Cerebrovascular Disease Flashcards
sudden onset, cortical symptoms, afib, subtheraputic INR-Which kind of stroke and etiology
cardioembolic stroke, ischemic
tx for cardioembolic stroke–what must be checked first
tPA/heparin; check INR, CT head + CTA
Contraindication to tPA
- elevated INR
- > 4.5 hours after onset of sx
- intercranial bleed
What is atherosclerotic plaque made of?
Subintimal proliferation of smooth muscle, fatty deposits of intima, inflammatory cells, and excessive elaboration of tissue matrix in vessel wall
How common is fibromuscular dysplasia in causing cranial vessel occlusion? Mechanism?
relatively uncommon; segmental overgrowth of fibrous & muscular tissue in media
Causes of meningovascular inflammation
syphilis, TB meningitis, sarcoid
Pure motor deficit, where’s the lesion/ what type of stroke
lacunar stroke/infarction
Lacunar stroke presentation
hemiplegia; no cognitive, sensory, visual deficits
Usual site of injury for lacunar stroke
posterior limb of internal capsule
How does lacunae form
occlusive lesion in arteriole that supplies injured structure
Presentation of cerebellar lesion
impaired coordination, strength preserved
Presentation of caudate or putamen lesion
grossly asymptomatic, does not cause weakness, subtle cognitive/motor deficits
Amygdala lesion presentation
memory formation and emotion changes
Pure sensory stroke, where’s the lesion/what type of stroke?
Where would eyes be deviated?
thalamus (specifically posteroventral nucleus of the lateral thalamus); infarct 2/2 emboli
Eyes deviated towards lesion
What might people feel while recovering from thalamus stroke? What is it called?
Paradoxical pain in the area of sensory impairment; “Thalamic pain syndrome”
Wallenberg is also known as ____
Lateral medullary infarction
Presentation of lateral medullary infarction
- ipsilateral ataxia
- ipsilateral Horner syndrome
- Trigeminal tract damage: ipsilateral loss of facial pain and temp perception & ipsilateral impairment of corneal reflex
- Lateral spinothalamic damage: contralateral pain and temp disturbance, contralateral to injury in limbs and trunk
- Dysphagia and dysphonia (9th nerve)
Nucleus Ambiguus lesion
- location
- what it innervates
- presentation
Location: ventrolateral medulla, contributes to glossopharyngeal 9th nerve and vagus nerve.
Innervates: striated muscles of larynx and pharynx + preganglionic para-sympathetic supply of thoracic organs (esophagus, heart, lungs)
Presentation: dysphagia & hoarseness
Nucleus solitarius, what does it do?
- combines afferents from CN VII, IX, and X responsible for visceral sensation
- Projections are to parasympathetic and sympathetic preganglionic neurons in medulla and spinal cord
What are cerebellar peduncles
fibers connecting cerebellum to brain stem
Wallenberg is caused by occlusion of which artery?
Most common: vertebral artery
Less common: PICA (largest branch of vertebral artery)
What are the structures that might be involved in lateral medulla infarction (Wallenberg)?
- lateral medulla
- nucleus of lateral medulla
- descending tract of 5th nerve
- nucleus ambiguus
- lateral spinothalamic tracts (pain+temp)
- inferior cerebellar peduncle
- descending sympathetic fibers
- vagus
- glossopharyngeal nerves
What does the basilar artery supply
ENTIRE posterior brain circulation (huge stroke if occluded)
What does the superior cerebellar artery supply?
superior portions of cerebellum
What does AICA supply
portions of the cerebellum and lower cranial nerves
Most common cause of lobar hemorrhage in elderly patients (>70yo) w.out HTN
Cerebral amyloid angiopathy
Which protein is deposited in vessel walls in cerebral amyloid angiopathy
beta-amyloid protein
Cerebral amyloid angiopathy presentation
multiple cortical hemorrhage, w. or w.out dementia
Gliomatosis Cerebri
related to glioblastoma multiforme, arises form glial cels, rare, threads that penetrates deep, invasive and aggressive
Mycotic aneurysm
infected aneurysm from bacterial infection of arterial wall. Orgs usually low virulence, but the more virulent types can cause meningitis or abscess.
Risk of mycotic aneurysm
Bleeding during exertion (like sexual activity or defecation)
Hematoma on CT
does not change b/w enhanced or unenhanced
CSF finding in SAH
xanthochromic, many RBCs, grossly bloody
Mycotic aneurysm appearance on CT
multiple, sometimes can’t see on CT
Tx of post hemorrhage seizure
levetiracetam (keppra)
Focal weakness following 24h after motor seizure
Todd paralysis
Sturge-Weber syndrome is also known as ___
encephalofacial angiomatosis
People with Sturge-Weber might have:
Facial cutaneous angiomas with intracranial abnormalities like leptomeningeal angiomas
Sturge-Weber/ Encephalofacial angiomatosis presentation
- Port-wine nevus (sensory distribution of 1st trigem nerve)
- Mental retardation
- Hemiparesis
- Hemiatrophy (opposite nevus)
- Angioma of choroid in eye
–Intracranial angioma unlikely if nevus doesn’t involve upper face–
Mechanism of neurologic deficit in Sturge-Weber
focal ischemia in cerebral cortex that underlies leptomeningeal angioma
Charcot-Bouchard aneurysms: what is it and where?
small and microscopic aneurysms in ppl with CHRONIC HTN; appear in perforating arteries of the brain (lenticulostreiate arteries); hematomas commonly appear in putamen.
Supplies:
- caudate
- nucleus
- thalamus
- pons
- cerebellum (dentate nucleus)
Difference between charcot-bouchard (CBA) and berry aneurysms (BA)
CBA: assoc. w/ chronic HTN, small vessel (<1mm) internal capsule and basal ganglia , SUDDEN onset of focal deficits
BA: assoc. w/ ADPKD, marfan’s, ehler danlos, large vessel (2-25mm) esp. Circle of Willis (anterior and posterior communicating arteries), SAH affecting bridging veins, sudden onset HA, altered mental status, neurologic deficits occur later
hemangioblastomas are ____ associated with ____ & _____
vascular tumors
APKD and telangiectasias of the retina (von Hippel-Lindau)
Fusiform aneurysm character and cause
widened arteries with evaginations along walls without stalks (which would be seen in typical berry-shaped structures in saccular aneurysm)
arteriosclerotic damage to artery wall
Optic radiation loops through which lobe on its way to the occipital cortex?
Temporal lobe
Posterior aphasia is also known as
fluent aphasia or wernicke’s aphasia or sensory aphasia
Wernicke’s aphasia vascular lesion, which vessel
posterior cerebral artery
Common etiology of hemorrhage if <40yo
if >40?
<40 yo: AV malformation
>40 yo: aneurysm (in 40s-50s F>M, especially internal carotid artery inside cavernous sinus)
Dull pain behind eye, diplopia intermittent, papillary edema, color separation…think about lesion where ___
cavernous sinus
CN III deficit, HA, pupillary dilation. What’s the mechanism and location of the lesion?
Posterior communicating artery aneurysm (compressing oculomotor nerve and pupilloconstrictor fibers
Complications after subarachnoid hemorrhage
vasospasm, seizures
Treatment/ppx for post SAH vasospasm
CCB (nimodipine)
Workup of TIA/amaurosis fugax
Doppler of carotids
lipid panel
HA1c
transient visual loss etiology
central retinal artery ischemia
Presentation of retinal vein thrombosis
rapidly progressive loss of vision, funduscopic exam with hemorrhages in retina
Indication for carotid endarterectomy (CEA)
symptomatic disease of internal carotid artery
Best way to prevent future stroke for symptomatic 90% sttenosis of R intercal carotid artery at bifurcation
CEA
not ASA, warfarin, carotid artery angioplasty or extracranial-intracranial bypass
Explain stroke p/w:
- left eye deviation,
- right dense hemiplegia,
- R visual field cut, & intact pain sensation on L
Where’s the lesion, what’s affected, and what kind of aphasia?
Global Aphasia–impaired comprehension, repetition, fluency
- Left eye deviation: Left lesion affecting left frontal eye fields (overriding signal from right pushes eyes to left)
- R Hemiplegia: Left cortex lesion, contralateral hemiplegia
- R Field cut: Optic radiation damage on L hemisphere
What type of aphasia p/w:
- language comprehension deficit
- Ability to produce intelligible phrases & sound fluently
- unable to follow simple instructions
- unable to repeat simple phrases
- agraphia*
- MRI + for lesion on L temporal lobe extending into superior temporal gyrus
Wernicke aphasia (fluent aphasia)
What is the arcuate fasciculus and where does it travel?
connects expressive language centers in frontal lobe and receptive centers in temporal lobe, travels through temporal and parietal lobes
Presentation of conduction aphasia, and what is the lesion
problems with repetition
speech does not sound fluent
lesion: arcuate fasciculus in temporal/parietal lobe
Broca’s aphasia prognosis
will regain ability to produce meaningful language if infarction is less than a few cms across. Usually with permanent loss of syntax
Mixed transcortical aphasia, presentation and probable type of stroke.
Presentation: after profound hypotension; speech limited to repetition of words and sounds; no comprehension of language and produces few sounds spontaneously.
Type of stroke: watershed infarction
Anomic aphasia presentation and localization
- naming impaired, duh. word-finding deficit.
- comprehension, repetition and fluency relatively maintained
- least localizable of major aphasias (common with diffuse brain dysfunction)
Transcortical motor aphasia
presentation and location of lesion
similar to broca’s but PRESERVED REPETITION
Location: L frontal white matter, spares overlying cortex (broca’s)
Transcortical sensory aphasia
presentation & location of lesion
similar to Wernicke’s but PRESERVED REPETITION
Location: white matter underlying cortex of wernicke area
Prognosis better than wernicke aphasia
