Chapter 86 - Cerebrovascular disease introduction Flashcards
first clinical anatomic correlation of carotid occlusion
Fisher 1951
First surgical treatment for carotid plaque with resection of disease
Eastcott, Pickering, Rob 1954
First CEA
Debakey 1953
% of stroke that are ischemic
87%
Risk factors for stroke
1) age (q10yr after 55 doubles risk) 2) male (age matched) 3) black 4) HTN (120/80 reduced risk by 50%) 5) DM 6) CAD 7) current smk: 3-4x increased risk than those that quit 10 yr 8) Family history: 1.4-3.3x (cva + cad) 9) Afib: 3-5x 10) hypercholesterol: 25% increase per 38.7 increase total cholesterol 11) physical activity: < 4/wk causes 20% risk 12) obesity especially abdominal obesity in men 13) CKD statin is protective Mediterranean diet is protective
Relative risk reduction of stroke with statin use
21%
INTERSTROKE study 5 most important factors for stroke
accounted for 80% of strokes 1) HTN 2) current smk 3) abdominal obesity 4) poor diet 5) physical inactivity
Risk of recurrent stroke and death after initial stroke
RECURRENT STROKE 7 days - 2% 30 days - 4% 1 year - 12% 5 years - 29% DEATH 7 days - 7% 30 days - 14% 1 year - 27% 5 years - 53%
NASCET 2 year risk of ipsilateral stroke with high grade carotid stenosis
26%
TIA definition
ministroke symptoms last < 24 hr clinical diagnosis
Risk of stroke in 5 year after TIA
30%
TIA’s that have infarction on imaging
24%
Percentage of strokes that have a herald TIA
15%
Rate of stroke after TIA in 90 days and 2 days
2 days - 3-10% 90 days - 9-17%
Asymptomatic carotid stenosis and risk of stroke
ACSRS - determine CVA risk on 1) degree of stenosis 2) clinical feature 3) US plaque characteristic 1) 1121 patients 2) 50-99% asymptomatic ICA stenosis 3) f/u 6-96 months
ASCAR factors that increase risk of ipsilateral stroke
1) stenosis 2) age 3) SBP 4) creatinine 5) smk x 10 years 6) contralateral CVA history 7) low gray-scale median 8) increased plaque area 9) absence of discrete white areas without acoustic shadowing 10) juxtaluminal black hypoechoic area
ASCAR prediction chart
TABLE 86.1
High intensity transient signals (HITS)
in transcranial doppler represent microemboli to brain
Asymptomatic carotid emboli study (ACES) key points
Use TCD to predict stroke risk 1) 70% + stenosis 2) 2 year follow up prospective 3) 267 patients (77 had HITS) stroke risk in those without signal 1-3.62% vs with signal 7.13-15.6% problem costly cumbersome 10% do not have acoustic window
TOAST 5 categories of ischemic stroke
1) cardioembolic 2) large vessel disease 3) small vessel disease 4) unusual causes 5) undertermined etiology
Percentage of ischemic strokes likely related to extracranial carotid artery atherosclerosis
20%
Medical therapy of ICA stenosis
1) HTN BP < 140/90 2) LDL < 100 3) TG < 150 4) HDL > 40 5) statins use 6) antiplatelet use
Rate of ICA stenosis
3.8-10.5% in men 2.7-5.5% in women higher in older age groups
Rate of stroke annually in asymptomatic high grade stenosis ACA, NASCET, ACST
2%
Progression of carotid stenosis natural course
19.8% will progress in 4 years
Multivariate predictor of outcome in asymptomatic carotid stenosis
TABLE 86.2
Vertebrobasilar territories
1) brain stem 2) cerebellum 3) thalamus 4) occipital cortex
Percentage of CVA from posterior circulation
20%
Sensorimotor deficits in subclavian steal indicates
Concomitant carotid occlusive disease usually symptoms should be cerebellar
Cerebellar infarction symptoms
1) vertigo 2) vomiting 3) blurred vision 4) difficult walking
Global cerebral ischemia cause
1) prolonged cardiogenic shock 2) dysrhythmias 3) cardiac arrest correct cardiac failure and return perfusion
Lacunar infarct definition
1) small cubcortical infarct (1-2 cm) 2) occlusion of single penetrating artery of brain 3) often in internal capsule, basal ganglia 4) areas supplied by lenticulostriate vessels
Percentage of CVA that are lacunar
20%
Symptoms of lacunar infarct
1) pure motor hemiparesis 2) pure sensory syndrome 3) sensorimotor syndrome 4) ataxic hemiparesis 5) dysarthria-clumsy hand syndrome
