Ddx: Vascular dz / Cerebral Ischemia Flashcards
Atherosclerosis
Giant Cell Arteritis
Giant cell (temporal) arteritis produces inflammatory changes that affect branches of the external carotid, cervical internal carotid, posterior ciliary, extracranial vertebral, and intracranial arteries.
Physical examination may show tender, nodular, or pulseless temporal arteries.
Laboratory findings include an increased erythrocyte sedimentation rate and evidence of vascular stenosis or occlusion on angiography or color duplex ultrasonography. Definitive
diagnosis is by temporal artery biopsy.
SLE
Systemic lupus erythematosus is associated with a vasculopathy that involves small cerebral vessels and leads to multiple microinfarctions.
PAN
Polyarteritis nodosa is a segmental vasculitis of small and medium-sized arteries that affects multiple organs. Transient symptoms of cerebral ischemia, including typical spells of transient monocular blindness, can occur.
Primary Angitis of the CNS
Primary angiitis of the central nervous system (also referred to as granulomatous angiitis) is an idiopathic inflammatory disease that affects small arteries and veins in the central nervous system and can cause transient or progressive multifocal ischemic lesions.
Syphilitc arteritis
Syphilitic arteritis occurs within 5 years after primary syphilitic infection and may cause stroke. Medium-sized penetrating vessels are typically involved producing punctate infarcts in the deep cerebral white matter that can be seen on CT scan or MRI.
AIDS
AIDS is associated with an increased incidence of TIAs and ischemic stroke.
Non-Inflammatory Cerebrocervical Arteriopathies:
Fibromuscular Dysplasia
Fibromuscular dysplasia produces segmental medial fibroplasia of large (especially renal, carotid, and vertebral) arteries and is associated with arterial dissection
(see below) and aneurysms. Familial cases suggest autosomal dominant inheritance with incomplete penetrance. Stroke is most common in children and young and middle-aged adults, especially females. A characteristic “string-of-beads” appearance on
angiography is diagnostically helpful. Symptomatic carotid artery disease is usually treated with antiplatelet drugs and intraluminal dilation of the affected vessel.
Carotid or Vertebral artery dissection
Carotid or vertebral artery dissection may occur spontaneously or in response to minor trauma, and is most common in middle age. It results from medial degeneration followed by hemorrhage into the vessel wall, and causes stroke by occluding the vessel or predisposing to thromboembolism. Carotid dissection may be accompanied by prodromal transient hemispheric ischemia or monocular blindness, jaw or neck pain, visual abnormalities that mimic those seen in migraine, or Horner syndrome. Vertebral dissection may produce headache, neck pain, and signs of brainstem dysfunction. Treatment is with antiplatelet drugs, sometimes combined with endovascular repair.
Muliple progressive intracranial occlusions (moyamoya)
Multiple progressive intracranial arterial occlusions (moyamoya) produce bilateral narrowing or occlusion of the distal internal carotid arteries and adjacent anterior
and middle cerebral artery trunks. Reactive arteriogenesis leads to a fine network of collateral channels at the base of the brain, which can be seen by angiography
. Moyamoya may be idiopathic (moyamoya disease) or due to atherosclerosis, sickle cell disease, or other arteriopathies. It is most common in children and middle-aged adults, and more common in females than males, but occurs in all ethnic groups, and
may be sporadic or inherited. Children tend to present with ischemic strokes and adults with intracerebral, subdural, or subarachnoid hemorrhage. Treatment includes antiplatelet drugs and surgical revascularization procedures.
Lacunar Infarction
Drug Abuse
Use of cocaine hydrochloride, alkaloidal (crack) cocaine, amphetamines, other stimulants (eg, phenylpropanolamine, ephedrine, or ecstasy), or heroin is a risk factor for stroke. Intravenous users may develop infective endocarditis leading to embolic stroke. Stroke also occurs in drug users without endocarditis, however, including those who take drugs only orally, intranasally, or by inhalation, often within hours of drug use. Cocaine hydrochloride and amphetamines are most often associated with intracerebral
hemorrhage, whereas stroke from alkaloidal cocaine use is usually ischemic. Proposed mechanisms include druginduced endothelial dysfunction leading to a prothrombotic
state, vasospasm, vasculitis, and rupture of preexisting aneurysms or vascular malformations.
Migraine
Migraine with (but not without) aura is a rare cause of ischemic stroke, which is most common in women, patients less than 45 years old, smokers, and oral contraceptive users.
Venous or sinus thrombosis
Cardiac Disorders:
Atrial fibrillation
Myocardial infarction
Mechanical prosthetic heart valves
Dilated cardiomyopathy
Rheumatic mitral stenosis
Infective endocarditis
Marantic endocarditis
Atrial myxoma
Paradoxical embolus
