CVD 2 Flashcards
This is a segmental, nonatheromatous, noninflammatory
arterial disease of unknown etiology, almost exclusively
in women
Fibro m u scu l a r Dysplasia
Arteries involved in FMD
internal carotid artery is involved most frequently,
followed by the vertebral and cerebral arteries
Histology of FMD
The narrowed arterial segments show degeneration
of elastic tissue and irregular arrays of fibrous and
smooth muscle tissue in a mucous ground substance
Mechanisms of ischemia in FMD
from thrombi in the pouches or in relation to intraluminal septa
In pts with FMD, between 7 and 20 percent of affected individuals are found to have intracranial
_________ (rarely a giant aneurysm),
saccular aneurysms
the process formerly
known as Erdheim’ s medionecrosis aortica cystica
I nte r n a l Ca rot i d Artery D i ssect i o n
The frequency of cerebral stroke with aortic dissection
has varied from ______ percent and that of spinal
stroke has been approximately ______ percent
10 to 50
10
___________are also associated with an increased risk of vascular dissection
The Ehlers-Danlos and Marfan syndromes,
osteogenesis imperfecta,
Loeys-Dietz syndrome (transforming growth factor [TGF]-,B receptor mutation), and alpha1 -antitrypsin deficiency
In most cases, dissection of the internal carotid artery
can be detected by ultrasonography and confirmed by
MRl and CTA, which show a _____
double lumen
In pts with Carotid artery dissection,
angiography usually reveals an elongated, but variable
length, irregular narrow column of dye, usually
begiruting 1 .5 to 3 em above the carotid bifurcation and
extending to the base of the skull, a picture that Fisher
has called the ________
string sign
Rapid
and extreme rotational movement of the neck is the most
common identifiable cause of ____________
vertebral artery dissection
Another interesting but rare
association with dissection has been the ________
reversible cerebral vasoconstriction syndrome
___________percent of patients
with the angiographic signs of cervical artery dissection;
mainly, these were patients who had fluctuating
ischemic symptoms but without stroke have a complete or excellent recovery
85%
Tx of cervical artery dissection
anticoagulation for several weeks
or months and followed up with some form of arteriography.
relative CI to anticoagulation in pts with cervical artery dissection
there is existing
subarachnoid blood on a CT scan or if there is a pseudoaneurysm
within the intracranial portion of the dissection
refer to an 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,
Moya-Moya
Associations of Moya-Moya dse
segmental stenosis or occlusion of the terminal intracranial parts of both internal carotid arteries
Certain hemoglobinopathies, particularly sickle cell anemia, may cause a vasoocculsive condition equivalent to moyamoya disease, possibly because of sickling of red blood cells in the vasa vasorum of the_______
supraclinoid carotid artery.
MC initial presentation of Moya Moya in adults
subarachnoid hemorrhage was the most common initial
manifestation.
in pts with Moya Moya, EEG phenomenon in which high-voltage slow waves reappear 5 min after the end of hyperventilation is called?
rebuild up
Histology of pts with Moya Moya
The adventitia, media, and internal
elastic laminae of the stenotic or occluded arteries were
normal, but the intima was greatly thickened by fibrous
tissue
Theories on the origin of the rete mirabile
congenital vascular malformation (i.e., a
persistence of the embryonal network) or a rich collateral
vascularization secondary to a congenital hypoplasia,
acquired stenosis, or occlusion of the internal carotid
arteries early in life.
Tx of Moya Moya
transplantation of a vascular muscle flap,
omentum, or pedicle containing the superficial temporal
artery to the pial surface of the frontal lobe temporal pial
synangiosis with the idea of creating neovascularization
of the cortical convexity
The term has come to denote a widespread degeneration of cerebral white matter having a vascular causation and observed in the context of hypertension, atherosclerosis of the small blood vessels, and multiple strokes.
Binswanger Disease
Imaging feature of Binswanger
leukoaraiosis describes the imaging appearance
of hypointense periventricular tissues, presumably
damaged by chronic ischemia
Clinical features of Binswanger
Dementia, a pseudobulbar state, and a gait disorder,
alone or in combination, are the main features of
Binswanger cases
A process with an imaging appearance of large confluent
cerebral white matter changes, somewhat similar to
Binswanger leukoencephalopathy, has been identified
as an autosomal dominant familial trait linked in several
families to a missense mutation on chromosome 19.
Fa m i l i a l Su bcortica l I nfarction
CADASI L a n d CARAS I L
A syndrome of early alopecia and lumbar spondylosis
with the white matter changes typical of CADASIL has
been identified as a recessively inherited disease _______________
(cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy [CARASIL])
Mutation associated with Binswanger
missense change on
chromosome 19 of the NOTCH 3 gene, in the same locus
as the gene for familial hemiplegic migraine
Biopsy of Binswanger disease
eosinophilic inclusions in the arterioles of a skill
biopsy
Mutation associated with CARASIL
HTAR1 gene
Result of HTAR1 gene mutation
fragmentation and duplication of the internal elastic
lamina of cerebral vessels with narrowing of their lumens
MC cause of inherited deficiencies of naturally
occurring anticoagulant factors as a cause of stroke
heterozygous mutations
in the genes encoding proteins in the clotting cascade
(antithrombin III, proteins S and C) and from those that
disturb clotting balance (resistance to activated protein C,
or factor V Leiden mutation, and prothrombin mutations
as well as excess factor VIII)
___________ in young women with an established history of migraine as a risk for strokes, most of which occurred in the posterior circulation
prolonged
aura
women who take oral
contraceptives in the childbearing years-particularly if
they are _________, _________, ________, _____________–are at increased risk of
cerebral infarction
older than 35 years of age and also smoke, are
hypertensive, or have migraine
The vascular lesion underlying cerebral
thrombosis in women taking oral contraceptives consists of__________
nodular intimal hyperplasia of eccentric distribution with increased acid mucopolysaccharides and replication of the internal elastic lamina.
The use of ________ has not been associated with stroke as far as can be currently determined
progestin-only
pills or of subcutaneously implanted capsules of progestin
The risk of both
cerebral infarction and intracerebral hemorrhage appears
to be mainly in the________ period after delivery rather
than during the pregnancy itself
6-week
The occurrence of ________ embolus is always a
consideration in pregnancy because of a tendency to form clots in the pelvic and leg veins, coupled with increased right heart pressures
paradoxical
Atherosclerotic
plaques may be dislodged during ________ and are an important source of cerebral
emboli.
cross-clamping of the
proximal aorta
Frequency of stroke depending on location
(1) the putamen and adjacent internal capsule (SO percent);
(2) the central white matter of the temporal, parietal, or frontal lobes (lobar hemorrhages, not strictly associated with hypertension);
(3) the thalamus;
(4) one or the other cerebellar hemisphere;
and (5) the pons
Phagocytosis of red cells begins within 24 h, and hemosiderin is first observed around the margins of the clot in ________
5 to 6 days
The _________ the appearance of contrast within the
hemorrhage during CT angiography, is associated with a
high rate of hematoma expansion
“spot sign,”
As _______ and _______ form, the hematoma signal becomes bright on Tl-weighted images and dark on T2
deoxyhemoglobin and
methemoglobin
The hypertensive vascular lesion that leads t o arteriolar
rupture in most cases appears to arise from an arterial
wall altered by the effects of hypertension, i.e., the change referred to in a preceding section as ______ and _________
segmental lipohyalinosis and the false aneurysm (microaneurysm)
The immediate prognosis for large and medium-sized
cerebral clots is grave; some _______ percent of patients
die in 1 to 30 days.
30 to 35
Scoring system for ICH
incorporates the patient’s age, size and location of hematoma, the presence of preexisting cognitive impairment, and Glasgow Coma score
FUNC
Scoring system for ICH
uses GCS, volume, presence of intraventricular hemorrhage, the location-supra- or infratentorial, and age above or below 80 years
ICH
Target Osm and serum Na in ICH Tx
osmolality kept at 295 to 305 mOsm/L and Na at 145 to
150 mEq
Findings of the STITCH Trial
failed to show a benefit from early surgery on survival or
neurologic functioning at 6 months.
Hematomas that are _______or more in largest diameter,
especially if located in the vermis, pose the greatest risk,
and some surgeons have recommended evacuation of
lesions of this size no matter what the clinical status of the
patien
4 em
They take the form of small, thin-walled blisters
protruding from arteries of the circle of Willis or its
major branches
“berry” aneurysms.
aneurysmal process is initiated by focal destruction
of the__________ which is produced
by hemodynamic forces at the apices of bifurcations
internal elastic membrane,
4 MC sites of aneurysms
(1) the proximal portions of the anterior communicating artery,
(2) at the origin of the posterior communicating artery
from the stem of the internal carotid,
(3) at the first major bifurcation of the middle cerebral artery, and
(4) at the bifurcation of the internal carotid into middle and anterior cerebral arteries.
Aneurysms of the carotid artery that rupture in the
cavernous sinus give rise to an ______
arteriovenous fistula
The
_______ is caused by a septic embolus that
weakens the wall of the vessel in which it lodges, almost
always at a site in a distal cerebral vessel, well beyond the
circle of Willis.
mycotic aneurysm
Fusiform deformities are
also referred to as _________, as they frequently
show atheromatous deposition in their walls, but
it is likely that they are at least partly developmental in
nature.
arteriosclerotic aneurysms
MC syndrome of SAH at the onset
severe generalized headache develops in the same
instantaneous manner but the patient remains relatively
lucid with varying degrees of stiff neck-the most common
syndrome
Percentage of Sz in SAH
Convulsive seizures, usually brief and generalized,
occur in 10 to 25 percent
An aneurysm on the posteroinferior
or anteroinferior cerebellar artery may cause unilateral
______ or _______
occipital or cervical pain