Lecture 10: Stroke Flashcards
Anterior circulation of the brain is supplied by the?
Carotid Artery
Posterior circulation of the brain is supplied by?
Vertebral-Basilar Artery
The circle of willis is comprised of? (3)
- Anterior Communicating Artery
- 2 Posterior communicating arteries
- 3 Cerebral Arteries
70-80% of strokes occur in which artery?
Middle Cerebral Artery
What are the deficits associated with a MVA stroke? (5)
- Contralateral Hemiparesis
- Sensory Loss
- Homonymous Hemianopsia
- Dominant Hemisphere (Left MCA): Aphasia
- Non-dominant (Right-MCA): Impaired spatial perception and contralateral neglect
What is the difference between a Right and Left MCA Stroke?
Right MCA: Impaired spatial perception and contralateral neglect
Left MCA: Aphasia
A stroke in the Anterior Cerebral Artery (ACA) leads to…
Weakness in the UE > LE
A stroke in the Middle Cerebral Artery (MCA) leads to…
More Upper Extremity Weakness
This artery supplies primarily the medial frontal and parietal lobes.
Anterior Cerebral Artery (ACA)
What are the deficits associated with an ACA Stroke?
- Contralateral LE Weakness
2. Contralateral LE Sensory Loss
This artery supplies the small penetrating arteries to midbrain and thalamus, and the occipital lobes and inferior medial temporal lobe
Posterior Cerebral Artery
What does the Posterior Cerebral artery supply? (4)
- Small penetrating arteries to midbrain
- Small penetrating arteries to thalamus
- Occipital lobes
- Inferior Medial temporal lobe
What are the deficits associated with a PCA stroke? (3)
- Homonymous Hemianopsia
- Alexia
- Sensory Loss
The Medulla is supplied by what arteries? (2)
- Vertebral
2. PICA
The Pons are supplied by what artery(s)? (3)
- Basilar
- AICA
- SCA
The midbrain is supplied by what artery? (1)
PCA
What are the general deficits associated with a stroke that effects the brainstem?
- LOC
- Nausea, vomiting
- Hemiparesis
- Cranial Nerve Involvement
- Can have crossed signs (Ipsilateral face/contralateral body)
- Can have ipsilateral cerebellar signs
Small Location => Big Consequences
Example: Internal Capsule
-Occlusions of single small perforating arteries
What is this called?
Lacunae Syndromes
Left sided hemiparesis and sensory loss is associated with what kind of CVA?
Right CVA
Right sided hemiparesis and sensor loss is associated with which CVA?
Left CVA
This is denial of paralysis or impairment, reduced insight, inattention to left side
Left Sided Neglect
Left sided neglect is associated with which CVA?
Right CVA
Left side visual field cut.
RIGHT or LEFT CVA?
Right CVA
Right sided visual field cut.
RIGHT or LEFT CVA?
Left CVA
Aphasia is associated with a Right or Left CVA?
Left CVA
Individuals with a CVA that experience spatial problems: depth perception have a …
Right or Left CVA?
Right CVA
Impaired ability to do math, or to organize, reason, and analyze items is associated with…
Right or Left CVA?
Left CVA
Inability to localize or recognize body parts is associated with
Right or Left CVA?
Right CVA
Behavioral changes: depression, cautious, and hesitation are associated with which sided CVA?
Left CVA
The inability to understand maps and find objects, such as clothing or toiletry items is associated with which sided CVA?
Right CVA
Patients who experience memory problems typically have a CVA on which side?
Right and Left CVA
Behavior changes, such as impulsivity, inappropriateness, and depression typically have a cVA on which side?
Right CVA
Impaired ability to read, write, and learn new information is associated with chi sided CVA?
Left CVA
This is the leading cause of serious long-term disability in the United States
Stroke
Which has a higher mortality rate, Ischemic or Hemorrhagic?
Hemorrhagic Stroke
Which stroke is more common
Ischemic or Hemorrhagic?
Ischemic Stroke: 80%
Hemorrhagic: 20%
What are the two types of hemorrhagic strokes?
Intraparenchymal Hemorrhagic (IPH) 10-15% Intracerebral Hemorrhagic (ICH) 10-15% Subarachnoid Hemorrhage (SAH) 5%
What are the two types of strokes
Ischemic: Artery Occlusion
Hemorrhagic: Artery Rupture
What are the two causes of Ischemic Strokes?
- Thrombotic: Atherosclerosis
2. Embolic: Embolism
What are the two sites of occlusion for a thrombotic stroke?
- Main Artery occlusion
2. Lacunar Stroke: Small Penetrating Artery Occlusion
What are the two types of Hemorrhagic Strokes? Artery Rupture
- Intracerebral/Intraparenchymal
2. Subarachnoid
What are the two causes of Subarachnoid Strokes?
- Aneurysm
2. Arteriovenous Malformation
This is partial or complete loss of blood supply to an area of the brain.
Ischemic Stroke
What are the causes of an Ischemic Stroke? (5)
- Embolic (15-30%): cardiac embolus occluded cerebral artery
- Thrombotic/Atherosclerotic (14-25%): Gradual narrowing of cerebral artery
- Lacunar (15-30%): Small, deep vessel occlusions
- Cryptogenic (20-40%): Unknown
- Arterial dissection 2%: More in patients <30yrs
What causes the brain tissue to die?
Mild to moderate ischemia
> Insufficient Oxygen and Glucose
- ->Inadequate energy supply
- —>Failure of neuronal activity regional brain dysfunction
What can cause a severe ischemia?
Insufficient oxygen and glucose leading to inadequate energy supply
What are the 3 causes of sever ischemia after insufficient oxygen and glucose leading to inadequate energy supply?
1) Influx of Water NA+ and Cl-
- Cytotoxic Edema
2) Influx of CA++
- Irreversible Cellular Injury
3) Anaerobic Metabolism
- Accumulating Lactic Acid and H+ compromise neuronal integrity
What are the 3 causes of an advanced ischemia?
- Influx of water NA+ CL-
- Influx of Ca++
- Anaerobic Metabolism
What is an advanced Ischemia?
Loss of function causes accumulation of glutamate and aspartame which bind to NMDA receptors
With advanced Ischemia, there is loss of function that causes accumulation of glutamate and aspartame, which bind to NMDA receptors. This leads to…
Influx of water, Na+ and Ca++
What is the end result of an advanced ischemia?
- Destruction of cell components
2. formation of free radicals, eicosanioids, and leukotrienes
What are the temporal feature of an ischemic stroke?
> Abrupt
- ->Stable
- —>Gradual Improvement
An ischemic stroke can be related with what medication?
rTPA within 3 hours
What are the signs and symptoms associated with an Ischemic Stroke?
- Sudden onset of focal neurological deficits
- Symptoms in minutes
- Headache: 25% of patients
- Nausea and vomiting: typical with brainstem and cerebellum
- Acute HTN: 70% of cases
- ACT FAST
What are the risk factors associated with an Ischemic Stroke?
- Hypertension
- Cardiac Disease
- Diabetes
- Hyperlipidemia
- Smoking
- Carotid Artery Stenosis
- TIA: transient ischemic attack
- Focal brain ischemia
- Usually lasts 10 minutes, resolves in 24 hours
How is an ischemic stroke diagnosed?
- Computed Tomography (CT)
- Magnetic Resonance Imaging (MRI)
- Carotid US
- Echo
- ECG
- Lab Tests
With an MRI T1, the infarct looks?
The bleed looks?
Infarct: Dark
Bleed: Bright
With an MRI T2: the infarct looks?
The bleed looks?
Infarct: Bright
Bleed: Dark
With a CT scan, an infarct looks?
A bleed looks?
Infarct: Dark
Bleed Bright
With MRI T1, T2, and CT, the bleed looks?
Bright
With MRI T1, T2, and CT scan, how does the infarct look?
MRI T1 and CT: Dark
MRI T2: Bright
This is a bleed within the brain. 2 types
IPH or ICH
This is a vessel rupture in the subarachnoid space
SAH: subarachnoid hemorrhage
What is the pathogenesis of a Hemorrhagic CVA?
> Hematoma Forms
- ->Cerebral Edema (peaks at 48 hours, resolved by 5 days)
- —>Tissue shifts
What is the most common cause of a Hemorrhagic stroke?
Hypertension
What are the common IPH sites? (6)
- Lobar
- Basal Ganglia
- Internal Capsule
- Thalamus
- Pontine
- Cerebellar
What are the signs and symptoms associated with IPH? (4)
- Focal Deficit that worsens over minutes
- Acute HTN
- Headache (50%)
- Large Hematoma: Nausea, vomiting, early decline in level of consciousness
What are the risk factors associated with IPH? (6)
- Hypertension
- <55yrs old
- Smokers
- Non-compliant with antihypertensive medications
- Heavy alcohol use
- Illicit drug use
What are the diagnostic tests for IPH? (3)
- CT Scan
- MRI
- Lab Tests
What is a subarachnoid hemorrhage?
Bleeding into subarachnoid space
What are the causes of aSubarachnoid Hemorrhage? (2)
- Ruptured Aneurysm
2. Vascular Malformation
What are the clinical findings for a SAH? (3)
- Sudden onset severe headache
- Neurologic Signs
- LOC, Coma
What are the diagnostic tests for a SAH? (4)
- CT Scan
- Catheter Angiography
- MRI
- Lumbar Puncture
What are the differential diagnoses for all strokes? (8)
- Seizures
- Psychogenic
- Migraine with Aura
- Hypertensive Encephalopathy
- Toxic-Metabolic Encephalopathy (Hypoglycemia)
- Head Trauma
- Tumor
- Drug Toxicity
What is the acute management protocol for a Stroke?
- rTPA: Intravenous Recombinant Tissue Plasminogen Activator
- Ischemic: Antiplatelet-Aspirin within 48hr
- All: blood pressure management
- Surgery
When should rTPA be administered for a stroke?
Within 3-4.5 hours of ischemic stroke
-1/3rd of patients have reversal of stroke
What is the risk with administering rTPA?
Risk of Hemorrhage (6.4%)
What type of surgery is administered for strokes?
- Carotid Endartectomy: for carotid stenosis (ischemic)
2. Craniotomy: surgical decompression for increased intracerebral pressure
What are the complications for a Stroke?
- Hemorrhagic transformation for infarcts
- Brain edema (max after 3-5 days)
- Seizures
- Medical complications
- Aspiration pneumonia, UTI
- DVT
- Hyperglycemia
