Chapter 96 - Unusual carotid artery conditions

Question 1

Nonatherosclerotic causes of cerebrovascular symptoms

Answer 1

1) carotid kinking/coiling
2) carotid aneurysms
3) dissections
4) FMD
5) radiation arteritis
6) GCA
7) takayasu arteritis
8) cardiac embolization
9) carotid sinus syndrome
10) moyamoya

Question 2

Carotid sinus syndrome

Answer 2

1) hypersensitivity of carotid sinus to daily life
2) syncopal symptoms 35% lifetime risk
3) reflex brady and hypotension

Question 3

Carotid sinus hypersensitivity

Answer 3

bradycardia or hypotension to carotid sinus massage

Question 4

3 types of carotid sinus hypersensitivity

Answer 4

1) carotid sinus hyperactivity: ventricular pause > 3 sec
2) asodepressor carotid sinus hyperactivity: BP drop > 50 mmHg without bradycardia
3) mixed

Treatment for 1 = pacing
treatment for 2 = drugs

Question 5

Afferent signal from carotid sinus via this nerve

Answer 5

Glossopharyngeal and vagus

Question 6

Efferent signal to heart and blood vessels for BP control

Answer 6

vagus

Question 7

Symptoms of carotid sinus hypersensitivity

Answer 7

presyncope/syncope

1) abnormal sensorium
2) vision changes
3) parethesia
4) paresis
5) cognitive dysfunction

provocative maneuver = head turning, age, tight neck collars

Question 8

Carotid sinus massage

Answer 8

1) upright position
2) monitor ECG adn BP
3) 5-10 s massage of one side
4) anterior margin of SCM at cricoid cartilage level
5) repeat on opposite side
6) if response then atropine then continue to determine extent needed

Question 9

Treatment for carotid sinus hypersensitivity

Answer 9

1) fluid + salt intake, avoid physical maneuvers
2) midodrine
3) SSRI
4) fludrocortisone
5) norepinephrine
6) PM (DDD)
7) surgery: adventitial stripping

Question 10

Moyamoya first described

Answer 10

Suzuki and Takaku 1969

Question 11

Define moyamoya disease (MMD)

Answer 11

chronic, idiopathic, progressive cerebrovascular disease with ICA stenosis and occlusion

1) abnormal vascular network at brain base
2) more in east asian
3) prevalence 0.35-2.3/100000
4) 5-15 yo and 30-40 yo bimodal
5) more in females

Question 12

symptom of MMD in children

Answer 12

1) paroxysmal hemiplegia
2) paresthesia
3) facial paralysis
4) paroxysmal headache
5) fine involuntary movement of extremity
6) progressive mental impairment

Question 13

Symptom of MMD in adults

Answer 13

1) sudden disturbance of consciousness
2) intracranial hemorrhage
3) bleeding into ventricle
4) subarachnoid hemorrhage

Question 14

Autoimmune disease associated with MMD

Answer 14

Graves

Question 15

Familial form of MMD consist of this percentage

Answer 15

10%

autosomal dominant inheritance with low penetrance

Question 16

Etiology of sporadic MMD

Answer 16

1) infectious
2) autoimmune
3) protein abnormality
4) genetic

Question 17

Genetic loci of MMD

Answer 17

1) 3p24-26
2) 8q23
3) 6q25
4) 17q25 (RNF213)
5) 10q23.31

Question 18

Pathophysiology of MMD

Answer 18

1) fibrocellular thickening of intima
2) SMC accumulation
3) stenosis to occlusion
4) HIF-1, VEGF, TGFB, hepatocyte GF, MMP expression
5) collateralization with Moyamoya vessels

Question 19

Moyamoya vessels

Answer 19

1) thin media
2) fibrin deposit in vessel wall
3) fragmented elastic laminae
4) increase tendency to form microaneurysms

Question 20

Suzuki and Takaku grading of MMD

Answer 20

Stage 1: narrowing or carotid fork
Stage 2: Moyamoya vessels, dilation of intracerebral main artery, no collateral from ECA
Stage 3: moyamoya affect MCA and ACA
Stage 4: moyamoya minimized with occlusion of ICA to level of Pcom
Stage 5: main ICA disappear, even less moyamoya
Stage 6: moyamoya and ICA totally gone

Question 21

Treatment of moyamoya

Answer 21

1) avoid hyperventilation/exercise
2) anti HTN, lipid, DM, smk, wt loss, stop OCP
3) surgery: direct superficial temporal to MCA
4) surgery indirect pial synangiosis (temporal artery secured onto pia)

not antiplatelet - high risk of bleed

Question 22

ICA coiling definition

Answer 22

Elongation and redundancy resulting in S shaped curvature

not clinically relevant stenosis on its own

Question 23

ICA kinking degree

Answer 23

Mild > 60 degrees
Moderate 30-60 degrees
Severe < 30 degrees

associated with neuro symptoms 4-20%

Question 24

epidemiology of carotid kinking/coiling

Answer 24

incidence 24.6%
female 70.6%
> 60 years old

kinking 56%
tortuosity 38%
coiling 6%

Question 25

Cause of coiling of carotid

Answer 25

Embryologically ICA from 3rd aortic arch and dorsal aorta
in embryo vessle naturally coiled
heart receds into thorax and therefore stretches this out

abnormal embryology causes this

Question 26

Cause of kinking of carotid

Answer 26

more related to atherosclerosis

Question 27

Treatment of kinking/coiling

Answer 27

1) antiplatelet
2) surgical transection and elongation
3) surgical transection and interpositional bypass
4) ICA to ECA reattachment

Question 28

Intracranial arterial stenosis causes

Answer 28

1) primary atherosclerosis
2) emboli
3) dissection
4) vasculitis
5) CNS infection
6) radiation
7) sickle cell disease
8) moyamoya disease

Question 29

Risk factors for intracranial arterial stenosis

Answer 29

1) HTN
2) smk
3) endothelial injury
4) increased vascular permeability

Question 30

Stroke outcomes and neuroimaging of intracranial atherosclerosis SONIA trial

Answer 30

MRI and TCD good for screening (high npv)
poor for PPV
therefore need DSA

Question 31

Warfarin and asa for symptomatic intracranial arterial stenosis (WASID) trial

Answer 31

1) 2005
2) double blind warfarin vs asa
3) no difference in stroke or death

Question 32

Clopidogrel plus asa for infarction reduction (CLAIR) study

Answer 32

1) 2010

2) combination therapy better than ASA alone for microembolif ormation (RRR 42.4%)

Question 33

Stenting vs aggressive medical therapy for intracranial arterial stenosis SAMMPRIS study

Answer 33

DAPT > ASA alone > ASA + stent

med therapy alone is the tx of choice

Question 34

EC/IC bypass study

Answer 34

EC-IC bypass not helpful to prevent stroke in MCA disease compared to ASA

Question 35

Concurrent carotid stenosis and intracranial aneurysm on life expectancy

Answer 35

Life expectancy 15-35 years
Age 45-70 years

aneurysm < 7 mm

go ahead and treat the carotid stenosis and ignore the aneurysm

Question 36

Diagnosis of cerebral vasculitis

Answer 36

1) symptoms
2) CSF fluid analysis
3) MRI, CTA
4) biopsy

Question 37

Vasculitides of cranial arteries
types

age and treatment

Answer 37

1) takayasu
2) wegener
3) temporal arteritis

40-60’s age
glucocorticoids
revascularization

Question 38

Lacunar infarct first description

Answer 38

Dechambre 1838

Question 39

Definition of lacunar infarct

Answer 39

1) noncortical infarct
2) single penetrating branch occlusion of larger cerebral arteries
3) diameter 0.2-15 mm

Question 40

Lacunar infacts as percentage of all ischemic strokes

Answer 40

20%

most asymptomatic

Question 41

Symptoms of lacunar infarct

Answer 41

1) motor hemiparesis
2) aphasia
3) dysarthria
4) change in LOC
5) mutism
6) sensorimotor dysfunction

Question 42

Parts of the brain affected by lacunar infarcts

Answer 42

1) putamen
2) pallidum
3) pons
4) thalamus
5) internal capsule
6) corona radiate
7) caudate nucleus

limited collateral circulation

Question 43

Pathophysiology of lacunar infarct

Answer 43

1) medial thickening from disease and occlusion

2) parent artery plaque penetrate occlusion

Question 44

Treatment of lacunar infarct

Answer 44

1) tpa within 3 hours
2) treat other medical condition
3) carotid endarterectomy if there’s stenosis

Question 45

Number needed to treat to prevent one stroke with CEA for lacunar infarct

Answer 45

83

higher than other ipsilateral infarcts