Cerebrovascular Disease

Question 1

What are the two classes of cerebrovascular disease?

Answer 1

Ischemic (85%)

Hemorrhagic (15%)

Question 2

What are the major etiologies of global cerebral ischemia?

Answer 2

Low perfusion (ie atherosclerosis)

Acute decrease in blood flow (ie cardiogenic shock)

Chronic hypoxia (ie anemia)

Repeated episodes of hypoglycemia (ie insulinoma)

Question 3

Clinical features of mild global ischemia?

Answer 3

Transient confusion with prompy recovery

Question 4

Clinical features of severe global ischemia

Answer 4

Diffuse necrosis

Survival leads to “vegetative state”

Question 5

What are 3 highly vulnerable structures in moderate global ischemia?

Answer 5

Pyramidal neurons of the cerebral cortex

Pyramidal neurons of the hippocampus

Purkinje layer of the cerebellum

Question 6

What is the effects of damage to the pyramidal neurons of the cerebral cortex?

Answer 6

Laminar necrosis

Question 7

What is the effect of damage to the pyramidal neurons of the hippocampus?

Answer 7

Damage to long term memory

Question 8

What is the role of the Purkinje layer of the cerebellum?

Answer 8

Integrate sensory perception with motor control

Question 9

What is an ischemic stroke?

Answer 9

Regional ischemia to the brain that results in focal neurologic deficits lasting > 24 hours

Question 10

What is a regional ischemia to the brain with symptoms that last for less than 24 hours?

Answer 10

Transient ischemic attack

Question 11

What are the subtypes of strokes?

Answer 11

Thrombotic stroke

Embolic stroke

Lacunar stroke

Question 12

Thrombotic stroke is due to _____________

Answer 12

rupture of an atherosclerotic plaque

Question 13

Where does atherosclerosis usually develop?

Answer 13

Usually develops at branch points (ie bifurcation of internal carotid and middle cerebral artery in the circle of Willis)

Question 14

Does a thrombotic stroke result in a pale or hemorrhagic infarct?

Answer 14

Pale infarct

Question 15

Where is the most common source of an emboli causing an embolic stroke?

Answer 15

emboli from the left side of the heart

Question 16

Which artery is usually involved in an embolic stroke?

Answer 16

Middle cerebral artery

Question 17

Does an embolic stroke result in a hemorrhagic infarct or pale infarct?

Answer 17

Hemorrhagic infarct

Question 18

Lacunar strokes are usually secondary to __________

Answer 18

Hyaline arterolosclerosis

Question 19

Lacunar strokes usually involve what vessels?

Answer 19

Lenticulostriate vessels

Question 20

How do the lacunar strokes involving the lenticulostriate vessels grossly present?

Answer 20

Small cystic areas of infarction

Question 21

What are the results of lacunar strokes afecting the internal capsule?

Answer 21

Pure motor stroke

Question 22

What is hte result of lacunar strokes affecting the thalamus?

Answer 22

Pure sensory stroke

Question 23

Ischemic strokes result in what kind of necrosis?

Answer 23

Liquefactive necrosis

Question 24

How does liquefactive necrosis progress from the time of initial necrosis to end result?

Answer 24

Eosionophilic change in the cytoplasm of neurons (red neurons) 12 hours after infarction

Coagulative necrosis 24 hours after infarction

Infilitration by neutrophils (days 1-3)

Microglial cell infiltration (days 4-7)

Granulation tissue (weeks 2-3)

Results in fluid filled cystic space surrounded by gliosis

Remember as:

Red neurons (hrs) –> Neutrophils and microglial cells (days) –> granulation tissue (weeks) –> gliotic cyst (months)

Question 25

Intracerebral hemorrhage is classically due to ________

Answer 25

Rupture of Charcot-Bouchard microaneurysms of the lenticulostriate vessels

Question 26

Rupture of Charcot-Bouchard microaneurysms of the lenticulostriate vessels is a complication of what condition?

Answer 26

HTN

Question 27

What site is most commonly affected by intracerebral hemorrhage?

Answer 27

Basal ganglia

Question 28

Presentation of intracerebral hemorrhage

Answer 28

Severe headache

Nausea

Vomiting

Eventual coma

Question 29

How does subarachnoid hemorrhage present?

Answer 29

Sudden headache (“worst headache of my life”) with nuchal rigidity

Question 30

What does a lumbar puncture show in subarachnoid hemorrhage?

Answer 30

Xanthochormia (yellow CSF due to bilirubin breakdown)

Question 31

MCC of subarachnoid hemorrhage

Answer 31

Rupture of berry aneurysm (85%)

Question 32

What are berry aneurysms?

Answer 32

Thin walled sacular outpouchings that **lack a media layer **

Question 33

What is the MC location of berry aneurysms?

Answer 33

Anterior circle of Willis at branch points of the anterior communicating artery

(branch points often missing media layer)