commonly affect basal ganglia
Hypertensive cerebrovascular disease:
What are slit hemorrhages?
Small caliber penetrating vessels
Hypertensive cerebrovascular disease:
What is hypertensive encephalopathy, what is a common RF for it?
What is vascular multi-infarct dementia?
What is Binswanger disease?
What are Charcot-Bouchard microaneurysms?
Malignant HTN; HTN is a risk factor most commonly a/w deep brain parenchymal hemorrhages
Vascular multi-infarct dementia: Dementia, gait abnormalities, pseudobulbar signs
Binswanger disease: Large area of subcortical white matter w myelin and axon loss
Charcot-Bouchard microaneurysms: A/w chronic HTN; minute aneurysms in the basal ganglia (less than 300 micrometers)
Hypertensive cerebrovascular disease:
What is cerebral amyloid angiopathy?
What is CADASIL? What age does it present? What gene is a/w it? What happens to vessels and what stain does it use?
CAA: Lobar hemorrhage; same A beta amyloid deposited in the walls of vessels (same as in Alzheimer’s ) producing microbleeds
CADASIL: Cerebral autosomal dominant arteriopathy w subcortical infarcts and leukoencephalopathy
- Recurrent strokes and dementia
- First detectable ~35yo
- NOTCH 3 gene
- Thickening of media and adventitia, loss of smooth muscle cells, basophilic PAS+ deposits
What is an aneurysm?
Where are they most
frequently located?
What increases incidence of aneurysm?
Localized abn dilation of blood vessel or the heart
Most frequently seen in anterior circulation (Circle of Willis, basilar SAH)
- Most frequent cause of clinically significant SAH is rupture of saccular (berry) aneurysm
Inc incidence if first-degree relative affected, adult (AD) polycystic kidney disease, Ehlers-Danlos, Marfans, and neurofibromatosis type 1 (NF1)
A few things to note about aneurysms
- Rupture more common in fifth decade of life and more frequent in females
- Repeat bleeding common
- First few days after SAH, inc risk of addt’l ischemic injurt from vasospasm
What are the 4 groups of vascular formations? Which is most common?
- AV malformations (most common)
- Cavernous malformations/hemangiomas
- Capillary telangiectasias
- Venous angiomas
Sx of AV malformations and Cavernous?
Hemorrhage & neurological sx
What are cavernous malformations and where/what do they affect? What can be seen in surrounding area?
Distended, loosely organized vascular channels arranged back-to-back with no intervening brain parenchyma
- Cerebellum, pons, subcortical regions
- No AV shunting
- Foci of old hemorrhage, infarction, calcifications seen in surrounding area
What are AV malformations? Where are they most common? What gene mutation are they a/w?
Tangle of vascular channels w prominent pulsatile AV shunting and high blood flow
- Often in subarachnoid space, may extend into brain parenchyma
- Seen as arteries to veins without intervening capillaries
Often a/w KRAS oncogene, some RAS signaling
What causes vascular dementia?
What is seen with this in the brain?
Binswanger disease?
Can be caused by cerebral atherosclerosis (from chronic HTN) or vessel thrombosis/embolus
Multiple bilateral grey matter (cortex, thalamus, BG) and white matter infarcts
Binswanger is subcortical white matter dementia (loss of white matter, myelin, axons)
What are symptoms of vascular dementia?
Sx: Dementia, gait abnormalities, pseudobulbar signs (frequent, involuntary and uncontrollable outbursts of crying or laughing that are exaggerated d/t upper motor neuron lesions of CNIX)
