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Pathophysiology > CVA > Flashcards

CVA Flashcards

1
Q

Definition of CVA

A

Interruption of blood flow to an area of the brain

robs brain cells of vital nutrients and supplies
results in loss of neuronal function
Sx’s last longer than 24 hours

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2
Q

Types of CVA

A

ischemia or hemorrhage

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3
Q

Ischemia

A

clot blocks or impairs blood flow
lack of blood flow deprives the neurons of oxygen and nourishment

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4
Q

Hemorrhage

A

vessel ruptures causing bleeding into the brain and leakage
extra-vascular release of blood causes damage by cutting off connecting pathways
results in local or generalized pressure injury

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5
Q

Modifiable Risk Factors

A

Lack of Exercise
Diet
Smoking

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6
Q

Non-Modifiable Risk Factors

A

HTN
HD-?
Increased Cholesterol
Cardiac Disorders
Cardiac arrhythmias
DM
CHF
Age
Family Hx
Sleep Apnea
Genetic Factors

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7
Q

Most vulnerable areas to ischemia

A

hippocampus - pyramidal cell layer
cerebral cortex - purkinje cell layer
cerebral cortex

These are areas that need glutamate and cannot receive it during an episode of ischemia

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8
Q

Significant reduction of death and disability if a person having an acute stroke arrives to ED within _______________ of symptoms

A

2 hours

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9
Q

Causes of Ischemia

A

thrombus (more common) and embolus

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10
Q

Influences on progression and extent of ischemia injury

A

rate and duration of ischemic event
collateral circulation in involved area of brain
systemic circulation and arterial blood pressure
coagulation abnormalities
temperature
glucose

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11
Q

CVA: Thrombus

A

formation or development of a blood clot within the cerebral arteries and their branches
often caused by atherosclerosis

typically gradual onset
progressive neurological decline x2-3 weeks
no loss of consciousness

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12
Q

Common sites of thrombus

A

carotid arteries at bifurcation
MCA

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13
Q

CVA: Embolus

A

matter formed elsewhere and released into the blood stream and travel into cerebral arteries and lodge in vessel

sudden onset
may induce hemorrhage

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14
Q

Common sites of embolus

A

L sided cardiac chambers
detachment from internal carotid arteries at site of plaque and lodges in another artery

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15
Q

Common sources of embolism

A

atrial fibrillation with cardiac disease - most common
bacterial endocarditis
atherosclerosis in carotid arteries

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16
Q

Pathogenesis of Ischemia

A

sudden cessation of cerebral blood flow causes O2 and glucose deprivation
loss of homeostasis
within minutes neuronal death begins (signs and symptoms result)
surrounding neurons at risk

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17
Q

What does loss of auto regulation secondary to lack of O2?

A

-vasodilation
-depletion of neurotransmitters
-lack of cerebral blood flow
-changes in ion balance

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18
Q

Ischemic Cascade

A

Release of excess neurotransmitters (glutamate and aspartate)
Brain can’t produce ATP
Excess influx of Ca and pump failure at neuronal cell membrane
Excess Ca causes increasing free radicals and stimulates other chemical imbalances
neuronal death and edema

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19
Q

Cerebral Edema

A

widespread cell death and failure of ion pumps causes cells to burst
fluids accumulate and occupy space in brain
causes increased permeability of blood-brain barrier causes increased fluid in the brain
starts within minutes and reaches max in 3-4 days

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20
Q

What is the most frequent cause of death in acute stroke?

A

cerebral edema

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21
Q

Results of Cerebral Edema

A

increased intracranial pressure
decreased level of consciousness
possible shifts in brain structures (herniation)

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22
Q

Signs of Increased InterCranial Pressure

A

decreased level of consciousness
increased HR
irregular respiration
vomiting
non-reactive pupils

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23
Q

Types of Hemorrhage

A

intracerebral
subarachnoid

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24
Q

Intracerebral hemorrhage (ICH)

A

bleeding from an arterial source into the brain parenchyma (bulk of brain)
worst type of CVA

25
Q

Primary ICH

A

spontaneous bleeding in the absence of any readily identifiable precipitant

often results from aging and/or HTN

26
Q

Secondary ICH

A

from trauma, exposure to toxins or anatomic lesion

27
Q

ICH Risk Factors

A

High BP**
Arterial Aneurysm**
AVM
TBI
secondary hemorrhage following ischemic stroke
surgery (atherosclerosis)
bleeding disorder/anticoagulation therapy
excessive ETOH or substance abuse

**most common

28
Q

Common Sites of ICH

A

cuadate
thalamus - most common
lobar subcortical
putamin

pontine - VERY RARE
cerebellum - RARE

29
Q

Subarachnoid Hemorrhage

A

bleeding into subarachnoid space

best confirmed with brain CT

30
Q

Symptoms of Subarachnoid Hemorrhage

A

SUDDEN ONSET OF SEVERE HEADACHE
stiff neck
photophobia due to blood in CSF
acute hydrocephalus
increased ICP
vomiting
nausea

Headache may occur after exertion and occurs in 40% of people with SAH

31
Q

SAH Risk Factors

A

Aneurisms
Atrial venous malformation (AVMs)

Women over 70

can occur secondary to:
trauma
developmental defects
neoplasm
infection

32
Q

Why does SAH have such a high mortality rate?

A

causes compression of brain stem where respiratory and cardiac centers are

33
Q

Aneurysm

A

abnormal stretching in the wall of artery, vein or heart itself

caused by trauma, HTN, atherosclerosis, heredity

34
Q

What is the best way to detect an Aneurysm?

A

CT scan

35
Q

Most common site of aneurysm

A

Men- anterior communicating artery or ACA
Women- junction of IJA with posterior communicating

36
Q

Signs and symptoms of aneurysm

A

sudden onset of unilateral focal deficits after activity
often preceded by headache

37
Q

AV Malformation

A

abnormal connection between arteries and veins, bypassing the capillary system

Acute onset of headache followed by bleeding leading to neurologic deficits depending on location of malformation

38
Q

Lacunar Infarcts

A

small subcortical infarcts in deep penetrating arteries (deep white matter)
strongly associated with hypertensive hemorrhage or DM

Typically have excellent outcomes- because a small artery is what was affected

39
Q

Transient Ischemic Attack

A

acute episode of temporary focal loss of cerebral function
rapid onset
always lasts less than 24 hours
FUNCTION RETURNS when blood flow is restored
increased likelihood of CVA

40
Q

ACA supply

A

frontal lobe
parietal lobe
basal ganglia
corpus collosum
branches of limbic system

41
Q

ACA Symptoms

A

contralateral hemiplegia
contralateral hemi-sensory impairments
incontinence
apraxia
LE > UE

collateral circulation in many areas

42
Q

MCA Supply

A

most of temporal lobe
frontal lobe
parietal lobe
internal capsule
globus pallidus
caudate
putamen

43
Q

MCA Dominant Symptoms

A

contralateral hemiplegia
contralateral sensory loss
aphasia- typically expressive
facial involvement
loss of conjugate eye movements (Area 8- frontal eye fields)

44
Q

MCA Non Dominant Symptoms

A

contralateral hemiplegia
contralateral sensory loss
homonymous hemiplegia
anosognosia- pt decides limb doesn’t belong to them
perceptual deficits- neglect, depth perception, spatial relations and agnosia
limb apraxia

45
Q

PCA supply

A

Occipital lobe
parts of temporal lobe
upper brainstem
midbrain
thalamus

46
Q

PCA causes

A

embolism from heart, aortic arch, vertebral artery, basilar artery

collateral circulation in many areas

47
Q

PCA: Thalamic branch occlusions

A

contralateral hemiplegia
contralateral sensory loss
central thalamic pain syndrome

48
Q

PCA: Occipital occlusions

A

homonymous hemianopsia
visual agnosia-unable to recognize things
paralysis of eye movements

49
Q

PCA: temporal lobe

A

memory deficits

50
Q

PCA: communicating arteries

A

minimal deficits

51
Q

Pusher Syndrome

A

disorder of postural orientation
actively push away from non paretic side
perceptual issue not vestibular

occurs with damage to L or R posterolateral thalamus

52
Q

Vertebral-Basilar Artery Syndrome

A

very small number of CVAs due to collateral circulation

Locked In Syndrome

53
Q

Thrombolysis

A

treatment for ischemic CVA

clot found in large vessel
restores blow flow in acute stage with improvement or resolution of neurological deficits

can cause hemorrhagic conversion

54
Q

Thrombolysis Agents

A

t-PA - must be administered within 3 hours
streptokinase
fibrinolytic snake venom

55
Q

Contraindications for t-PA

A

Seizures at onset
Sx of SAH
CVA or BI within 3 months prior
major surgery or trauma within 2 weeks prior
Hx of ICH, AVM/aneurism, neoplasms
Oral anticoagulant
improving neuro signs
high BP
GI bleed within 21 days prior

56
Q

Ischemia Treatments

A

surgical catheterization - removal of clot
anticoagulation- heperin, coumadin, aspirin

57
Q

Hemorrhage Treatments

A

Treat HTN - to get bleeding under control
surgical removal of hematoma
ICU

58
Q

Ischemic vs Hemorrhagic

A

Ischemic:
at risk for other CVA/MI
most return within 3 months

Hemorrhagic:
high mortality
extend of bleed
return can be slower

both: often hand function does not return

Pathophysiology (10 decks)

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