lecture 2 gold- cerebrovasculat diseases Flashcards
what is Abnormality of the brain resulting from a
pathologic process of blood vessels
cerebrovascular disease
define ischemia
Decreased blood flow, reversible
define infarction
death of tissue due to lack of blood flow
what is a Formation of clot within a vessel,
generally due to atherosclerosis
thrombosis
what is a Blood clot formed elsewhere travels
to the brain and lodges in a cerebral vessel
embolism
what is Bleeding (into the brain,
subarachnoid space, etc.)
hemorrhage
what is An acute clinical event related to
interruption of blood supply or
bleeding of a blood vessel resulting
in a change in neurologic function
(lasting more than 24 hrs) with
evidence of cerebral ischemia on
brain imaging.
a stroke
how long does a stoke last
more then 24 hours
what is a –Brief episode of focal neurologic
dysfunction from brain or retinal
ischemia w/o evidence of acute
infarction on MRI
transient ischemia attack
how long is a TIA
<1 hour but by definition < 24 hours
when is the highest risk that after a TIA you can have a stroke
1st 30 days
___ day risk of stroke after TIA is 3-17 %-
90
those with TIA have a ____ % stoke risk int he next 10 years
18.8
what tool is used for TIA evaluation
ABCD2
what is the ABCD2
a tool to see what is the probabaility that a stroke will happen in the next 2 days
what score is considered high risk from the ABCD2 score ? moderate ? low ?
6-7
4-5
0-3
what are 5 mimickers of a stroke
– Hypoglycemia or hypoxia
– Seizures (Todd’s paralysis)
– Migraines
– Multiple sclerosis attacks
– Brain tumor swelling
what is considered not an ischemic stroke (7)
- Sudden loss of consciousness
- Syncope/pre-syncope
- Numbness in both feet
- Waxing and waning confusion
- Diffuse weakness
- Numbness in one hand or foot
- Pain
what is the 5th leading cause of death in the Us
strokes
in the US how many strokes are averaged every 40 seconds
1
what is the leading cause of serious disability in the US
stroke
globally what is the 2nd leading cause of death
stroke
what is considered a major risk factor for strokes
age
Hypertension
Pregnancy
Diabetes
OCPs
High cholesterol
Alcohol abuse
Heart Disease
Obesity
Smoking
Physical activity
Drug abuse
Obstructive sleep apnea
these are all examples of what
modifiable risk factors for stroke
• Older age (72% occur in people > age 65)
• Male gender
• Family history
• Race (Blacks > Whites)
these are examples of what
non modifiable risk factors for stroke
what stroke subtype is 87% of stroke
ischemia
what stroke subtype is large vessel atherosclerosis
ischemia
what are small vessel subcortical strokes called
lacunar
what stroke subtype is 13% of stoke
hemorrhagic
what are the 2 types of hemorrhagic strokes and which is most common
intra cerebral and subarachnoid , and intra cerebral is more common
what are teh 5 ischemic stroke subtypes
– Large vessel atherosclerosis
– Cardio-aortic-embolism
– Small vessel subcortical strokes (lacunar)
– Other Rare/Unusual Etiology
– Undetermined etiology (~25 – 30%)
for a thrombotic infarction what % of people have had a warning episode (TIA)
> 50
when is the onset for a thrombotic infarction
during sleep , awakens with deficits
what do the symptoms of a thrombotic infarction depend on
the vessel invovled
what are branches of the internal carotid artery
OPAAM
Ophthalmic Artery
Posterior Communicating
Anterior choroidal
Anterior Cerebral Artery
Middle Cerebral Artery
if someone has a ACA stroke what is it affecting
leg weakness
if someone has a MCA stroke what is it affecting
hemiparesis of face and arm on the contralateral side
someone with a MCA will have neglect on which side and aphasia on which side
neglect on the non dominant and aphasia on dominant
what else will be impaired with a MCA infarction
cortical sensory loss
homonymous hemianopsia
paralysis of conjugate gaze to opposite side (eyes look toward the lesion)
what is aphasia
disorders of language
where is motor aphasia/expressive aphasia
anterior MCA territory near broca’s area
what is decreased and what is intact with motor aphasia
decreased fluency and intact comprehension
where is sensory aphasia/ receptive aphasia located
posteior MCA territory near wenickes area
what is intact and poor in sensory aphasia
fluent is intact and poor comprehension
which aphasia is more common
motor aphasia (brocas)
what is it called when both motor and sensory aphasia happens
global aphasia
what are the impairments with an ACA infarction *rare)
- hemiparesis in the legs
- hemisensoyr int he legs
- urinary incontinence (usually only with bilateral infarcts )
- slowness
- akinetic mutism
what is abulia
slowness , delay , lack of spontaneity
what are the impairments for a PCA infarction
-homonymous hemianopsia
- visual hallucination
-cortical blindness
-some contra sensory deficit
-inability to read (alexia)
- top of the basilar syndrome
what is the summary of symptoms for ACA infarct
contralateral leg weakness & problems with motivation and organization
what is the summary of symptoms of a dominant MCA infarct
contral weakness in arm and face
neglect
gaze deviation
aphasia
what is the summary of symptoms for non dominant MCA infaract
-contralateral weakness in arms and face
-neglect
-gaze deviations
what are th summary of symptoms for a PCA infarct
-contra homonymous hemianopsia
- splenium of corpus callosum
-may affect thalamus
– Sensory &/or motor abnormalities in any combo of
extremities/face
– Vertigo, clumsiness, ataxia,
– Diplopia, Dysarthria, Dysphagia
– Nausea/vomiting
– Hearing loss, hiccups
these are all symptoms of what kind of large vessel ischemic stroke
vertebrobasilar (brainstem)
where do most cerebral embolism arise in
the heart
what is the most common cause of a cardioembolic infarction
atrial fibrillation
what is an endocarditis
infection of heart valves
if someone has atrial fibrillation what is the increased risk for stroke and death
• 5x increased risk for stroke
• 2x increased risk of death
what reduces the risk for stroke by 2/3 with people with a fib
oral anti coagulation therapy
what are the examples for atrial fibrillation anticoagulation
warfarin (coumadin)
novel oral anticoagulants
• Rivaroxaban (Xarelto)
• Apixaban (Eliquis)
• Dabigatran (Pradaxa)
what are other sites for embolism infarction
–aorta
–large intracranial arteries
–patent foramen ovale
what are small infarcts of less than 1.5 cm called
lacunar infarction
a lacunar infarction is an occlusion of small penetrating vessels in what 6 things
-pons
-putamen
-caudate
-internal capsule
- thalamus
-corona radiata
what is a lacunar infarction usually related to
hypertension and DM
what is a effected in a pure motor stroke of an lacunar infarction
hemiparesis of face , arm and leg
internal capsule or base of pons
what is a effected in a pure sensory stroke of an lacunar infarction
face, arm and leg-
posterolateral thalamus
what is a effected in a sensorimotor stroke of an lacunar infarction
thalamus and internal capsule
what is a effected in a dysarthria , clumsy hand syndrome of an lacunar infarction
base of pons
what is a effected in a ataxia hemiparesis of an lacunar infarction
Pons/Internal capsule or
subcortex
what is affected in a thalamic stroke
contralateral sensory loss to all modalities
what is the symptoms of a thalmic stroke
spontaneous pain and dysesthesias
do people with thalamic stoke have hemiparesis ?
mildly
what is affected with an ACIA stroke
hearing loss, facial weakness, ataxia, Horner’s
syndrome
what artery is affected in lateral medullary syndrome or wallenberg syndrome
PICA/ vertebral artery
what is affected with a superior cerebellar artery stroke
ipsilateral ataxia, scanning speech
• Inherited disease
– MELAS
– CADASIL
– Fabry disease
• Inflammatory disorders
– Vasculitis
• Hematologic disorders
– Coagulation disorders
– Sickle cell
• Other
– Radiation
– Moya Moya
– Cocaine
these are all what
rare casues of strokes
what does BE FAST stand for
-balance
-eyes
-face
-arms
-speech
-time
the standard is door to needle time in ___ minutes but what is the goal
60
45 mins is the goal
for every 30 min delay what % decline is there in a good outcome
10
what is the most important thing in the history
time of onset
what are the 11 NIH stroke scale items
1a. LOC
1b. LOC questions
1c. commands
2. best glaze
3. visual field
4. facial palsy
5. motor arm
6- motor leg
7- limb ataxia
8- sensory
9- best language
10- dysarthria
11-extinction/ neglect
what is tPA (tissue plasminogen activator)
clot busting medication
what is the only FDA approved medication from acute stroke
tPA ( tissue plasminogen activator)
what are the contraindications from tPA
– > 4.5 hours from last known normal
– Hemorrhage (internal, intracranial)
– Head trauma or stroke in past 3 months
– Severe uncontrolled high blood pressure (<185/110)
– Endocarditis or aortic dissection
– Bleeding disorder or anticoagulated
– Glucose < 50
how should we monitor Bp in tPA patients
check BP every 15 min for 2 hours and then every 30 mins for 6 hours then 1 hour for next 18 hours
what is the BP that patients need to maintain when taking tPA
< 180/105
how long is blood pressure management post stroke
first 3-4 days
what is the post tPA blood pressure goal post stroke ?
<180/105
what is the no tPA medication blood pressure goal post stroke
< 220/110
what are secondary preventions for stroke care
– Quit smoking, drugs, alcohol
– Medical management (antiplatelet;
hypertension, diabetes mellitus, obesity,
hyperlipidemia)
– Anticoagulation in cardioembolic strokes
– Carotid artery surgery versus stenting
what is the Surgical procedure to remove
atherosclerotic plaque from the carotid
artery.
carotid endarterectomy
Symptomatic carotid artery stenosis”
implies a patient has had what
a TIA or stroke referable to the territory of the stenosis vessel
what on the imaging is bright colored and tells u about new stroke
DWI
when is the highest rate of recovery from a stroke
1st 3-6 months
what deficits have better recovery rather than others
swallowing , facial movements , and gait
what deficits tend to recover more slowly
language , spatial attention and dominant hand movements
does recovery from a stroke tend to being proximal or distal
proximally
what kind of intracerebral hemorrhagic stroke is most common caused by HTN
subcortical
Aneurysms, AVMs, venous, trauma,
intracranial artery dissections,
cocaine/amphetamine
these are what kind of strokes
subarachnoid hemorrhagic strokes
• Focal neurologic deficits rapid in onset
• Symptoms of increased intracranial pressure
common (headache, vomiting, decreased
consciousness)
• CT readily shows blood
these are clinical signs of what kind of strokes
intracranail hemorrhage
what is the most common causes of a intracerebral hemorrhage
hypertension
Intracerebral hemorrhage due to HTN are located where
– putamen
– pons
– cerebral
hemisphere
– cerebellum
– thalamus
according to the glasgow coma scale what is considered severe , moderate and mild scores
severe.. 3-8
mod… 9-12
mild.. 13-15
what is the management for intracerebral hemorrhage
treat increased intracranial pressure
80% of subarachnoid hemorrhage is caused by what
rupture of intracranial aneurysm
what % die before medial attention for a Subarachnoid hemorrhage (SAH)
10
what % die within 3 months with a Subarachnoid hemorrhage (SAH)
40
what % are survivors of Subarachnoid hemorrhage (SAH) that live with disabilities
50
what is a Sudden explosive headache which may lead to loss of consciousness
aneurysm rupture
what is the leading causes of death and disabilities for an aneurysmal subarachnoid hemorrhage
– Effects of initial hemorrhage
– Recurrent hemorrhage
– Vasospasm leading to ischemic
Thrombosis of venous system: can involve both____ and ____
ischemia and hemorrhage
strokes of venous origin may present with
– Headache
– Focal neurologic signs
– Hemorrhage- SAH or ICH
– Altered mental status, seizures
how do you diagnose strokes of venous orgina and how do u treat it
diagnose with CT or MRI and treat with anticoagulation
