Cerebrovascular Disease

Question 1

What is the primary cause of ischemic cerebrovascular disease?

Answer 1

Atherosclerosis

Risk factors: smoking, diabetes, hypertension, hyperlipidemia, positive family Hx

Question 2

Where in the cerebral vasculature does atherosclerosis build up?

Answer 2

Bifurcation points or large, major cervical or intracranial arteries

Question 3

Define “transient ischemic attack”

Answer 3

A reversible, focal neurological deficit lasting 24 hours or less (typically 10-20 minutes)

Question 4

What is the cause of a TIA?

Answer 4

Temporary obstruction of a large artery by an embolus (from an arterial or cardiac source)

Question 5

Define “amaurosis fugax”

Answer 5

monocular blindness

Painless, temporary loss of vision in one eye

Question 6

Name two types of neurologic deficits caused by a carotid artery TIA

Answer 6

Amaurosis fugax

aphasia, hemiparesis (hemispheric syndromes)

Question 7

Name three types of neurologic deficits caused by a vertebrobasilar TIA

Answer 7

Homonymous hemianopsia (due to visual cortex involvement)

ataxia, diplopia (typical of by brain stem/cerebellar syndrome)

Question 8

Differentiate causes of amaurosis fugax and a scotoma

Answer 8

Amaurosis fugax: cholesterol emboli in retinal arterioles with occlusion of superior temporal arteriole

Scotoma: infarction of inferior retina

Question 9

Define ischemic infarction

Answer 9

a persistent, focal neurologic deficit from an arterial occlusion which may improve over time

Question 10

Occlusions of large vessels affects which part of the brain?

Answer 10

The cortex

Question 11

Occlusions of the small vessels affects which parts of the brain?

Answer 11

The subcortex – suggested by lacunar syndrome

Question 12

What four cardiac abnormalities can lead to a cardiac embolus –> stroke? Which is the most common

Answer 12

Atrial fibrillation–> most common
Valvular lesions
Right to Left shunt (Patent foramen ovale[ transmits venous clots)
Myocardial infarction

Question 13

Name a vasoactive recreational drug that leads to a hypercoagulable state

Answer 13

cocaine

Question 14

What are the important steps in the evaluation of a TIA or infarction?

Answer 14

1) MRI/CT to both confirm the vascular territory involved and to rule out any atypical presentation of a tumor, hemorrhage, abscess or encephalitis
2) Diagnostic testing to identify the source/cause of the infarction/embolus etc

Question 15

What three things need to be evaluated following an infarction/TIA of large vessel (therefore involving the cortex)

Answer 15

1. Vascular evaluation- Carotid ultrasound or MR/CT angiogram or a conventional angiogram to look for vascular occlusion
2. Echocardiography- r/o or r/i cardiac sources of emboli
3. Test for hypercoagulability/drug screens etc

Question 16

What is the cause of a lacunar infarction?

Answer 16

thrombosis of atherosclerotic lenticulostriate arteries due to HTN, diabetes or older age (or hypercoagulable state)

Generally NOT due to embolism- they don’t lodge here.

Question 17

A lacunar infarct in the internal capsule, pons, or corona radiata leads to what three clinical syndromes?

Answer 17

1. Pure motor hemiplegia
2. Ataxic-Hemiparesis
3. Clumsy hand- dysarthria (Dysarthria-clumsy hand syndrome is characterized by the combination of facial weakness, severe dysarthria, and dysphagia, with mild hand weakness and clumsiness

Question 18

A lacunar lesion in the thalamus leads to what type of clinical syndromes?

Answer 18

pure sensory stroke

Question 19

Patients can receive IV tPA for a stroke if they present within how many hours of the onset?

Answer 19

3 hours

Question 20

What class of drugs is generally given to a stroke patient to prevent recurrence?

Answer 20

Anti-platelets

aspirin, clopidogrel, dipyridamole

Question 21

What is a carotid endarterectomy and why might it be done following a stroke?

Answer 21

Vascular procedure- clear the carotid artery of atherosclerotic plaques

It is done in cases where the flow is limited >70% through the cervical internal carotid artery and is causing symptoms.

Question 22

What drugs are given to prevent further cardiac emboli (especially in the presence of atrial fibrillation?)

Answer 22

Anticoagulants such as warfarin, heparin

Question 23

What symptoms differentiate an infarction from hemorrhage?

Answer 23

Severe headache with early impairment of consciousness

• atypical for infarction

Question 24

Does hemorrhagic blood originate from veins, arteries, or both?

Answer 24

Higher pressure arteries

Question 25

How may a hemorrhage cause death?

Answer 25

Shifting or herniation of the brain….it gets smooshed and you die.

Question 26

CT brain scan readily shows location and extent of acute hemorrhage. When might you need a CT angiogram?

Answer 26

Subsequent angiography if abnormal blood vessels (e.g., AVM) are the suspected cause of the hemorrhage

Question 27

What is the most common cause of cerebral hemorrhage?

Answer 27

Hypertension

Question 28

What are the two typical bleeding sites for cerebral hemorrhage?

Answer 28

Thalamus and basal ganglia

Question 29

How do illicit drugs cause cerebral hemorrhage?

Answer 29

They can cause severe, acute HTN

Question 30

What is the most common cause of a subarachnoid hemorrhage?

Answer 30

Trauma

Question 31

What is the most common nontraumatic cause of a subarachnoid hemorrhage?

Answer 31

Ruptured berry aneurysm

Question 32

Where do congenital aneurysms occur?

Answer 32

85% occur within the anterior circulation (anterior cerebral artery, internal carotids, middle cerebral arteries)

Question 33

How might a ruptured berry aneurysm present?

Answer 33

1. Could be asymptomatic
2. Warning leak –> “worst headache of my life”
3. Mass effect –> CN III palsy (fixed, dilated pupil)
4. Death if massive