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Adams 10th ed > Cerebrovascular Diseases > Flashcards

Cerebrovascular Diseases Flashcards

1
Q

3 criteria by which stroke is identified

A

Temporal profile
Evidence of focal brain disease
Clinical setting

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2
Q

Most important modifiable risk factors for stroke

A 
Hypertension
Atrial Fibrillation
Diabetes mellitus
Cigarette smoking
Hyperlipidemia

Others include:
Systemic dses assoc with a hypercoagulable state
Use of OCPs

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3
Q

Atrial Fibrillation increases risk of stroke by about ____ and if with rheumatic valvular dse by about ____

A

6-fold

18-fold

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4
Q

Low levels of this electrolyte has been associated with increased stroke rate albeit through an obscure mechanism

A

Potassium

Low K intake and reduced serum K levels are associated with an increased stroke rate in several studies…

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5
Q

TIAs are generally considered more closely aligned with
A. Atherothrombotic stroke
B. Embolic stroke

A

A

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6
Q

Atheromatous plaques preferentially form at

A
  1. ICA at its origin from the common carotid
  2. Cervical part of the VA at their jxn to form the basilar artery
  3. Stem or main bifurcation of the MCA
  4. Proximal PCA as they wind around midbrain
  5. Proximal ACA as they pass ant and curve over the corpus callosum
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7
Q

Mechanisms through which atherothrombosis causes cerebral infarction

A
  1. Plaque or thrombus occupies lumen of a major intracerebral vessel (also watershed infarction)
  2. Atherothrombotic lesion in proximal vessel serve as nidus for formation of embolus (artery-to-artery embolism)
  3. Atherosclerotic plaque in large vessel occludes orifices of small penetrating vessels
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8
Q

What degree of stenosis and size of residual lumen of the carotid artery is most likely to be associated with strokes in the distal territory of the vessel?

A

Stenosis of >90%

Residual lumen < approx 2mm

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9
Q

Risk of stroke conferred by Afib according to age

A

<65y 1% per year

>75y 8%per year

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10
Q

What is the CHA2DS2-VASC score?

A 
Heart failure or EF<35% - 1pt
Hypertension - 1
Age 66-74y - 1
Age > 75y - 2
Previous stroke or TIA - 2
Diabetes -1
Coronary or peripheral vascular dse - 1
Female - 1
Predicted yrly stroke risk by total score
0 - 0%
1 - 1.3%
2 - 2.2%
3 - 3.2%
4 - 4.0%
5 - 6.7%
6 - 9.8
7 - 6.9%
8 - 6.7%
9 - 15.5%
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11
Q

Thickness of echogenic atherosclerotic plaques in the aortic arch found to be statistically associated with strokes.

A

> 4mm thickness

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12
Q

Migrating or traveling embolus syndrome and vessel involved

A

Artery-to-artery PCA occlusion from a thrombus in the proximal VA: mins or more before hemianopsia, fleeting dizziness diplopia or dysarthria from transient occlusion as clot traverses the BASILAR ARTERY

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13
Q

What is a paradoxical embolism

A

When an AbN communication exists bet R and L sides of the heart or alternative route connection via pulmonary arteriovenous fistula

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14
Q

Mechanism of embolism following thyroidectomy

A

Thrombosis in stump of superior thyroid artery extends proximally into lumen of the carotid and a portion is carried into the cerebral circulation

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15
Q

Clinical presentation of fat embolism

A

Associated to severe bone trauma
First pulmonary sx then multiple dermal (ant axillary fold and elsewhere) and cerebral petechial hemorrhages
Encephalopathy

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16
Q

Cerebral Air embolism may occur as a complication of the ff

A 
Abortion
Scuba diving
Cranial, cervical or thoracic operations
Venous catheter insertion
Prev. Pneumothorax therapy
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17
Q

Percentage of presumed embolic strokes in which point of origin cannot be determined

A

20-30%

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18
Q

Brief ischemic attacks that precede a stroke leaving no clinical or imaging trace almost always stamp the process as

A

Atherothrombotic

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19
Q

In patients with TIAs caused by atherosclerotic dse, the 5-yr cumulative rate of fatal and nonfatal cerebral infarction is
And of myocardial infarction esp in those with carotid lesions

A

23% for cerebral infarction

21% for myocardial infarction

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20
Q

Risk of stroke over 3 yrs ff an attack of transient monocular blindness

A

2% if no other risk factors for atherosclerosis

24% in older pts with risk factors for atherosclerosis

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21
Q

What is the”capsular warning syndrome”

A

Escalating episodes of weakness in the face arm and leg culminating in a capsular lacunar stroke

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22
Q

A single transitory episode of TIA esp lasting >1hr and multiple episodes of different patterns suggest

A

Embolism

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23
Q

Brief 2-10min recurrent attacks of the same clinical pattern suggests TIA from

A

Atherosclerosis and thrombosis in a large vessel

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24
Q

TIAs induced by hyperventilation are characteristic of

A

Moyamoya disease

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25
Q

Hemodynamic changes on retinal or cerebral circulation make their appearance when lumen of ICA is reduced to:

A

2mm or less (normal diameter of 7mm, range of 5-10mm)

Or a 95% reduction in cross-sectional area of the vessel

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26
Q

Collateral vessels that may modify the effects of cerebral ischemia

A
  1. Subrachnoid interarterial anastomoses (linking MCA ACA and PCA)
  2. Persistent Trigeminal artery (ICA and BA proximal to circle of Willis)
  3. Ophthalmic artery (ICA and ECA)
  4. Deep cervical, thyrocervical, or occipital arteries (VA and ECA)
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27
Q

Cerebrovascular autoregulation through dilation and constriction of small pial vessels is operative over mean BP of approximately

A

50-150mmHg

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28
Q

Critical threshold of CBF below which functional impairment occurs

A

23mL/100g/min

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29
Q

CBF below which infarction occurs regardless of duration

A

Below 10-12mL/100g/min

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30
Q

Critical level of hypoperfusion that abolishes function and leads to tissue damage

A

CBF 12-23mL/100g/min

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31
Q

CBF that invariably leads to histologic signs of necrosis

A

CBF 6-8mL/100g/min

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32
Q

Spontaneous, recurrent or migratory venous thromboses (superficial or deep) in people with occult or recently diagnosed visceral malignant disease or hypercoagulable state associated with any malignant disease

A

Trousseau’s syndrome

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33
Q

Hollenhorst plaque

A

Crystalline cholesterol sloughed from an atheromatous ulcer, seen on retinal exam as emboli within retinal arteries either shiny white or reddish in appearance

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34
Q

Bruit loudest at
A. the angle of the jaw
B. Lower in the neck

A

A. Stenosis at proximal ICA

B. Common carotid or Subclavian artery

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35
Q

Occlusion , which occurs most frequently in the first part of the ICA immediately beyond the carotid bifurcation may be clinically silent in what percent of cases?

A

30-40%

Because no part of the brain is completely dependent on it

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36
Q

Headache on the ff locations is associated to occlusion of which artery?
A. Above the brow
B. At the temple
C. In or Behind the eye

A

A. Intracranial ICA
B. MCA
C. PCA

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37
Q

Approximate area of
A. Cortical watershed
B. Internal or deep watershed

A

A. High parietal and frontal cortex and adj subcortical WM (if w longstanding carotid stenosis, shifts down to perisylvian portion of MCA)
B. Subfrontal and subparietal portions of the CSO

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38
Q

Watershed areas in tital circulatory collapse

A

Sickle-shaped strip from cortical convexity of the frontal lobe through the high parietal lobe to the occipitoparietal junction

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39
Q

Cardinal clinical signs of stenosis, ulceration, and dissection of the ICA

A

TIAs

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40
Q

Most carotid occlusions are ____
Whereas most MCA occlusions are ______

A. Embolic
B. Thrombotic

A

Carotid - B. Thrombotic

MCA - A. Embolic

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41
Q

Percent of population wherein a persistent fetal circulation is seen with 1 PCA arising from the ICA?
Both PCA arising from corresponding ICA

A

20-25%

<5%

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42
Q

What is the thalamic syndrome of Dejerine and Roussy (clinical features, vessel involved)?

A

Sensory loss that includes hemibody up to the midline, which return after an interval, and pt may develop a painful paresthetic syndrome that may last for years
Thalamogeniculate branches

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43
Q

Sundromes of the paramedian arteries have as their main feature a 3rd nerve palsy combined with:
Weber?
Claude?
Benedikt?

A

Weber - contralateral hemiplegia
Claude - contralateral ataxic tremor
Benedikt - homolateral ataxia, hemiplegia with contralateral 3rd nerve palsy

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44
Q

Vascular cause of the amnesic Korsakoff syndrome

A

Occlusion of the paramedian thalamic branches to the mediodorsal nucleus

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45
Q

The vertebral arteries are most often occluded by atherothrombosis in what portion?

A

Intracranial portion

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46
Q

Dissection of the vertebral artery declares itself by

A

Cervicooccipital pain and deficits in brainstem function

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47
Q

Subclavian Steal

A

If the Subclavian artery is blocked proximal to the origin of the L VA, exercise of L arm may draw blood from the R VA and BA to L VA to distal L subclavian
Presenting with vertigo and brainstem signs with transient weakness on exercise of the L arm

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48
Q

Medial medullary syndrome

A

Medullary pyramid - Contra paralysis of arm and leg (sparing of face)
Medial lemniscus- contra loss of position and vibration sense
Hypoglossal fibers - paralysis and later atrophy of 👅

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49
Q

Lateral Medullary or Wallenburg syndrome

A

8/10 cases from Occlusion of the VA by atherothrombosis then PICA or one of the lateral medullary arteries
Usu. Infarction
1. Vestibular nuclei - vertigo, nystagmus, oscillopsia, vomiting
2. Spinothalamic tract - contra pain and temp impairment
3. Descending sympathetic trunk - ipsi Horner
4. CN 9&10 nerves - dysphagia, hoarseness, dec gag, ipsi palatal and vocal cord paralysis
5. Utricular nucleus - vertical diplopia, illusion of tilting of vision
6. Olivocerebellar, spinocerebellar, restiform, inf cerebellum - ipsi limb ataxia, falling to same side, lateropulsion
7. Descending tract and n of CN5 - pain, burning impairment of sensation ipsi face
8. Nucleus tractus solitarius - loss of taste
Rarely
9. Cuneate and gracile nucleus - ipsi numbness of limbs

50
Q

Most frequent feature of Lateral Medullary syndrome

A

Vertigo

Though alone, it is not an indication of lateral medullary syndrome

51
Q

This nystagmus feature suggests labyrinthine disease from brainstem forms of nystagmus but intfaction of the verstibular nucleus as part of the lateral medullary syndrome may also produce this sign.

A

Direction-changing nystagmus

52
Q

Occlusion of the SCA

A

Middle and superior cerebellar peduncles - IPSI cerebellar ataxia
Spinothalamic tract - CONTRA loss of pain and temp
- Nausea and vomiting
- partial deafness
- static tremor of the IPSI UE
- IPSI Horner
- palatal myoclonus

53
Q

AICA Occlusion

A

Vertigo, vomiting , nystagmus, tinnitus,
Sometimes: unilateral deafness, facial weakness, IPSI cerebellar ataxia, IPSI Horner and paresis of conjugate lateral gaze and CONTRA loss of pain and temp

54
Q

Size of small arteries occluded in lacunar infarction

A

50-200 microns in diameter

55
Q

3 mechanisms for lacunar infarction

A
  1. Local fibrohyalinoid arteriolar sclerosis that involves orifice or prox part of small penetrating blood vessel (seems to be most common)
  2. Atherosclerosis of a large trunk vessel that occludes origin of small vessels
  3. Entry of small embolic material into one of the vessels (least frequent)
56
Q

Cavities of lacunes

A

3-15mm

57
Q

Lacunes are situated in descending order of frequency:

A
  1. Putamen and caudate
  2. Thalamus
  3. Basis pontis
  4. Internal capsule
  5. Deep in the central hemispheral white matter
58
Q

The relative improvement in neuro state from tPA in the NIH study came at the expense of this much risk of symptomatic cerebral hemorrhage, which is approximately ___ times the expected rate without thrombolysis

A

6%

Two times

59
Q

Extension of treatment time for low-risk patients up to 3-4.5hrs after symptom onset is based on the following benefits

A

10% more achieved a good outcome

More cerebral hemorrhage seen BUT Overall Mortality was the same

60
Q

What class of antihypertensive drugs was found to be a factor for occurrence of angioneurotic edema with tPA treatment?

A

ACE inhibitors

61
Q

Special circumstance in which rapid removal of clot or repair of an intimal tear is performed more or less routinely

A

If vessel has closed or caused an embolus immediately after carotid endarterectomy

62
Q

2 situations in which immediate admin of heparin or equivalent have drawn support from clinical findings

A
  1. BA thrombosis with fluctuating deficits
  2. Impending Carotid Artery Occlusion from thrombosis or dissection
    But no evidence!!!
63
Q

With use of heparin, bleeding into any organ may occur at a PTT of?
And at what level of PTT should heparin infusion be discontinued?

A

PTT >3x the pretreatment value

at PTT>100s, discontinue the infusion

64
Q

Rare but dangerous complication of warfarin therapy that occur in patients with unsuspected deficiencies in protein C and S

A

Hemorrhagic skin necrosis

- paradoxical microthrombosis of skin vessels

65
Q

One third of adults with Afib are lone fibrillators and these patients, younger than this age without additional cerebrovascular risk factors did not clearly benefit from long-term prophylactic anticoagulation.

A

younger than 65years

66
Q

With long-term administration of warfarin, the risk of hemorrhage outweighs benefit except in the ff

A

Severely stenotic cerebral vessel
Atrial Fibrillation
Prosthetic heart valve
Certain blood disorders

67
Q 
Potential toxicity of the ff drugs
A. Ticlodipine
B. Clopidogrel
C. Ximelagatran
D. Dipyridamole
E. Statin
A

A. Ticlodipine - neutropenia
B. Clopidogrel - thrombotic thrombocytopenic purpura
C. Ximelagatran - hepatotoxicity
D. Dipyridamole - dizziness (not well tolerated)
E. Statin - statin-induced myopathy

68
Q

Vasodilators may be harmful on theoretical grounds (in tx of acute stroke) prob due to the ff

A
  • lowering systemic BP
  • dilating vessels in normal brain tissue (autoregulation lost within infarct)
  • may reduce intracranial anastomotic flow
  • vessels in the margin of the infarct already maximally dilated
69
Q

In decompressive hemicraniectomy for patients with large MCA infarction, approximately this proportion of surviving patients will be dependent for care

A

One third of surviving patients will be dependent for care

70
Q

Region of the carotid artery that most often lends itself to surgical management of occlusion

A

Carotid Sinus

Other suitable for surgical management:
Common carotid, Innominate, Subclavian

71
Q

Symptomatic carotid artery stenosis includes patients with

A

TIAs

Large or small strokes IPSI to stenosis (some evident only on imaging)

72
Q

In those with bilateral carotid disease
A. the risk of stroke after 2 years?
B. If operated?

A

A. Risk of stroke after 2y of 69%

B. If operated dec to 22%

73
Q

Conclusion of the North American Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST)

A

Endarterectomy for sxic lesions causing stenosis >70-80%
= REDUCED incidence of IPSI hemispheral strokes
= Greater benefit with increasing degrees of stenosis

74
Q

Timing of endarterectomy for maximum benefit

A

Within 2 weeks of TIA or minor stroke

75
Q

A carotid artery stenosis of greater than 70% roughly corresponds to residual luminal diameter of

A

<2mm

76
Q

In a pt post endarterectomy who presents, in the hrs after the procedure, with a new hemiplegia or aphasia, the patient is brought back to the OR, cause will usu be:

A
  • intimal flap at the distal end of the endarterectomy and varying amounts of fresh clot proximal to it

BUT even after removal and repair, effects of stroke usu not improved 🙁

77
Q

Hyperperfusion syndrome

A

Several days to a week after carotid endarterectomy
Headache, focal deficits, seizures
Brain edema, or cerebral hemorrhage
(Autoregulatory failure of cerebral vasculature in abrupt restoration of N BP and perfusion)

78
Q

Most common symptom, which may also be the only manifestation of Hyperperfusion Syndrome

A

Unilateral severe headache

79
Q

A carotid bruit generally corresponds to a reduction in luminal diameter of the artery to A mm?
But also heard in up B % of older patients with little or no stenosis

A

A. 2mm or less

B. 10%

80
Q

This refers to continued TIAs or strokes while on low doses of Aspirin

A

Aspirin failure

81
Q

Measures for secondary prevention of stroke as enumerated in the Adams stroke chapter

A
  1. Aspirin
  2. Antihypertensive agents
  3. Cholesterol-lowering drugs
  4. Smoking cessation
  5. During future surgical procedures, maintenance of systemic BP and O2
82
Q

Accdg to the SPARCL trial, magnitude of benefit of high dose atorvastatin for secondary stroke prevention in pts with stroke or TIA in the prev 6mos

A

Approximately 3%

83
Q

Damage produced by pure hypoxia-anoxia without hypotension

A

Mainly affects hippocampi

Korsakoff syndrome

84
Q

Vessel most frequently involved in fibromuscular dysplasia

A

ICA

85
Q

Radiologic picture and pathology of fibromuscular dysplasia

A

Radio: Series of transverse constrictions, giving the appearance of irregular string of beads or a tubular narrowing

Pathology: degeneration of elastic tissue and irregular arrays of fibrous and smooth muscle tissue in a mucous ground substance

86
Q

Raeder Syndrome

A

Unilateral headache associated with an IPSI Horner’s syndrome in ICA dissection

87
Q

Localization of severe cranial pain from intracranial arterial dissection
A. MCA
B. Basilar artery
C. Vertebral artery

A

A. MCA - retroorbital
B. Basilar artery - occipital
C. Vertebral artery - occipital + supraorbital

88
Q

Rate of stroke in cases of cervical artery dissection

A

5% or less

89
Q

Cervical artery dissection is usually treated with anticoagulation for several weeks or months (heparin or warfarin) except for the ff instances

A

(+) subarachnoid blood on CT

(+) Pseudoaneurysm within intracranial portion of the dissection

90
Q

Moyamoya disease

A

Extensive basal cerebral rete mirabile (a network of small anastomotic vessels at the base of the brain around and distal to the circle of Willis) associated with segmental stenosis or occlusion of the terminal intracranial parts of both ICA

91
Q

Genetic associations of moyamoya disease

A

Down syndrome

Chromosome 17q autosomal dominant with incomplete penetrance

92
Q

Most common initial manifestation of Moyamoya dse in younger patients?
In older patients?

A

Sudden unilateral weakness of an arm, leg or both

In older patients - SAH

93
Q

Characteristic of TIAs in Moyamoya

A

Prolonged

Induced by hyperventilation or hyperthermia

94
Q

What is the rebuild EEG phenomenon?

A

High voltage slow waves reappear 5mins after the end of hyperventilation

95
Q

Radiologic appearance of confluent areas of white matter signal change consisting of hypointense periventricular tissues possibly damaged by chronic ischemia. This probably exists in a continuum with Binswanger disease

A

Leukoariosis

96
Q

Main features of Binswanger disease

A

Dementia, pseudobulbar state, gait disorder, alone or in combination

97
Q

Genetic association of CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy)

A

Missense mutation on Chromosome 19 of the NOTCH 3 gene

With incomplete penetrance until after 60y of age

98
Q

An autosomal recessive syndrome of early alopecia, lumbar spondylosis with white matter changes typical of CADASIL

A

CARASIL (Cerebral Autosomal Recessive Arteriopathy with Subcortical Infarcts and Leukoencephalopathy)

99
Q

MRI CT appearance most characteristic of CADASIL

A

Multiple confluent white matter lesions ANTERIOR to the TEMPORAL HORNS of the lateral ventricles

100
Q

Genetic association and pathology of CARASIL

A

Autosomal recessive mutation in the HTAR1 gene resulting in fragmentation and duplication of the internal elastic lamina of cerebral vessels with narrowing of their lumens

101
Q

This treatment may prevent or retard the formation of Moyamoya and reduce risk of stroke among patients with sickle cell anemia

A

Exchange transfusions

102
Q

Main diagnoses to consider overall among children and young adults with ischemic stroke

A 
Carotid and vertebral artery dissection
Drug abuse (mainly cocaine)
Thrombosis induced by contraceptive estrogens
APAS
cardiac disease including PFO

Inherited prothrombotic states arise in the younger age group

103
Q

Vascular lesion underlying cerebral thrombosis in women taking oral contraceptives

A

Nodular intimal hyperplasia of eccentric distribution with increased acid mucopolysaccharides and replication of the internal elastic lamina

104
Q

The risk of cerebral infarction and ICH in pregnancy appears mainly in this period in general: A
B: timing of arterial occlusion?
C: of venous occlusion?

A

A. In the 6-week period after delivery
B. Arterial: 2nd, 3rd trimester and 1st wk postpartum
C. Venous: 1-4weeks postpartum

105
Q

Most common sites of cerebral hemorrhage

A
  1. Putamen and adj internal capsule
  2. Central white matter (lobar- not hpn)
  3. Thalamus
  4. Cerebellar hemisphere
  5. Pons
106
Q

Pathogenesis of hypertensive ICH

A

Segmental lipohyalinosis and formation of Charcot-Bouchard aneurysms

On EM: breaks in the elastic lamina at multiple sites almost always at bifurcations of small vessels

107
Q

Targets in the management of acute ICH
PCO2
Osmolality
Na

A

PCO2 25-30mmHg
Osmolality 295-305mOsm/L
Na 145-150mEq

108
Q

Location of intracranial aneurysm with bleeding rates many times higher compared to other locations

A

Vertebrobasilar and posterior cerebral artery aneurysms

109
Q

Size of giant cerebral aneurysms and usual locations

A

By definition, greater than 2.5cm in diameter.

Mostly located on a carotid, basilar, anterior, or middle cerebral artery
Also found on vertebral artery

110
Q

Dural arteriovenous fistula most at risk for bleeding

A

Anterior cranial fossa

Tentorial incisura

111
Q

Marker, in increased amounts, associated with severe amyloid angiopathy and risk of ICH

A 
Apolipoprotein E4 (same as for Alzheimer's disease)
Also assoc is E2 allele
112
Q

Distinctive pattern or location of hemorrhages in cerebral amyloid angiopathy

A

Subcortical, frequently posteriorly and sometimes subpial

113
Q

Call-Fleming syndrome

A

Idiopathic widespread segmental vasospasm of cerebral vessels
Severe headache usu “thunderclap”
Fluctuating TIA-like episodes

114
Q

Inflammatory diseases that Affects medium and smaller sized vessels

A

Polyarteritis nodosa, Churg-Strauss, Wegener granulomatosis, SLE, Behcet, hypersensitivity Angiitis, Kohlmeier-Degos, Susac

115
Q

Usual neurologic symptoms of Takayasu disease

A

BOV esp upon physical activity

Fever, dizziness, hemiparetic and hemisensory symptoms

116
Q

The presence in the blood of cytoplasmic antineutrophil cytoplasmic antibodies has been found to be relatively Sp and Sn for Wegener dse but may also be present in what other condition

A

Intravascular lymphoma

117
Q

Criteria for the diagnosis of Antiphospholipid Antibody Syndrome

A

Ischemic event accompanied by detection of autoantibodies on two occasions at least 6weeks apart.
Lupus anticoagulant
Anticardiolipin
B2-glycoprotein 1

118
Q

Most frequent neuro abnormality in Antiphospholipid Antibody Syndrome

A

TIA (often amaurosis fugax)

119
Q

Most specific antibody for the Hughes Syndrome

A

Antibody to B2-glycoprotein 1

120
Q

Arteriopathy producing deep blue-red skin lesions of livedo reticularis and livedo racemosa in association with multiple ischemic strokes

A

Sneddon syndrome

Adams 10th ed (11 decks)

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