Cerebrovascular Diseases

Question 1

T/F: If symptoms neurologic deficit improves for less than or equal to 24 hours, it is still stroke

Answer 1

F = transient ischemic attack

Question 2

Three main processes of cerebral vascular occlusion

Answer 2

Atherosclerosis with superimposed thrombosis
Cerebral embolism
Occlusion of small cerebral vessels

Question 3

T/F: Intracerebral hemorrhage can be caused by coagulopathies that arise endogenously

Answer 3

T

Question 4

T/F: Vascular malformations of the brain is the most common cause of intracerebral hemorrhage

Answer 4

F= Chronic hypertension leading to rupture

Question 5

This is the initial step of artherogenesis inside the lumen of the artery

If the cerebral blood flow is less than _______, infarction occurs

Answer 5

Endothelial dysfunction

less than 12 ml/min

Question 6

Ischemic core is (hypo/hyper)intense on MRI

This contains at risk but viable neurons

Answer 6

HYPERINTENSE

Penumbra

Question 7

4 important processes that contribute to cerebral ischemia

Answer 7

Impaired Energy metabolism
Activation of phospholipases
Alteration of neuronal membrane function
Excitotoxicity

Question 8

Explain how impairment of energy metabolism occurs due to cerebral ischemia

Answer 8

When there is cerebral ischemia > reduced glucose and oxygen > reduced ATP > impairs choline and phosphocholine > damage to phospholipids in the cell membrane

Question 9

Explain how activation of phospholipases occurs due to cerebral ischemia

Answer 9

Phospholipase activates arachidonic acids > fatty acids , free radicals , protein kinase C > attack the cell membrane > neuronal membrane damage

Question 10

Explain how alteration of neuronal membrane function occurs due to cerebral ischemia

Answer 10

alterations in ionic exchange, receptor functions, and neurotransmissions > neuronal dysfunction

Question 11

Explain how excitotoxicity occurs due to cerebral ischemia

Answer 11

Ischemia increases glutamate levels > activates NMDA channel > raises intracellular calcium > produces NO and formation of free radicals

Question 12

This clinical stroke syndrome refers to:

1. Maximum neurologic deficit at onset and symptoms does not worsen further
2. Abrupt in onset that is virtually static or steadily progressive over a period of minutes or hours
3. It evolves more slowly with a stepwise progression
4. Characterized by severe/worst headache; almost instantaneous

Answer 12

1. Embolic stroke
2. ICH
3. Thrombotic or artherothrombotic stroke
4. SAH

Question 13

1st essential feature of stroke:

2nd essential feature:

Answer 13

1st: abruptness
2nd: focal signature and the size of infarct or hemorrhage

Question 14

3 criteria at which stroke is identified

Answer 14

Temporal profile of the clinical syndrome
Focal brain disease/tissue damage
Clinical setting

Question 15

T/F: The TOAST classification is the 5 subtypes of hemorrhagic stroke according to their etiology

T/F: In TOAST classification, small vessel occlusion is the most common

Answer 15

F- ischemic stroke

F= large artery atherosclerosis

Question 16

T/F: The evolution of clinical phenomena in central thrombosis is more variable than that of embolism and hemorrhage

Answer 16

T

Question 17

T/F: The stroke cannot be preceded by minor signs or transient attacks of focal neurologic dysfunction

Answer 17

F= half of the patients experience minor signs prior to stroke

Question 18

One of the characteristic “minor signs” preceding stroke

Answer 18

Stuttering

Question 19

Atheromatous plaques preferentially form where?

Answer 19

Branching points and curves of cerebral arteries

Question 20

What are the frequent sites of atheromatous plaques in these vessels?

Internal Carotid Artery
Vertebral Artery
MCA
Proximal PCA
Proximal ACA

Answer 20

Internal Carotid Artery - at the ORIGIN from the COMMON CAROTID
Vertebral Artery - CERVICAL PART of VA and their JUNCTION forming the BASILAR ARTERY
MCA- at the STEM or MAIN BIFURCATION
Proximal PCA - as they wind around the MIDBRAIN
Proximal ACA- as they pass anteriorly and curve over the CORPUS CALLOSUM

Question 21

T/F: Cerebral embolism is usually due to cardioembolic

T/F: Hemorrhagic infarction nearly always indicates embolism

Answer 21

T
T

Question 21

Most common cause of cerebral embolism

Answer 21

Atrial fibrillation

Question 22

What do you check when there is possible cardioembolism?

Answer 22

Carotid bruit, murmurs, heart rhythm, ECg

Question 23

If the patient has cardioembolic infarct, which scoring system must be used?

Answer 23

CHA2DS2-VASc score (new)

Question 23

T/F: Small vessel disease affects the penetrating arteries What are the two mechanisms of these lacunar thromboses? What scale is used? On MRI, cerebral small vessel disease is hyperintense on which area of the head?

Answer 23

T 2 mechanisms: Lipohyalinosis Atheroma formation Fazeka scale Periventricular areas

Question 24

Explain the pathophysiology of ischemic infarction

Answer 24

Loss of O2 and glucose supply d/t vascular occlusion > collapse of energy-producing processes > disintegration of cell structures and membranes > necrosis > Na-ATPase pump gets damaged > necrotic tissue swells (cytotoxic edema) > compresses adjacent brain parts > herniation > deterioration of the px

Question 24

Identify the use of the ff scoring systems: Fazekas ABCD3-I CHADS2M CHA2DS2-VASc TOAST

Answer 24

Fazekas: Small vessel disease ABCD3-I: TIA CHADS2M CHA2DS2-VASc: AF (Cardioembolic Stroke) TOAST (Ischemic Stroke)

Question 25

Range of mean blood pressures

Answer 25

50-150 mmHg

Question 25

What happens on these CBF? 50-55 12-23 6-8

Answer 25

50-55 - normal 12-23 - critical level of hypoperfusion that abolishes function and leads to tissue damage 6-8 - marked atp depletion, increase in extracellular K, Intracellular Ca2+, cellular acidosis, leading to necrosis

Question 26

T/F: CBF of 10-12 causes irreversible infarction regardless of duration At what CBF causes reversible infarction regardless of duration?

Answer 26

T 23

Question 27

Hemorrhagic stroke is histologically known as

Answer 27

Charcot-Bouchard Microaneurysms

Question 28

T/F: Ischemic stroke is more fatal than primary intracerebral hemorrhage

Answer 28

F- PIH is more fatal

Question 29

Most common sites of cerebral hemorrhage

Answer 29

1. Putamen and adjacent internal capsule 2. Lentiform Nucleus 3. Basal ganglia

Question 30

T/F: Lobar hemorrhages are strictly associated with hypertension

Answer 30

F= not strict

Question 31

T/F: Hydrocephalus may occur from the compression of the lateral ventricles

Answer 31

F- third ventricle

Question 32

This imaging modality is the best for ischemic stroke this is best for hemorrhage:

Answer 32

Ischemia- MRI Hemorrhage- CT Scan

Question 33

This sequence of MRI can detect infarcted lesion within minutes, earlier than CT and other MRI sequences

Answer 33

Diffusion weighted

Question 34

Color of hemorrhage and infarct on CT Scan

Answer 34

Hemorrhage- white Infarct - dark

Question 35

Color of hemorrhage and infarct on MRI

Answer 35

Hemorrhage- white Infarct - dark

Question 36

T/F: Results from a T1 weighted MRI are similar to that of a CT scan T/F: MRA is not as accurate as CT angiography in measuring the degree and morphology of changes within a cerebral or intracranial vessel

Answer 36

T T

Question 37

This demonstrates atheromatous plaques and stenosis of large vessels, particularly of the carotid but also of the vertebrobasilar arteries

Answer 37

Doppler Ultrasound Flow Studies

Question 38

This is requested if you want to know the blood flow or the presence of stenosis in cerebral circulation

Answer 38

Transcranial doppler

Question 39

NIHSS below _____ will have an 80% good/excellent outcome NIHSS above _____ will have less than 20% good or excellent outcome

Answer 39

12-14 20-26

Question 40

polymorphism on chromosome _____ have putative connections to vascular disease

Answer 40

chromosome 12

Question 41

This drug is the most consistently useful drug in the prevention of thrombotic and possibly, embolic strokes

Answer 41

Heparin