Ischemic Disease - Bradleys

Question 1

Epidemiology of stroke: What % of strokes are Ischemic? What are the long term morbidities of strokes?

Answer 1

88% of strokes are Ischemic. Morbidity of stroke: 30 % require assitance with ADLs, 20 require assistance with ambulation, and 16% require insitutional care.

Question 2

What are non-modifiable stroke risk factors? (Five)

Answer 2

age, male gender, ethnicity, family history, and prior history of stroke

Question 3

What are modifiable stroke risk factors? lifestyle + Non-lifestyle + Non-lifestyle without much proof.

Answer 3

smoking + drug use NON-LIFESTYLE hypertension, dyslipidemia SES - low arterial hypertension Heart disease Asymptomatic carotid artery disease Sickle Cell NON-LIFESTYLE risk factos which have yet to be shown to decrease risk when modified - Hypertension - Homocysteinuria - Left Ventricular hypertrophy

Question 4

What inherited diseases are associated with nonatherosclerotic vasculopathies? Think 1. collagen-vascular 2. cardiac 3. hemtological 4. inherited mitochondrial disorders. Mnemonic: CHIC (collagen-vascular, hematological, inherited mitochondrial, cardiac)

Answer 4

Ehlers Danlos Type IV Marfans Rendu-Osler-weber disease (Hereditary hemorrhagic telengectiasias) Sturge Weber Syndrome CARDIAC - familial atrial myxomas -hereditary cardiomyopathies - hereditary cardiac conduction disorders HEMATOLOGICAL - protein C and S or antithrombindeficiencies Inherited Mitochondrial disorders - Fabry - MELAS - Homocystinuria

Question 5

What is the pathophysiology of cerebral ischemia?

Answer 5

* loss of aerobic glycolysis * intracellular accumulation of sodium and calcium ions * release of excitotoxic neurotransmitters, * elevation of lactate levels with local acidosis, free radical production, cell swelling, overactivation of lipases and proteases, and cell death. * Apoptosis of many neurons.

Question 6

What are the three most predictive examination findigns for the diagnosis of acute stroke (UPTODATE)?

Answer 6

1. Facial Paresis 2. Arm drift/weakness 3. Abnormal Speech

Question 7

What are immediate lab tests you need for Strokes?

Answer 7

CT Head Serum Glucose O2 saturation Ischemic and Hemorrhagic Stroke - EKG, - cardiac enzymes - CBC + Plts - lytes, urea, creatinine - INR - PTT - APTT

Question 8

What does CT perfusion in normal brain show? MTT, CBF, CBV

Answer 8

Normal perfusion parameters are: gray matter MTT: 4 s CBF: 60 ml/100 g/min CBV: 4 ml/100 g white matter MTT: 4.8 s CBF: 25 ml/100 g/min CBV: 2 ml/100 g

Question 9

What does CT perfusion in ischemic penumbra show?

Answer 9

Prolonged MTT

>> MODERATELY reduced CBF

Near normal or INCREASED CBV

CBVVVVV VERRRRY GOOD. — if CBV is increased - that’s good. penumbra is larger!

Question 10

What does CT perfusion in infarct core show?

Answer 10

• Prolonged MTT,
• markedly DECREASED CBF,
• markedly DECREASED CBV

Question 11

What options for antiHTN medications are available for ICH?

Answer 11

Labetalol, Nicardipine are first line agents. Nitroprusside should be considered second-line therapy. It has added risks of increasing ICP and affecting PLT function

Question 12

What is the recurrence rate for extracranial dissections? Name risks for recurrence (3) What is the recurrence rate for ischemic events?

Answer 12

1% per year Young patients, FMD, Fam history of dissections 0-13%, highest in the first few weeks after presentation

Question 13

Name the causes of extracranial dissections (lots)

Answer 13

Blunt or penetrating trauma FMD Marfan Ehlers Danlos type IV Pseudoxanthoma elasticum Coarctation of the aorta Menke’s disease Alpha-1 antitrypsin deficiency Mucopolysaccharidosis Osteogenesis imperfecta Adult polycystic kidney disease Elevated arterial elastase content Lentiginosis Atherosclerosis Vessel tortuosity Moya Moya Homocysteinuria Pharyngeal Infections Sympathomimetic drug abuse Luetic (syphilitic) arteritis

Question 14

What are the diagnostic criteria for Moya Moya?

Answer 14

Review Suzuki’s 6 angiographic stages

Question 15

What are conditions associated with the formation of aneurysms

Answer 15

AD inherited polycystic kidney disease (13% risk increases with age >60 to 23%) Ehlers Danlos syndrome type IV Fibromuscular dysplasia Coarctation of the aorta (10% risk) Moya Moya Pseudoxanthoma elasticum Alpha-1 antitrypsin deficiency SLE Sickle cell anemia Bacterial endocarditis Fungal infections NF1 Tuberous sclerosis Pheochromocytoma AV Malformations Anomalous carotid-vertebrobasilar anastomoses Cocaine use Cigarettes Family History

Question 16

What is Terson Syndrome?

Answer 16

SAH + vitreous hemorrhage. Associated with worse outcomes and more severe SAH

Question 17

What is the timeline for Xanthochromia in CSF

Answer 17

appears about 12 hours after symptom onset, lasts several weeks.

Question 18

How do you choose between clipping and coiling?

Answer 18

COILING: Advanced age, poor clinical grade, systemic illness, top of the basilar , high surgical risk, patient preferance. CLIPPING: medically well, wide neck-Body ratio aneursms, normal arterial branches arising from dome or body. MCA arter aneurysms, aneurysms associated with large parechnymal hematoma CLIPPINGS have worse prognosis and mortality ISAT study: - risk reduction for coiling (better than clipping). Coiling has risk of aneurysm recurrence or rebleeding but still preferred compared to clipping.

Question 19

What are some DDX in CNS vasculitis?

Answer 19

Primary angiitis of the CNS GCA Systemic vasculitides (Behcet’s, ANCA, PAN) Cryoglobulinemic vasculitis Systemic inflammatory conditions (SLE, RA APLAS (more likely a thrombotic syndrome than a vasculitic one)) Infectious (syphilis, lyme, bartonella, TB, HIV) Lymphoma

Question 20

What are Risk factors for RCVS?

Answer 20

Women Post-partum Migraine history Drugs: Ergots, other anti-migraine therapies, SSRI’s Sympathomimetics OTC Cocaine Marijuana

Question 21

WHat are EGPA (pANCA) diagnostic Criteria?

Answer 21

• Asthma (with or without pulmonary opatcities on imaging) - Blood eosinophils > 1.5g/L (or > 10% of leukocytes) - Vasculitis (systemic)

Question 22

What are GPA (CANCA) diagnostic criteria?

Answer 22

At least two of: -Nasal or oral inflammation -Abnormal CXR -Urinary sediment, microhematuria -Granulomatous inflammation on biopsy When it is meningeal, GPA usually involves the lower CNS structures.

Question 23

What are diagnostic criteria for Behcet’s?

Answer 23

Recurrent oral ulceration (recurring at least 3x/year) plus two of: -Recurrent genital ulcers -Skin lesions (erythema nodosum, acneiform lesions, papulopustular eruption, psueodfolliculitis -Eye lesions (anterior uveitis, posterior uveitis, retinal vasculitis) -Positive pathergy test

Question 24

WHAT is the CHADS2 score? And what is the conferred stroke risk?

Answer 24

Question 25

WHAT is the CHADS2-VASC score?

Answer 25

Question 26

How do you treat ivTPA angioedema?

Answer 26

STOP THE OFFENDING DRUG!!!!

Hydrocortisone 100 mg IV

Benadryl 50 mg IV

Ranitidine 50 mg