Cerebrovascular Disease Flashcards
What are the sx for Asx Carotid Bruit?
No sx
Who gets Asx Carotid Bruits?
4% of pts >40yo
Carotid bruit are more ominous in ______.
Pt w/ vascular RF
Where can carotid bruit be heard BEST at?
Immediately under the angle of the mandible
Where can asx carotid bruits be heard?
Internal, common or external carotid
What are high pitched asx carotid bruits assoc w/?
Higher grade stenosis
What are the technical features of asx carotid bruit?
- Carotid doppler US
- Magnetic resonance agniography (MRA)
- CT arterigoraphy
What are Bruits?
Turbulent BF through area of lumen narrowing
Where is turbulence greatest?
Arterial bifurcations
What are the MCC of bruits?
Atherosclerosis & Plaque formation
What is the management of asx carotid bruit?
Aggressive management of vascular RF, as aggressive as if the pt had incurred a stroke or heart attack
When bruit becomes sx the risk
If a bruit is heard best near the clavicle what does that mean?
Probably referred cardiac murmur
What is the significance of a sx bruit?
What is the risk of a stroke in a pt w/ an asx bruit?
<2%/year
What are the RF for strokes?
- HTN***
- DM
- Hyperlipidemia
- Alcohol
- Smoking
- Vasculitis
- Carotid bruit
- Embolic cardio d/o
- Berry aneurysm
- AVM
- Coagulopathy
- Anticarolipid Ab
What is a Transient Ischemic Attack (TIA)?
Focal neurological deficit is caused by reduced BF
Resolves completely w/in 24 hours
What is a Reversible Ischemic Neurologic Deficit (RIND)?
Same as TIA except lasts >24 hours & completely resolves w/in 2 weeks
Vascular causes of TIA happen in pt w/ ___.
Vascular RF
Non-vascular causes of TIA happen in pt w/ ____.
- Partial or focal seizures
- Migraine auras
- an MS attack may be as breif as a couple of days
What are the PE findings of TIA/RIND?
- During attack physical findings indicates stroke
- May have carotid bruit or A-fib
- Normal neuro exam
- HTN is common
What is used to dx a TIA/RIND?
Clinical dx not technological exam
What are the technolgical features of TIA/RIND?
- No imaging ABN
- May be carotid stenosis Carotid doppler US or A-fib on ECG
- ABN labs indicate RF
What is the prognosis of untx TIA?
- 10% stroke in 6 mo
- 6% stroke in 2yr
- 13% sroke & die by 1yr
- 23% die by 2nd yr
- 33% die by 3rd yr
What are the RF for Atherosclerosis?
- HTN**
- DM
- Age
- Smoking
- Genetics
What is the greatest RF for stroke?
Previous stroke or TIA
What is the 2nd greatest RF for stroke?
Atrial Fibrillation
What are the signs of ischemia to the Internal carotid artery?
- Contralateral weakness & numbness
- Speech disturbances
- Monocular ischemia to ipsilateral eye
What is Amerosis fugax?
Transient loss of vision in one eye→ “shade being pulled down”
What causes Amerosis fugax?
Internal carotid artery or Ophthalmic artery problem
What are the signs of ischemia to the ACA?
Motor & sensory sx in leg
What are the signs of ischemia to the MCA?
- Arm & leg weakness
- Sensory loss
- Speech compromised if in dominant hemisphere
What are the signs of ischemia to the PCA?
Hemiopsia or complete cortical blindness
(near calcarine fissure)
What are the signs of ischemia to the Basilar artery?
Loss of consciousness OR CN dysfxn
(brainstem)
What are the treatable RF for TIA/RIND?
HTN, hyperlipidemia & DM
What are the guidelines that should be followed to dec the RF for stroke?
- Smoking cessation
- BP <120/80
- LDL <70
- Cholesterol <100
- Antiplatelet tx (81mg/day apsirin)
What is the tx for stenosis >70% in internal carotid artery?
Carotid endarterctomy
If there is A-fib present the stroke pt should be on ____ therapy.
Anticoagulation
If no A-fib present the stroke pt should be on _____ therapy.
Begin anti-platelet therapy
What is the MCC of Ischemic stroke?
Atherosclerosis in 85% of cases
What is the hx of a pt w/ ATH Ischemic stroke?
- Preceding TIA’s
- Vascular RF
- CAD or peripheral artery dz
What are the PE findings of ATH Ischemic stroke?
- Focal neuro deficits
- Not rapidly improving during the exam
What is the imaging test of choice for ATH Ischemic stroke?
Brain CT scan w/o contrast if urgent medical care being considered
What will a CT scan w/o contrast immediately reveal?
Hemorrhage or acute blood
How long will it take for an ischemic infarct to be visualized on CT?
may take 24 hours or longer
What are the pros & cons of Brain MRI for ATH Ischemic stroke?
- More sensitive than CT at showing ischemic infarctions
- Less sensitive at detecting acute hemorrhage
After a pt is stabilized what tests should be run to see if hemodynamically significantly stenosis is present in a pt w/ an ATH ischemic stroke?
Carotid Doppler US or MRA of the carotid arteries
What test should be run to rule out A-fib?
EKG
What is the timing of Embolic strokes?
More acute than ATH strokes
What is the tx for ATH Ischemic stroke?
- tPA <3 hrs after onset of stroke
- Bed elevated >30 degrees
- Monitor vital signs & neuro findings
- Cardiac monitoring
What are the CI of tPA tx?
- Hemorrhage on CT
- Seizure activity @ stroke onset
- Recent intracranial hemorrhage, trauma or surgery
- Active bleeding or bleeding d/o
- Coagulation ABN
- Uncontrolled HTN
- Rapidly improving
What indicates a Coagulative ABN?
- Heparin w/in 48 hours
- Prolonged PT (INR)
- <100k platelets
What are the Cardioembolic RF?
- A-fib
- Previous subendocardial MI
- Mechanical prosthetic cardiac valve
- Patent foramen ovale
- Atrial myxoma
What are the PE findings of Cardioembolic Ischemic stroke?
- Acute in onset
- Focal neuro deficits
- Not rapidly improving during exam
- A-fib detected as “irregular irregularity” of heart rhythm
- Murmurs on auscultation
What are the technical features of Cardioembolic Ischemic stroke?
- CT & MRI appearance of ischemic infarction
- A-fib or prior anterior wall MI on EKG common
- Heart murmurs MC
- Cardiomegaly on X-ray MC
Cardioembolic stroke is more likely to undergo ____ ____ w/in 72 hours.
Hemorrhagic transformation
What is the tx for Cardioembolic stroke?
tPA
What is the management of Cardioembolic stroke?
LT anticoagulant therapy after the acute event unless there is a CI
What is a Lacunar stroke?
Very small infarcts 2-3mm up to 1-2cm in size
What do pt w/ lacunar strokes have a high incidence of?
DM & HTN
What are the sx of Lacunar stroke
Many are asx, so by the time of the “1st stroke” there may be >10 lesions on MRI
What is Thalamic syndrome?
Contralateral unilateral numbness & pain
What is the prognosis of a Intraparenchymal (intralobal) hemorrhagic stroke?
Much more lethal d/t edema
What is the hx of Intraparenchymal hemorrhagic strokes?
- Very abrupt acute strokes
- HA’s
- Early seizures are freq
- HTN
- Fewer ATH RF
What are the PE findings of Intraparenchymal hemorrhagic strokes?
Deteriorate quicker but otherwise similar to other types of strokes
What is the best dx imaging for intraparenchymal hemorrhagic strokes?
Brain Ct w/o contrast (dx ~99% of cases)
What causes intraparenchymal hemorrhagic strokes?
HTN
What is the tx for Intraparenchymal hemorrhagic strokes?
- Management of HTN
- Dexamethasone & mannitol to manage brain edema
- Keep bed elevated
- Manage complications
- ICP monitoring
- Craniotomy can be life saving
What are the sx of AVM?
Asx until they rupture & bleed
What can pt present w/ if the AVM is peripheral near the cortex?
Seizures or HA’s
How can AVM’s be discovered?
Incidentally upon brain imaging for HA or seizures
Who gets AVM’s?
Pts younger than stroke pts
What will be found on PE in AVM’s?
Large AVM or rupture can cause focal neuro deficits
No physical ABN
What are the technological features of AVM?
- Dx w/ CT or MRI
- Arteriography is important for deciding definitive tx
What are AVM’s?
Vascular anomalies or benign neoplasms in the brain
What is the tx for AVM’s?
Left untx b/c M/M assoc w/ tx
