CVD Flashcards
If cerebral ischemia is short lived?
Syncope
What is cerebral ischemia?
Inadequate blood flow/O2 to the brain
What is syncope?
no air for temp time –> faint –> come back to life
If cerebral ischemia is long?
hypoxic-ischemia encephalopathy
What is cerebral vascular accident?
FOCAL vascular (blood) cause affecting PORTION OF THE BRAIN
What is the main difference between cerebral ISCHEMIA and cerebral VASCULAR ACCIDENT?
ischemia: NO BLOOD/O2 TO THE BRAIN
vascular accident: BLEEDING TO ONE POINT IN THE BRAIN
What is intraparenchymal damage?
damage w/in the brain
What is the most important thing to distinguish when patient comes in with a “stroke”?
is it: 1) ischemic or 2) hemorrhagic
Which stroke is more common?
ischemic (85%)
hemorrhagic (15%)
Cx of ischemic stroke?
1) thrombosis
2) embolic
What is thrombosis?
clotting of bv d/t a large amount of platelets
What is embolic?
can be from a thromobus but also includes air bubbles, FB
occurs in a fib pts, patent foramen, R->L shunt
What is TIA?
transient ischemic attack
- short time when brain does not receive O2/blood but quickly resolves –> usually when pt is brought into ER they are asymptomatic
- MUST COMPLETELY RESOLVE IN 24 HRS OR ELSE CONSIDERED STROKE
What links ischemic and hemorrhagic strokes?
ischemic can turn into hemorrhagic stroke
Cx for TIA?
many cxs!
- a fib
- carotid artery
- foreman ovale
- carotid stenosis
What is a hallmark of TIA?
resolves in 24 hours
-usually short (<1hr)
What can happen in the next 48 hrs of a TIA?
STROKE (15%)
What are some sx of TIA?
- suddenly not able to talk: ischemia to broca’s
- transient blindness: AMAUROSIS FUGAX
Tx TIA?
ASPIRIN
What is the diff between aspirin and heparin?
Aspirin prevents platelet aggregation
heparin is a coag that helps blood keep moving (pts who are stasis/bedridden
TIA - imaging?
CT
What is small vessel stroke-lacunar stroke?
occlusion of the small vessel (pons)
Cx of small vessel stroke?
thrombosis 3mm to 2cm
Small vessel stroke - sx?
pure motor hemiparesis (internal capsule)
pure sensory stroke (ventral thalamus)
ataxic hemiparesis (ventral pons)
dysarthria and clumsy hand
Small vessel stroke - prognosis?
fast and complete
Small vessel stroke - hallmark?
clumsy hand
Pt cannot talk suddenly?
TIA
Pt suddenly has blindness?
TIA
Pt has clumsy hand?
small vessel stroke
Middle cerebral artery - sx?
contralateral hemianesthesia (paralysis) ipsilateral gaze preference (looks to the side of the stroke)
What is PCA? What arteries are included?
Posterior Cerebral Arteries
- vertebral
- basilar
- posterior
PCA - what parts of the brain is affected?
mid brain
subthalamic
thalamic
cerebellum
PCA - PE?
third nerve palsy
ataxia
coma
What is third nerve palsy?
eye is closed
cannot move eyeball up
eyeball does not react to light
Distal PCA affect which part of the brain?
occipital
temporal lobes
Distal PCA - sx?
cortical blindness (blind but has reactive pupils to light)
hemianopia (vertical blindness)
acute memory disturbances
Ischemic stroke RF?
ASCVD - thrombosis (w/in the CNS), embolism (rusty pipes from thrombosis)
older age, fam hx, DM, HTN, smoking, lipids
A fib (emoblic form clot in atria)
MI
valvula dz (emoblic vegetation)
patent foramen ovale
vascular dz (gient cell arteritis, lupus, sarcoidosis, syphilis)
cancer, thrombocytosis, factor V leiden, oral contraceptives
HIV/AIDs
Acute Ischemic stroke -tx?
1) ABC
2) tPA w/in 4.5 hrs of sx - usual contradictions still stand (MI, surgery, pregnancy, trauma)
3) antithrombotic (ASA) - clopidogrel if allergic to ASA
* anticoagulation (heparin) is USELESS (b/c there is a prob w/ the platelets, NOT blood)
Cerebral hemorrhage - cx?
HTN (preventable)
trauma
cerebral amyloid angiopathy (age related arteriolar degeneration)
Hemorrhagic stroke - RF?
age
drinking
anticoagulation
cocaine (young)
What are types of hemorrhagic stroke?
1) basal ganglia hemorrhage
2) thalamic hemorrhage
3) cerbellar hemorrhage
4) lobar hemorrhage
What are the types of ischemic strokes?
1) TIA
2) small vessel
3) middle artery
4) posterior artery
Which ischemic stroke goes away quickly - self resolves?
TIA and small vessel artery
If pt has high HTN comes in w/ “stroke” - what are you suspecting?
1) CT - differeniate between ischemic and hemorragic
2) look for sx of: face sag, slurred speech, arm/leg weakness
* if severe: flaccid paralysis, coma, deep irregular breathing, dilated fixed ipsilateral pupil
Thalamic hemorrhage - sx?
sensory defect
contralateral hemiplegia/hemiparesis
Why is there dilated fixed ipsilateral pupil in hemorrhagic strokes?
increased ICP: parasympathetic is not working –> sympathetic overrides cxing the widening of the pupil and “stuck”
Pontine hemorrhage - sx?
coma w/ quadriplegia over minutes decerebrate rigidity pinpoint pupils w/ reactive to light dolls eye phenomena hyperapnea, severe HTN, hyperhidrosis
Cerebellar hemorrhage - sx?
occipital headache N&V ataxia gait dizziness/vertigo HOURS (can intervene)
Lobar hemorrhage - sx?
depends on which part of the lobe is hemorrhaging
focal headache
VOMITTING
Lobar hemorrhage - occipital?
hemianopia (vertical visual loss)
Lobar hemorrhage - left temporal?
aphasia
Lobar hemorrhage - parietal?
sensory loss
Lobar hemorrhage - frontal?
arm weakness
How long does pontine, cerebellar, lobar hemorrhage take?
pontine - min
cerebellar - hours
lobar - min
Headaches of cerebellar vs lobar hemorrhage?
cerebellar- occipital
lobar - focal
Sx of intraranial hemorrhage?
increased ICP
increased ICP sx?
headahce
pailledema
cushings triad (increasing BP, dec pulse, widening pulse pressure)
how is intracranial hemorrhage named?
depending on the location of the hemorrhage
ie) subdural hemorrhage
ie) subarachnoid hemorrhage
What is cushing triad?
incr BP
dec pulse
widening pulse pressure
Subarachnoid hemorrhage occurs where most commonly?
between arachnoid and pia mater
Subarachnoid hemorrhage found…?
circle of willis
Subarachnoid hemorrhage - RF
polycystic kidney
Subarachnoid hemorrhage prognosis?
not very good - mortality 50-70%; morbidly 70%
Subarachnoid hemorrhage - hallmark
WORSE HEADACHE OF MY LIFE
THUNDERCLAP HEADACHE
Subarachnoid hemorrhage - what happens in the head?
ICP suddenly rises –> passes out (headache, vomitting, seizures, papilledema, cushings triad)
Subarachnoid hemorrhage - sx?
headache, vomitting, BP increases (trying to perfuse brain)
Subarachnoid hemorrhage - little bleeding - sx?
headache
stiff neck
focal neurological deficit (loss of vision)
Subarachnoid hemorrhage - cx?
trauma - check w/ manometer and give mannitol until surgery
Subarachnoid hemorrhage - gold standard?
angiogram
Subarachnoid hemorrhage - labs?
1) CT FIRST!!!!!! to r/o “mass lesion” (if there is a mass lesion and you LP –> brainstem herniation occurs!!)
2) LP - SF has blood (HALLMARK)
Subarachnoid hemorrhage - tx?
1) ABC
BP should be ~150 (keep brain perfused)
2) elevate head
3) sedation
4) cerebral vasospasm (4-14 days after) - cx “delayed” death
5) surgical clipping/endovascular coil placement
Subdural hemorrhage - acute vs. chronic?
acute: sloshing the brain around (no trauma needs to happen - accelerating/deceleration) ie) shaken baby syndrome
chronic: common in elderly ie) overtime the briding veins are stretched as brain shrinks
* BOTH: BRIDGING VEINS (venous bleed) is torn
Subdural hemorrhage - acute RF?
a fib
anticoagulation
elderly that bump their head
Subdural hemorrhage acute - sx?
unilateral headahce w/ slightly enlarged pupil
-stupor, coma, blow pupil
acute subdural hemotoma - acute - dx?
CT scan - CRESCENT SHAPE
Subdural hemorrhage acute - tx?
burr hole drainage
craniotomy
until surgery: mannitol, hyperventilation
Subdurl hemorrhage chronic subdural hemotoma - sx?
dementia slow thinking headache seizure personality changes, depression
Subdural hemorrhage chronic - RF?
elderly
chronic alcoholics: they have smaller brains so the venous bridging stretches!
anticoagulation
Subdural hemorrhage chronic -tx?
surgical
watchful waiting
Subdural hemorrhage chronic - imaging?
CT
Epidural hemorrhage?
arterial bleed between skull and dura
Epidural hemorrhage - cx?
trauma that tears the middle meingeal artery w/ skull fx (pt is in coma)
Epidural hematoma - sx? Hallmark
1) hit and unconscious
2) comes to life - “LUCID INTERVAL”
3) deteriorates over min to hrs –> fall into coma
CN 3 is altered –> fixed, dilated pupil
CN III injured?
subdural and epidural hemorrhage
fixed, dialted pupil - if traumatic
Epidural hemorrhage - imaging?
CT - NOT crescent (unlike subdural hemorrhage) –> rounded b/c the bleeding can’t expand out of the sutures in the skull
Epidural hemorrhage - tx?
rapid surgery and control bleeding
Pt comes in after a fight, was hit in the head w/ a baseball bat. He was knocked unconscious and now he is awake. What to expect?
fixed dilated pupil - CN III damaged lucid interval (patient is normal but will deteriorate overtime)
Pt comes in w/ a headache, pulsating noise in the head. Pt is 10-30yo. What to expect?
arterial-venous malformation
What is arterial-venous malformation?
congenital or developmental abnormality
can be surface or deep in the brain
asymptomatic until bleeding occur
can calcify overtime
Who is most likely to get aterial - venous malformation?
younger patients w/ intercranial bleeding (10-30yo)
Arterial-venous malformation - imaging
MRI»_space;> CT
angiogram is gold standard
Arterial venous malformation - tx?
surgery if accessable
stereotactic radiation
Moyamoya dz?
“puff of smoke” when the collateral vasculature is weak and prone to bleeding and thrombosis - stenosis of the cerebral vessel develops (so the other collateral vasculature is useless as well!)
Who can help pts w/ stroke?
PT
OT
SLP (esp those who are prone to getting pneumonia - if they can’t aspirate - pneumonia!)
RT
case manager (esp if pt is not going back home after discharge)
psychologist - watch out for depression (b/c pt feels useless after stroke)
