CH33: Stroke Flashcards
Most readily recognized factor in the genesis of primary intracerebral hemorrhage (p. 801)
Hypertension
Simple measures such as the use of this drug for blood pressure control may be overall the most effective (p. 801)
Hydrochlorothiazide
The presence of atrial fibrillation increases the incidence of stroke how many times? (p. 801)
6x
The presence of Rheumatic Valvular disease increases the incidence of stroke how many times? (p. 801)
18x
Most common cause of ischemic strokes and all the types of stroke (p. 802)
Cerebral embolism
Most common vessel involved in cerebral embolism (p. 802)
Middle Cerebral Artery
Atheramotaois plaques in the ascending aorta greater than this thickness is found to be associated on a statistical basis with stroke (p. 803)
4mm
Migrating or traveling embolus syndrome most evident in cases of which artery (p. 803)
Posterior cerebral artery occlusion
Risk of stroke with PFO alone (p. 804)
2%
Risk of stroke with PFO + atrial septal aneurysm (p. 804)
15%
Most common sites of atheromatous plaques (p. 805)
- ICA at the origin from the common carotid
- Cervical part of the vertebral arteries or at their origins at the subclavian vessels and their junction from basilar artery.
- Stem or at the main bifurcation of the MCA
- Proximal posterior cerebral artery as they wind around the midbrain
- Proximal anterior cerebral arteries
TIAs that occur with exercise or the assumption of upright posture are particularly suggestive of (p. 807)
stenosis of aortic branches
dissection of the carotid artery
TIAs that occur with hyperventilation are particularly suggestive of (p. 807)
moyamoya disease
At this pressure, small pial vessels are able to dilate and to constrict in order to maintain cerebral blood flow (p. 810)
50 to 150mmHg
Critical level for infarction is approximately (p. 810)
23ml/100g/min
At this level, regardless of its duration, decreased CBF causes infarction (p. 810)
10-12ml/100g/min
At this level marked ATP depletion, increase in extracellular K, increase in intracellular Ca, cellular acidosis (p. 811)
6-8 ml/100g/min
Swelling of capillary endothelial cells which prevents the restoration of circulation (p. 811)
no-reflow phenomenon
Role of excitatory neurotransmitters which are formed by glycolytic intermediates of Krebs cycle (p. 811)
glutamate and aspartate
one of several calcium channels that open under conditions of ischemia and set in motion a cascade of cellular events eventuating in a neuronal death (p. 811)
NMDA channel
Vitamin K dependent protease that is in combination with its cofactors protein S and antithrombin III which inhibits coagulation (p. 811)
Protein C
Syndrome wherein a hypercoagulatble state does not often produce in situ arterial occlusion but it does lead to thrombotic vegetation on heart valves that precipitate strokes (p. 811)
Trosseau syndrome
Bruit: angle of the jaw
Proximal internal carotid
Bruit: lower in the neck
Common carotid or subclavian artery
Bruit: posteriorly in the neck
vertebral arteries
Transient monocular blindness occurs prior to the onset of stroke in how many percent of cases of symptomatic carotid occlusion (p. 815)
10% to 25%
Contralateral hemiplegia, hemihypoesthesia, homonymous sectorial hemianopia (p. 820)
Anterior choroidal artery syndrome
T/F Despite the small caliber of the vessel and its blood supply of deep structures, the most common cause of occlusion of the anterior choroidal artery is embolic. (p. 821)
TRUE
Third nerve palsy + contralateral hemiplegia (p. 824)
Weber syndrome
Third nerve palsy + contralateral ataxic tremor (p. 824)
Claude syndrome
Third nerve palsy + contralateral hemiplegia + ataxic tremor (p. 824)
Benedikt syndrome
Patient is unaware of being blind and denies the problem even when it is pointed out to him (p. 825)
Anton syndrome
Numerical segments of the vertebral artery (p. 825)
V1 from origin to the first entry into the cervical transverse foramen
V2 from the transverse foramen to the uppermost foramen
V3 dural penetration at the foramen magnum
V4 dural entry to the junction with the opposite vertebral artery and the origin of the basilar artery
Declares itself by cervicooccipital pain ipsilateral to the dissection and deficits of brainstem function (p. 826)
Dissection of the vertebral artery
Most frequent feature of lateral medullary syndrome (p. 827)
Vertigo
Tinnitus may be overwhelming called ‘screaming’ by some of our patients (p. 830)
Anterior inferior cerebellar artery infarction
When the position sense, two-point discrimination, and tactile localization are affected relatively MORE than pain or thermal and tactile sense (p. 831)
Cerebral lesion (if opposite, brainstem localization)
4 lacunar syndromes (p. 831)
Pure motor
Pure sensory
Clumsy hand- dysarthria
Ipsilateral hemiparesis-ataxia
Dysarthria and clumsiness syndrome (p. 831)
Paramedian midpons, posterior portion of the internal capsule apposite the affected limb
According to NIH study, when giving tPA, what is the risk of symptomatic cerebral hemorrhage? (p. 833)
6%
According to NIH study, when giving tPA, what is the risk of insignificant cerebral hemorrhage? (p. 833)
4%
Patients taking this medication seem to display angioneurotic edema as a side effect of tPA (p. 834)
ACE inhibitor
Heparin drip dose (p. 835)
100U/kg bolus then continuous drip (1,000 U/h)
An advantage in survival favoring the group operated (hemicraniectomy) are those operated within ___ (p. 837)
48 hours
SE: Neutropenia (p. 839)
Ticlopidine
SE: TTP (p. 839)
Clopidogrel
What does symptomatic TIA mean? (p. 841)
large or small strokes, or TIAs
Maximum benefit is accrued if CEA is performed within __ of a TIA or minor stroke (p. 841)
2 weeks
CEA for symptomatic lesions causing degrees of stenosis greater than ____ in diameter reduces the incidence of ipsilateral hemispheral strokes and shows greater benefit with increasing degrees of stenosis (p. 841)
70% to 80%
Most common symptom of hyperperfusion syndrome (p. 842)
Unilateral severe headache
Asymptomatic carotid stenosis should be more than ___ to be operated? (p. 843)
60% to 70%
Found in some patients with fibromuscular dysplasia (p. 846)
phosphatse and actin regulater 1 gene variant (PHACTR1)
CT scan findings in Fibromuscular dysplsia (p. 846)
series of transverse constrictions; irregular string of beds or a smooth tubular narrowing; bilateral carotid in 75% of cases
Why is there diltations in FMD?(p. 846)
Atrophy of the coat of the vessel wells
Is FMD ammenable to endarterectomy? (p. 846)
No
Diseases associated with vascular dissection (p. 846)
Ehlers Danlos, Mrfan syndrome, osteogenesis imperfecta, Loeys Dietz syndrome, alpha1- antitrypsin deficience
T/F Painful Horner syndrome is usually due to a underlying structual lesion (p. 847)
TRUE
Elongated but variable length, irregular narrow column of dye 1.5 to 3cm above the carotid bifurcation extending to the base of the skull (p. 848)
string sign
Most identifiable cause of vertebral artery dissection (p. 848)
Rapid and extreme rotational movement of the neck
Carotid dissection most commonly originatees in which segment (p. 848)
C1 and C2 where it is mobile but thethered as it it leaves the transverse foraen of the axis and turns sharply to enter the cranium
T/F Re:Cervical artery dissecion, If the dissection has produced complete occlusion of the vessel, the role of anticoagulation is les clear (p. 849)
T
In older patients, this is the most common initial manifestation of Moyamoya (p. 849)
SAH
Describes the imaging appearance of hypointense periventricular tissues in Biswanger Disease (p. 851)
leukoariois
Main features of Biswanger cases (p. 851)
Dementia, pseudobulbar state, gait disorder
Recurrent small strokes beginning in early childhood, subcortical dementia, migraine headaches (p. 852)
CADASIL
CADASIL+early alopecia and lumbar spondylosis with white matter changes (p. 851)
CARASIL
Pathology findings in CADASIL (p. 851)
small vesels n the regions of infarctions, 100 to 200mm in diameter containing basophilic granular deposits in the media with degeneration of smooth muscle fibers
CADASIL vs Binswanger disease (p. 851)
Anterior temporal changes are typicl of Binswanger. Migraine headaches are not a component of Binswanger.
Gene responsible for CADASIL (p. 851)
chromosome 19 of the NOTCH3 gene
Gene responsible for CARASIL (p. 851)
HTAR1 gene
pathologic findings in CARSAIL (p. 851)
duplication of internal elastic lamina of the cerebral vessels with narrowing of their lumens
T/F Use of progestin- only pills or of subcutneously implanted capsules of progestin has nt been associated with stroke (p. 855)
TRUE
When is stroke in pregnancy increased? (p. 855)
6 week post partum than during pregnancy itself
Appearance of contrast within the hemorrhage during CT angiography associated with high rate of hematoma expansion (p. 857)
spot sign
Etiology of ring of enhancement in CTof ICH (p. 857)
hemosiderin- filled macrohages and the reacting cells that form a capsule for the hemorrhage
Massive ICH means how much? (p. 857)
More than 50ml
Pathologic findings of ICH (p. 857)
segmental lipohyalinosis and false aneurysm
Giving of this anti-hypertension causes increased ICP in some studie (p. 862)
Nifedipine
Treatment of tpa related bleeds (p. 863)
Factor VII within 4 hours of spontaneous cerebral hemorrhage
Surgical evacuation of cerebellar hematoma. Size cut off (p. 863)
4cm
Incidence of unruptured aneursms in routine autopsies (p. 864)
2 pecent
Aneurysyms are multiple in how many percent of cases (p. 864)
20%
An accompanying saccular aneursm is found in approximately ___% of cases of cerebral AVM (p. 864)
5%
How many percent of sacular aneurysms lie on the anterior part of the circle of Willis (p. 865)
90-95%
Most common syndrome of ruptured aneurysm (p. 865)
severe generalized headache in the same instantaneous manner but remains relatively lucid with varying degreees of stiff neck
Convulsive seizures happen in how many percent of SAH (p. 865)
20 to 25%
Localized cranial pain. Aneurysm in first part of MCA (p. 865)
orbit
Localized cranial pain. Aneurysm in first part of PICA or AICA (p. 865)
occipital or cervical pain
Important in differentiating SAH from traumatic tap (p. 867)
increased pressure as high as 500mm H2O but usually closer to 250mm in SAH
Important in differentiating SAH from traumatic tap (p. 867)
Aside from xanthrochromia, clearing of blood as one continues to collect fluid and a marked reduction in the number of RBC in spinal fluid in traumatic tap
Most sensitive means of demonstrating an aneurysm (p. 867)
DSA with bilateral carotid and vertebral contrast injections
Percent of patiens with SAH due to aneurysmal rupture but will not have an aneurysm evident (p. 867)
5 to 10%
Most severe vasospasm occurs in arteries that are surronded by collections of clotted subarachnoid blood after __h (p. 868)
24 hours
velocity that suggests a focal vasospasm is occuring (p. 869)
over 175cm/s
Single bedst index of outcome in aneurysmal SAH (p. 870)
state of consciousness at the time of arteriography
Leading cases of morbidity and mortlity in those who survive the initial hemorrhage (p. 870)
vasospasm and rebleeding
Patients who are HH1 and HH2 should be operated within (p. 871)
24 hours
Current operative mortality of aneurysmal SAH (p. 871)
2 to 3 percent
Location of this unruptured intracranial aneurysms have bleeding rate many times higher than the others (p. 872)
vertebrobasilar and posterior cerebral aneurysms
Cut off size for giant cerebral aneurysms (p. 872)
2.5 cm
AVM and saccular aneurysm are asocaited in approximately in how many percent of cases (p. 873)
5%
T/F A systolic bruit heard over the carotid in teh neck or over the mastoid process or the eyeeballs in a young adult is suggestive of AVM (p. 874)
T
Risk of bleeding from a known AVM is approximately (p. 874)
3% a year
ARUBA findings (p. 874)
stroke occured in 10% of expectant managemetn group compared to 31%of group that had intervention
Types of complications of radiation occur in radiation (p. 876)
delayed radiation necrosis
venous congestion
Dural fistula presentation (p. 877)
fluctuating ischemic like deficit appropriate to the cerebral or spinal location underlying the lesion or at some distance from it
Dural lesions (AVF) with the most risk of bleeding are found where? (p. 877
Anterior cranial fossa and tentorial incisura
A posible causative in familal cavernoma (p. 877)
KRIT1
Most common cerebral vascular malformation estimated to occur in almsot 3%of large autopsy series (p. 878)
Deep venous anomaly
Nex to HPN, what is the msot common cause of cerebral hemorrhage (p. 879)
Anticoagulant use
Top three secondary brain tumors that bleed (p. 880)
choriocarcinoma, melanoma, renal cell carcinoma
Basic neuropathologic changes in hypertensive encephalopathy (p. 882)
clustering of multiple micorinfarcts and petechial hemorrhages
Cocaine hydrochloride vs crack cocaine stroke manifestations (p. 884)
cocaine hydrochloride: prone to cause cerebral hemorrhage due to acute hypertension
crack cocaine: ischemic usually large artery occlusion
Pulseless disease (p. 887)
Takayasu Disease
Bsis in distinguishing polyarteritis vasculitis from Churg Strauss graulomatous angitis (p. 888)
sparing of the lungs
Subacutely evolving vasclitis with necrotizing granuloms of the upper and lower respiratory tracts followed by necrotizing glomerulonephritis are its main features (p. 888)
Wegener Granulomatosis
Relatively specific nd sensitive for WEgene disease but may be alpresent in intravascular lymphoma (p. 888)
cytoplsmic antineutrophil cytoplasmic antibodies (CANCA)
Sensitive indicator of SLE(p. 889)
anti- dsDNA
microangiopathy affecting mainly the brain and retina (p. 889)
Susac Syndrome
Psychiatric symptoms, headache, dementia, sensorineural deafness, vertigo, impariment of vision (p. 889)
Susac Syndrome
Relapsing iridocyclitis, recurrent oral and genitalulcers (p. 889)
Behcet Disease
Formation of sterile pustule t the site of needle prick in Behcet diseae (p. 890)
Pathergy test
Essential pathologic finding in DIC (p. 892)
widespred fibin thrombi in smll vessels resulting in neumerous small infarctions of many organs including the brain (p. 893)
Antibodies in APAS (p. 893)
Lupus anticoagulant, anticoardiolipin, b2- glycoprotein 1
Most specific antibody in APAS (p. 893)
b2- glycoprotein
Antibody which correlates the risk of thrombosis and specificit for the syndrome is higher for IgG than for IgM autoantbodies (p. 890)
anticardiolipin antibody
Most frequent neurologic abnormality in APAS (p. 893)
TIA
Arteriopathy producing deep blue-red skin lesions of livedo reticularis and livedo racemosa in assocation ith multiple ischemic strokes (p. 893)
Sneddon syndrome
TTP is caused by acquired circulating IgG inhibitor of the VWF cleaving protease called (p. 894)
ADAMTS13
A high proportion of patients with polycythemia vera will have mutations in (p. 894)
JAK2
