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Clin Med III Unit 3 > Cerebrovascular Disease > Flashcards

Cerebrovascular Disease Flashcards

1
Q

Fifth leading cause of death in US and leading cause of disability

A

CVA

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2
Q

What part of the US has the highest regional incidence and prevalence of stroke and higher stroke mortality than the rest of the country?

A

Southeastern US (the “stroke belt”)

B/c of higher risk factors (ie DM, HTN, diet)

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3
Q

What is the difference in incidence between men and women when it comes to stroke/

A

Men have higher incidence than women at YOUNGER ages but not older

Incidence is reversed and higher for women by age 75

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4
Q

Risk factors for stroke

A

Similar to those for CAD

HTN
DM
Smoking
Dyslipidemia

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5
Q

A stroke is the acute neurologic injury that occurs as a result of one of these two pathologic processes…

A

Hemorrhage

Ischemia

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6
Q

Hemorrhage is characterized by ….

A

Too much blood within the closed cranial cavity

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7
Q

Ischemia is characterized by ….

A

Too little blood to supply an adequate amount of oxygen and nutrients to a part of the brain

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8
Q

Ischemic strokes are due to…

A

Thrombosis
Embolism
Systemic hypoperfusion

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9
Q

Local in situ Obstruction of an artery

A

Thrombosis

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10
Q

Particles of debris originating elsewhere that block arterial access to a particular brain region

A

Embolism

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11
Q

Major causes of embolism —> ischemic stroke

A

Atrial fibrillation (clots form in the heart b/c of stagnant blood flow then travel to the brain)

Carotid artery plaques rupturing

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12
Q

General circulatory problem —> insufficient blood flow —> ischemic stroke

A

Hypoperfusion

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13
Q

Ischemic strokes caused by hypoperfusion typically present a bit differently. Explain.

A

Typically diffuse and non focal compared to embolic/thrombotic events

Most affected patients have evidence of circulatory compromise with hypotension and may present with pallor, sweating, tachycardia, or severe bradycardia, kidney dysfunction etc

Neurologic signs are typically bilateral

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14
Q

What is the mechanism for watershed infarcts?

A

Secondary to low flow states from vessel overlap or systemic hypotension

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15
Q

Brain hemorrhage due to intracerebral hemorrhage or subarachnoid hemorrhage

A

Hemorrhagic stroke

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16
Q

What are the types of hemorrhagic stroke?

A

Intracerebral hemorrhage (aka parenchymal) - bleeding directly into brain tissue

Subarachnoid hemorrhage - bleeding into the CSF that surrounds the brain and spinal cord

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17
Q

Which type of CVA is more common?

A

Ischemic CVAs make up 87% of all strokes in the US

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18
Q

What percentage of CVAs are hemorrhagic and of those, what percentage are intracerebral vs subarachnoid?

A

13% hemorrhagic

10% intracerebral

3% subarachnoid

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19
Q

Why is it so important to know the difference between hemorrhagic vs ischemic CVA?

A

B/c they have the opposite treatments

If you want to differentiate - CT scan!

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20
Q

What are the two categories of stroke syndromes?

A

Large vessel (stroke within a particular vessel)

Small vessel (disease of either vascular bed - a lacunar stroke)

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21
Q

Anterior circulation strokes result from a defect in ______ supply

A

Carotid artery

Extracranial and intracranial carotid arteries, the middle and anterior cerebral artery branches

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22
Q

Posterior circulation strokes result from a defect in _______

A

The vertebrobasilar system

Extracranial and intracranial vertebral arteries, basilar artery, and posterior cerebral arteries

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23
Q

MOST COMMON TYPE OF CVA (looking for the specific vessel)

A

Middle Cerebral Artery (MCA)

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24
Q

An MCA stroke affects the ______, ______, and ______ lobes

A

Frontal
Temporal
Parietal

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25
Q

SSx of an MCA stroke

A

Contralateral hemiplegia/hemianaesthesia (weakness/numbness) variably affecting the face and arm greater than the leg

Dominant hemisphere involved = global aphasia present

Non-dominant hemisphere affect = hemineglect is seen

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26
Q

What do we mean when we say a patient “looks to the lesion”?

A

Contralateral homonymous hemianopia, and a day or two of gaze preference to the ipsilateral side

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27
Q

Is an anterior cerebral artery stroke common?

A

Nope - only 3% of all cerebral infarcts

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28
Q

Anterior cerebral artery strokes affect the _______

A

Frontal pole/lobe

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29
Q

Contralateral hemiplegia/hemianaesthesia in the leg greater than the arm

A

Anterior cerebral artery stroke

Patient may present with profound abulia (delay in verbal and motor response) or perseverating speech

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30
Q

What is abulia?

A

A delay in verbal and motor response

Seen more with ACA strokes

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31
Q

Anterior communicating artery (AComm) strokes are characterized by…

A

Impingement of cranial nerves

VISUAL FIELD DEFICITS****

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32
Q

Posterior cerebral artery strokes affect the _______

A

Occipital cortex

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33
Q

Contralateral homonymous hemianopia, with significantly reduced light touch and pinprick sensation

A

Posterior cerebral artery stroke

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34
Q

PCA strokes may go unnoticed by patient because…

A

Motor involvement is usually minimal unless it is a large infarct

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35
Q

What is Wallenberg’s syndrome?

A

Lateral medullary syndrome - stroke in the Posterior Inferior Cerebellar Artery (PICA)

Affects the lateral medulla —> ipsilateral loss of facial pain and temp sensation with contralateral loss of these senses over the body

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36
Q

SSx of PICA stroke (Wallenberg’s syndrome)

A 
Vertigo
Vomiting
Nystagmus
Ipsilateral ataxia
Hoarseness
Dysarthria
Dysphagia
Hiccups
Ipsilateral Horner’s Syndrome (typically incomplete - ptosis/miosis without anhidrosis)
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37
Q

“Locked-in syndrome” is the result of …

A

Complete basilar artery occlusion affecting the pons —> quadriplegia and facial/mouth/tongue weakness but preserved consciousness and preservation of vertical eye movements/blinking

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38
Q

Why do you get such a diversity of symptoms with a basilar artery occlusion?

A

Because it supplies the brainstem, which contains many structures in close apposition

39
Q

What is a lacunar stroke?

A

Occlusion of one of the small, penetrating branches of the Circle of Willis, middle cerebral artery stem, or vertebral and basilar arteries

Thrombosis of these vessels causes small infarcts that are referred to as lacunes

40
Q

Lacunar strokes are commonly associated with…

A

Chronic HTN

Especially older patients with uncontrolled HTN

41
Q

Whether the presumed stroke is ischemic or hemorrhagic, the initial assessment is the same and should include…

A

Airway
Breathing
Circulation

42
Q

Why do you have to be so careful about airway/breathing with stroke patients?

A

Increased ICP can lead to a decreased respiratory drive

Depending on location/severity they may also have decreased level of consciousness

Intubation may be necessary to restore adequate ventilation and to protect the airway

43
Q

Mean arterial blood pressure (MAP) is usually _______ in patients with an acute stroke

A

Elevated

May be due to chronic HTN, which is a major risk factor for the stroke

Often represents an appropriate response to maintain brain perfusion

44
Q

The decision to treat elevated BP in a stroke patient requires a fine balance between…

A

The potential danger of severe increases in BP and a possible decline in neurologic functioning when BP is lowered

45
Q

Most consensus guidelines agree that you should not start treating BP for ISCHEMIC stroke unless…

A

It is greater than 220/120 - the risk of further ischemia is too great otherwise

Exception is if you are treating with thrombolytics

46
Q

Many guidelines suggest keeping BP _______ for hemorrhagic stroke to prevent increases in bleeding

A

<160/90

Keep in mind it is undesirable for the systolic BP to drop “too” low (<140) and cause ischemia in other areas

47
Q

What is the most important initial question when taking history on a suspected stroke patient?

A

WHEN DID THE SYMPTOMS START?

Then consider DDx and evaluate for any focal neuro deficits that may point to the location of the problem

48
Q

The first diagnostic test in the assessment of a stroke

A

NON CONTRAST CT scan of the brain

Why? R/o hemorrhage

49
Q

Diagnostic imaging that is more sensitive for ischemia early in the course of a CVA but that is not widely available yet

A

STAT diffusion weighted MRI

50
Q

In addition to CT, what dx tests do you need to do for your CVA patient?

A 
ECG
CBC incl platelets
Serum glucose
PT/INR and PTT
Cardiac enzymes (troponin)
BMP
51
Q

With a hemorrhagic CVA, your diagnosis is based on…

A

The CT scan

Ct will show blood in the area of the brain that is suffering from stroke

52
Q

With an ischemic CVA, how will the CT look?

A

May very likely be normal

Ischemia takes a certain length of time to be evident on CT

53
Q

When will you need to diagnose a stroke clinically?

A

If symptoms have been present for <6 hours, the affected area is small or located in an area of the brain not well seen on CT (ie posterior fossa)

AND

The CVA is secondary to ischemia

54
Q

Treatment for an acute CVA depends upon…

A

Whether the stroke is ischemic or hemorrhagic in nature

55
Q

Early (~48 hours) initiation of ____ has shown benefit for the treatment of acute ISCHEMIC CVA

A

Aspirin

Short-term use of dual antiplatelet therapy (Clopidigrel) plus aspirin may be beneficial for patients with high-risk transient ischemic attack or minor stroke

56
Q

If the brain CT shows no bleed, ______ should be given within 48 hours

A

Full dose aspirin

If patient is suffering from dysphasia, it should be given rectally to prevent aspiration

57
Q

What is the most effective maneuver for salvaging ischemic brain tissue that is not already infarcted in an ischemic stroke?

A

Timely restoration of blood flow using thrombolytic therapy

Extremely disputed - because does it help if you convert their ischemic stroke into a hemorrhagic one?

58
Q

Currently, tPA is not recommended beyond _______

A

4.5 hours of symptoms

59
Q

What is the caveat for BP control if giving thrombolytic therapy?

A

Desired systolic CP ≤185 and diastolic BP ≤ 110 to reduce risk of hemorrhage

60
Q

What is the timeline you should shoot for when evaluating and treating an ischemic stroke?

A

Eval by physician in first 10 min

Stroke team in first 15 min

Heat CT or MRI within 25 min

Interpretation of neuro scan within 45 min

Start of IV tPA if eligible within 60 min

61
Q

As a general rule, CT scan must be _____ to consider tPA

A

Normal

If it shows blood —> hemorrhage, and tPA obviously out

If it shows ischemia (acute hypodensities) you known Sx have been going on too long for tPA to be considered safe

62
Q

What is Intra-arterial thrombolysis?

A

Catheter-directed tPA

Smaller dose than peripheral IV tPA, can be done after peripheral IV tPA

NOT proven beneficial thus far but it’s a thing

63
Q

What is mechanical thrombectomy?

A

Endovascular treatment with a stent retriever improves outcomes for patients with acute ischemic stroke caused by large artery occlusion in the proximal anterior circulation who can be treated within 6 hours of sx onset

64
Q

What is the mainstay of therapy for hemorrhagic strokes?

A

All anticoagulant and antiplatelet drugs should be d/c immediately

Anticoagulant effect should be reversed immediately with appropriate agents
• Example - fresh frozen plasma, Vitamin K, possibly prothrombin complex concentrates (PCCs) to replenish clotting factors and reverse the effects of warfarin

65
Q

Methods to lower ICP in patients with hemorrhagic stroke

A

Initially:
Elevate HOB to 30 degrees
Use analgesia/sedation

More aggressive therapies:
Osmotic diuretics (ie mannitol)
Ventricular catheter drainage of CSF (bolt)
Neuromuscular blockade
Hyperventilation (short term)
66
Q

What is the BP goal for patients with hemorrhagic stroke?

A

160/90

Higher BPs can caused continued force for bleeding

Use antihypertensives to achieve - Nicardipine drip is common

67
Q

Your patient with a hemorrhagic stroke may also need…

A

Antiepileptic treatment to quickly control any seizures they may have

68
Q

Any brain hemorrhage warrants _______

A

Immediate neurosurgical consult - but many will not require operative intervention

69
Q

Which types of hemorrhages will likely require surgical removal of the hemorrhage immediately?

A

Cerebellar hemorrhages >3cm in diameter

Those who are deteriorating

Brainstem compression

Hydrocephalus due to ventricular obstruction

70
Q

Secondary prevention for specifically for ISCHEMIC CVAs

A

Antiplatelet meds

Warfarin if afib or prosthetic heart valve

Carotid endarterectomy if justified

71
Q

Secondary prevention for either type of CVA

A

Treatment of underlying condition (DM/HTM/HLD)

Cessation of smoking/heavy alcohol or illicit drug use

72
Q

Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction

A

Transient Ischemic Attack (TIA)

73
Q

TIA was originally defined as a sudden onset of focal neurologic symptom and/or sign lasting _______ and caused by ________

A

<24 hours

Transient decrease in blood supply

Using 24 hours was an arbitrary cut-off and therefore lack of tissue damage regardless of the timing is more precise/adequate

74
Q

The “classic” definition of TIA is inadequate b/c…

A

Even relatively brief ischemia can cause permanent brain injury

With diffusion weighted MRI becoming more prevalent, “Transient symptoms with infarction” has become its own category - the patient is clinically unharmed but the brain has still suffered injury

75
Q

Why do we care about TIA?

A

The stroke risk in the first two days after TIA is ~4-10% and just under 30% over the following 5 years

Symptoms do NOT have to be focal either - even global sx such as numbness/tingling can be a TIA

76
Q

Testing/therapy for TIA is based upon….

A

Lessening the risk for impending stroke

EKG - looking for afib
Carotid U/S - assess need for carotid endarterectomy
Lipid lowering meds
Anti-HTN meds
Diet/lifestyle mods

Start daily aspirin unless contraindicated

Some hospitals are even using CTA of the circle of Willis and carotids to assess for blockage/aneurysm

77
Q

What is a “high risk” headache?

A

Severe HA w/o previous hx of HA

Sudden onset

Somnolence

Vomiting

78
Q

Patients with high risk features to their HA need…

A

Urgent Non-contrast CT

If abnormal, you may likely have your diagnosis and can manage

79
Q

If your urgent non-contrast CT of your patient with a sudden severe headache is normal, what do you do next?

A

LP to obtain CSF for analysis

80
Q

The headache onset with subarachnoid hemorrhage is usually…

A

Sudden and sometimes described as “thunderclap”, WORST HEADACHE OF MY LIFE

81
Q

Subarachnoid hemorrhages are most often caused by…

A

Ruptured secular aneurysms or trauma

82
Q

Most aneurysmal SAH occur between ____ and _____ years of age

A

40 and 60

Slightly higher incidence in women too

83
Q

Risk factors for SAH

A 
Aneurysms in other blood vessels
Fibromuscular dysplasia or other connective tissue disorders
HTN/HLD
DM
Heart disease
Obesity
Hx of Polycystic kidney disease
Smoking/alcohol abuse
Family hx of SAH
84
Q

What is the most common complication of SAH?

A

Rebleeding

Occurs more often within the first day

85
Q

A common complication of SAH that causes symptomatic ischemia and infarction in approx 20-30% of patients with aneurysmal SAH

A

Vasospasm

86
Q

Vasospasm complications of SAH typically begins __________ after hemorrhage

A

No earlier than day 3, reaching a peak at day 7

87
Q

_______ and ________ are the leading causes of death and disability after aneurysm rupture in SAH

A

Vasospasm

Re-bleeding

88
Q

How is SAH diagnosed?

A

Noncontrast CT —> blood in the subarachnoid space IF scan performed within 24 hours of bleed

If CT normal, LP looking for bleeding or infection

89
Q

How to differentiate between SAH and traumatic tap following LP?

A

If traumatic tap (you hit a vessel as you were obtaining CSF), the RBC numbers tend to decrease from 1st tube to 4th tub

If SAH, the RBC numbers tend to stay the same

90
Q

Most sensitive indicator of SAH on CSF analysis

A

Xanthochromia (pink or yellow tint of the CSF) - represents hemoglobin degradation products

91
Q

How do you manage SAH patients?

A

Admit to ICU

Analgesia - can diminish hemodynamic fluctuations to help prevent re-bleeding

Control of ICP

Transcranial Doppler U/S to monitor for vasospasm

92
Q

What do you do to prevent vasospasm in SAH patients?

A

IV fluids and nimodipine

93
Q

Once admitted and diagnosed, how do you treat SAH patients?

A

Stop all blood thinners

Seizure prophylaxis

Nimodipine (start w/in 4 days and continue for 21 days)

Surgery (aneurysm clipping or endovascular coiling) to prevent re-bleeding and prevent another aneurysm

94
Q

Are traumatic SAHs more or less serious than spontaneous SAH

A

Generally NOT as severe as spontaneous SAH

Clin Med III Unit 3 (5 decks)

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