Cerebrovascular disease & stroke

Question 1

When referring to Cerebrovascular Diseases, we
are referring to any condition that affects ____

Answer 1

blood flow in the brain

Question 2

When we speak of Cerebrovascular Disease, this includes:

Answer 2

○ Transient Ischemic Attack (TIA)
○ Stroke (CVA)- Either ischemic or hemorrhagic
○ Carotid Artery Stenosis
○ Vertebral Artery Stenosis
○ Cerebral Aneurysms (Aneurysmal SAH)
○ Vascular Malformations (such as AVMs)

Question 3

Transient Ischemic Attack (TIA)

Answer 3

● Transient Ischemic Attacks are characterized by focal ischemic cerebral neurologic deficits that last for less than 24 hours.
○ Most commonly, the deficit lasts for less than 1-2 hours

Question 4

Transient Ischemic Attack (TIA) pathophysiology

Answer 4

● The pathophysiology is essentially the same as the pathophysiology behind a large stroke, except that the blockage is temporary.
● Stroke-like symptoms occur,
but the blockage dislodges before any permanent damage is done.

Question 5

Symptoms of TIA may include, but are not limited to

Answer 5

○ Sudden numbness or weakness in a face, arm, or leg
○ Sudden confusion, trouble speaking, or understanding
○ Sudden trouble seeing in one or both eyes (Amaurosis Fugax)
○ Sudden trouble walking, dizziness, loss of balance or coordination
○ Sudden, severe headache with no known cause

Question 6

Subclavian Steal Syndrome

Answer 6

○ A less common cause of TIA that results in
symptoms of vertebrobasilar ischemia.
■ Dizziness, vertigo, diplopia, loss of vision in
one or both eyes, sudden and severe
weakness causing “drop attacks,” loss of
balance and coordination, etc.

Question 7

Subclavian Steal Syndrome etiology

Answer 7

○ Occurs when an atherosclerotic plaque
occludes the Subclavian artery proximal to the
source of the vertebral artery, which results in
“stealing” of blood from that vertebral
○ The affected Subclavian is fed blood by retrograde flow of the ipsilateral vertebral, drawing blood away from the vertebrobasilar system, causing signs and symptoms of this Vertebrobasilar Insufficiency.
○ The patient will have unequal radial pulses and
lower blood pressure in the affected arm (lower by 20 mmHg or more)

Question 8

An important cause of TIA (and stroke for that matter) is ______

Answer 8

embolization

Question 9

Cardiac causes of TIA

Answer 9

Atrial fibrillation, Rheumatic heart disease, mitral valve disease,
infective endocarditis, atrial myxoma, and mural thrombi complicating
myocardial infarction.
■ Atrial septal defects and patent foramen ovale may permit emboli from the
veins to reach the brain (Paradoxical emboli)

Question 10

Extracranial Artery causes of TIA

Answer 10

Ulcerated atherosclerotic plaque in one of the four major arteries supplying blood to the brain may serve as a source of emboli.
■ Most commonly at the bifurcation of the Carotid, but can occur in the
vertebral arteries as well.

Question 11

Transient Ischemic Attack (TIA) imaging

Answer 11

● CT scan (and possibly MRI) is indicated within 24 hours of symptom
onset, in part to exclude hemorrhagic stroke or other pathology.
● MRA or CTA of the cervical vasculature should be performed.
● Carotid Duplex Ultrasound is useful for Carotid stenosis evaluation.
● EKG and possibly Echocardiogram to look for cardiac causes.
● If these non-invasive studies do not reveal an etiology, conventional
cerebral angiography is indicated

Question 12

An ABCD2
score of ____ or more points suggests need for hospitalization with a TIA

Answer 12

4

Question 13

ABCD2 score guidelines

Answer 13

○ Age 60 or older (1 point)
○ Blood pressure over 140/90 mmHg (1 point)
○ Clinical symptoms of focal weakness (2 points)
■ Or speech impairment without weakness (1 point)
○ Duration of more than 60 min (2 points) or 10-59 min (1 point)
○ Diabetes Mellitus (1 point)
○ ABCD2 I may be better - Additional 3 points for abnormal diffusion-weighted MRI.

Question 14

Transient Ischemic Attack (TIA) Treatment

Answer 14

○ Management is aimed at preventing another TIA and stroke
○ Patients with diabetes, hematologic conditions, heart disease, hypertension, and other risk-increasing conditions should be managed completely and appropriately for those conditions.
○ Patients with atherosclerosis should be treated for LDL reduction
■ High-intensity atorvastatin with or without Ezetimibe is preferred.
○ Any and all lifestyle-related interventions should be initiated.
■ Cigarette smoking should be stopped, weight reduction pursued if
appropriate, regularly physical activity initiated (if not already), etc
○ Systemic anticoagulation with warfarin or a DOAC may be necessary

Question 15

The risk of stroke is highest in_____following the TIA

Answer 15

the month
immediately

Question 16

Cerebrovascular Accident (CVA)

Answer 16

● Another name for Stroke is Cerebrovascular
Accident (CVA).
● Stroke is the fifth leading cause of death in
the United States.
Cerebrovascular Accident (CVA)
● About 25% of people who recover from their first stroke will experience
another stroke within 5 years.
● Approximately 700,000 people are affected
each year in the US

Question 17

Types of stroke

Answer 17

■ Ischemic Stroke:
● Lacunar infarct (small, subcortical strokes)
● Carotid circulation obstruction (classic big strokes)
● Vertebrobasilar occlusion
■ Hemorrhagic Stroke:
● Spontaneous intracerebral hemorrhage
● Aneurysmal subarachnoid hemorrhage

Question 18

Pathophysiology of ischemic-type strokes

Answer 18

○ The reduced blood flow to the tissue starves the cells of nutrients and
quickly leads to cell malfunction.
○ The area where blood is completely cut off is the core infarction and
those cells die within 5 minutes.
○ The area surrounding the core is called the
ischemic penumbra and consists of cells
that are malfunctioning, but still alive and
can survive for about three hours in this
idling state

Question 19

Pathophysiology of a hemorrhagic stroke

Answer 19

○ Most commonly occurring as a result of
hypertension, weakened blood vessels can
rupture causing an intracerebral
hemorrhagic stroke.
○ Causes an intraparenchymal blood clot
with surrounding edema (mass effect)

Question 20

CVA clinical presentation

Answer 20

○ Onset of symptoms is usually quite abrupt and symptoms depend on where in the brain the stroke is occurring.
○ Symptoms are often contralateral to the affected hemisphere, but again,
depends on where the lesion is.
○ Because the symptoms depend on the
location of the lesion, the symptoms can
often indicate where the stroke is based on
arterial distribution.

Question 21

Lacunar Infarction vs Cerebral Infarction

Answer 21

■ Lacunar infarcts do not affect the cerebral cortex
● Small stroke lesions (usually less than 1.5 cm) that occur in the distribution of the short penetrating arterioles and affect the
basal ganglia, pons, cerebellum, internal capsule, thalamus, and less commonly, the deep cerebral white matter.
■ Cerebral infarcts do affect the cerebral cortex.
● Potentially larger stroke lesions that occur when a major vessel (not the small penetrating arterioles) is occluded and a portion
of the cortex is made acutely ischemic

Question 22

CVA diagnosis

Answer 22

○ If stroke is suspected (based on H&P), CT head without contrast should be performed immediately
○ As long as noncontrast head CT reveals no hemorrhage, CT Angio of the head and neck should be performed to identify large vessel occlusions (LVO) amenable to endovascular therapy
○ MRI scan (specifically diffusion weighted series) is the gold standard for identifying acute ischemic stroke
○ Some facilities have the ability to do CT Perfusion studies, which utilizes CT
contrast to differentiate salvageable ischemic brain tissue

Question 23

Acute Management of a CVA

Answer 23

○ Patients with ischemic strokes should be considered for rapid treatment
with IV recombinant tissue plasminogen activator (rtPA/TNK)
○ tPA/TNK is effective in reducing
neuro deficits in selected patients
when administered ASAP, but not
more than 4.5 hours after the onset of
symptoms. The strongest evidence is
for Tx within 3 hours of Sx.
○ Attempts to lower the blood pressure during an acute stroke is often times not advised, especially in ischemic strokes
○ Early decompressive hemicraniectomy may be used for malignant MCA infarcts
○ ICP can increase early due to swelling. Head elevation should occur and
sometimes osmotic agents (like mannitol) might be used to decrease edema.
○ Dual antiplatelet therapy should be used for 21 days in patients with minor
stroke (NIHSS of 3 or less). Monotherapy longterm for most patients.
○ Systemic anticoagulation is indicated in those with ischemic
strokes and A-fib or other sources of cardioembolism.

Question 24

Treatment for hemorrhagic stroke

Answer 24

○ Treatment for hemorrhagic stroke is largely
supportive and sometimes involves surgery,
although surgery is for saving life, not
function.

Question 25

Modifiable/Treatable risk factors of stroke:

Answer 25

○ Smoking
■ Even second-hand
○ Hypertension
○ Diabetes Mellitus
○ Hyperlipidemia
○ Carotid Artery Stenosis
○ History of TIAs (secondary prevention)
○ Physical Inactivity and Obesity
○ Poor diet high in saturated fats and carbs
○ Receiving hormone replacement therapy
(HRT) or estrogen birth control pills

Question 26

Non-Modifiable Risk Factors of stroke:

Answer 26

○ Age
○ Biological sex
■ Slightly more common in males than females
○ Heredity and Race
■ Family history of CVA increases your risk
■ Individuals of African descent have a higher
risk than other racial groups (see readings)
○ Prior Stroke or Heart Attack

Question 27

Carotid Artery Stenosis

Answer 27

● Atherosclerotic plaques frequently develop at the bifurcation of the common
carotid in patients with risk factors.
● As the plaque develops and grows,
stenosis develops.
● These plaques can become irritated
and inflamed, which can result in ulceration and rupture of the plaque itself

Question 28

Carotid stenosis is often times discovered
after _____

Answer 28

a provider hears bruits over the
carotids or incidentally on unrelated
imaging, such as a thyroid ultrasound

Question 29

Medical management of carotid stenosis

Answer 29

■ For asymptomatic patients with less than
about 70% stenosis
■ Lifestyle modifications for all
■ Aspirin 325 mg QD or Clopidogrel (Plavix)

Question 30

Surgical management of carotid artery stenosis

Answer 30

■ For symptomatic patients or for
asymptomatic patients with more than about
70% stenosis
■ Carotid Endarterectomy (CEA) is preferred
■ Don’t D/C Aspirin 325 mg QD for surgery

Question 31

Cerebral Aneurysm

Answer 31

● Saccular aneurysms, often referred to as “Berry Aneurysms,” are small
outpouchings coming off of larger arteries in the brain
● They can result from congenital defects,
hypertension, atherosclerosis, trauma, etc.
● Can occur at any age, but incidence
steadily increases after 25 years of age and
is most prevalent in the 50’s and 60’s.

Question 32

Cerebral Aneurysm pathophysiology

Answer 32

○ They tend to occur at arterial bifurcations at the
Circle of Willis or in the Sylvian Fissure.
○ A natural weakness exists at these bifurcations.
Cerebral Aneurysm
“A Comprehensive Review for the Certification and Recertification Examinations for Physician Assistants,” O’Connell and Zarbock.
○ The adventitia of the arterial
wall pushes through the elastic
membrane of the artery, results
in the berry aneurysm.
○ Berry Aneurysms may be
associated with Polycystic
Kidney Disease and Coarctation
of the Aorta

Question 33

Clinical Presentation of a cerebral aneurysm

Answer 33

○ May remain asymptomatic throughout life.
○ May grow and push on cranial nerves, causing
cranial nerve palsies (especially CN VI).
Cerebral Aneurysm
“A Comprehensive Review for the Certification and Recertification Examinations for Physician Assistants,” O’Connell and Zarbock.
○ If and when they rupture, the patient
experiences a severe and sudden headache
○ May experience rapid deterioration with
altered mental status and coma
○ Patients commonly present with extremely high
BP due to high ICP (which often occurs due to
Obstructive Hydrocephalus).
○ The Subarachnoid Hemorrhage that occurs with
the rupture can cause fever, stupor, coma,
nuchal rigidity and other signs of meningismus

Question 34

About 40% experience a “Herald Bleed” in a _____

Answer 34

Cerebral Aneurysm

Question 35

Diagnosis of cerebral aneurysm

Answer 35

○ Ruptured Berry aneurysms account for 75% of non-traumatic cases of
SAH seen on CT scans (Aneurysmal SAH)
○ Order CT head without contrast STAT as soon as you suspect SAH!
○ LP should be done to confirm negative CT
○ In a patient in whom you suspect an unruptured aneurysm, or if a CT or
MRI suggests possible aneurysm…
■ MRA
■ CTA
■ or Cerebral
Angio

Question 36

Cerebral Aneurysm management

Answer 36

○ Rupture of a Berry aneurysm carries a mortality rate of 40-50%.
○ Many patients die within minutes of the rupture, while others die days later as a result of cerebrovascular spasm or decreased cerebral perfusion
○ Surgical care may involve Endovascular Coiling (preferred) or Open Craniotomy for Clipping (old school but good).
○ Unruptured aneurysms are often watched with serial imaging, and if they get to more than 8 mm, coiling or clipping is often performed to prevent rupture

Question 37

Arteriovenous Malformations (AVM)

Answer 37

● Almost all AVMs are congenital and are often
found in multiple places, not just one.
● Dural-based AVMs are an acquired condition
that may be triggered by injury
● AVMs can occur anywhere in the body, but the
ones in the brain present substantial risk when
they decide to bleed

Question 38

Arteriovenous Malformations (AVM) pathophysiology

Answer 38

○ AVMs result from a localized maldevelopment of part of the
primitive vascular plexus and vary in size from tiny to massive.
Arteriovenous Malformations (AVM)
“A Comprehensive Review for the Certification and Recertification Examinations for Physician Assistants,” O’Connell and Zarbock.
○ They consist of abnormal arteriovenous
communications without intervening capillaries
○ AVMs have a tendency to rupture

Question 39

Clinical Presentation of an AVM

Answer 39

■ Hemorrhage (less intense than aneurysm) in 30-60%
■ Recurrent seizures in 20-40%
■ Abnormal headache in 5-25%
■ Miscellaneous complaints (including focal deficits) in 10-15% of cases
○ Hemorrhages are sometimes both intraparenchymal as well as into the
subarachnoid space and mortality rate is about 10%.
○ Up to 70% of AVMs bleed at some point, usually before 40 YOA.
○ Small AVMs are more likely to bleed than larger ones

Question 40

Diagnostic Evaluation of AVMs

Answer 40

○ If a hemorrhage is suspected, CT head STAT.
○ In patients without hemorrhage (but maybe with
seizure, etc.), CT or MRI usually reveal the lesion.
○ To confirm the presence of
an AVM, and to delineate
the size and borders, order a
Cerebral Angiogram

Question 41

Arteriovenous Malformations (AVM) management

Answer 41

○ As long as the AVM is easily accessible and
the patient has a good life expectancy,
surgical treatment to prevent further
hemorrhage is justified.
Arteriovenous Malformations (AVM)
“A Comprehensive Review for the Certification and Recertification Examinations for Physician Assistants,” O’Connell and Zarbock.
○ Removal might involve…
■ Open microsurgical excision
■ Stereotactic Radiosurgery (radiation)
■ Endovascular Embolization