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NEURO 210 > Lecture 8: Brain Circulation and Stroke > Flashcards

Lecture 8: Brain Circulation and Stroke Flashcards

1
Q

What is a stroke?

A

acute neurological impairment due to brain ischemia or brain hemorrhage

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2
Q

What is an ischemic stroke?

A

a clot blocks blood flow to an area of the brain

acute onset of neurologic deficits caused by impaired blood flow to the central nervous system

leading cause of disability
30% impaired activities of dally living
20% impaired ambulation
16% require institutional care

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3
Q

What is an hemorrhagic stroke?

A

bleeding occurs inside or around brain tissue

on an MRI blood shows white

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4
Q

What is the epidemiology of strokes?

A

60,000 strokes occur in Canada each year

5th leading causes of mortality

1st leading cause of adult disability

men > women at younger age
women > men at older age

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5
Q

What is the pathophysiology of an ischemic stroke?

A

blood flow to brain from 2 carotid arteries and 2 vertebral arteries (only blood sources to the brain)

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6
Q

What causes impaired blood flow to brain?

A

vessel problem: atherosclerosis, vasculitis, dissection, lipohyalinosis

heart problem: atrial fibrillation (most common), valvular disease, cardiac ischemia

blood problem: hypercoagulable state (more easily form blood clots)

mitochondrial disease (very rare, if they can’t generate enough energy)

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7
Q

What happens to the brain when it is ischemic?

A

cellular injury and death

death of neurons, astrocytes, oligodendrocytes, endothelial cells

blood brain barrier disrutption

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8
Q

What is the mechanism of cell injury and cell death?

A

apoptosis, autophagy, necrosis

excitotoxicity (glutamate)

inflammation

oxidative stress/reactive oxygen species

mitochondrial dysfunction

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9
Q

How are brain vessels different than other blood vessels?

A

blood brain barrier/neurovascular unit (limits entry of blood products into brain, endothelium, astrocytes, pericytes, neurons)

autoregulation: neuronal regulation, pCO2 neuropeptides, cytokines

no external elastic lamina

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10
Q

What is the presentation of brain ischemia?

A

TIA (Transient Ischemic Attack): complete recovery of symptoms in 24 hours, no infarct on CT or MRI

Ischemic stroke: persisting neurological deficit > 24 hours, infarct on CT or MRI

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11
Q

What are lacunar strokes?

A

small and hard to see

in the small arteries caused by high blood pressure or diabetes

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12
Q

What is acute stroke mangement?

A

ABCs, reperfusion, neuroprotection

prevent complications (seizures, infection)

rehabilitation

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13
Q

What is stroke prevention?

A

treat vascular risk factors (hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation)

antiplatelet or anticoagulant

treat underlying cause

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14
Q

What are the steps of acute stroke treatment?

A
  1. ABCs
  2. Recanalization: time is brain (~1.9 million neurons lost / minute), IV TPA (tissue plasminogen activator), endovascular therapy (stent retriever)
  3. Neuroprotection: no approved neuroprotective drug, 120 trials, prevent hyperglycemia, hypoxia, hypoperfusion, hyperthermia
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15
Q

What is tissue plasminogen activator?

A

tPA activates plasminogen to form plasmin

plasmin degrades fibrin based blood clots

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16
Q

What are the effects of tissue plasminogen activator on ischemic stroke?

A

absolute benefit 11-13%

30% better chance of mild neurologic deficit at 3 months

risk of brain hemorrhage 6.4%

17
Q

What is endovascular therapy?

A

EVT removes blood clot

EVT reduces those dead or dependent from 71% to 47%

18
Q

How are patients selected for endovascular therapy?

A

time is brain (early reperfusion better)

small core infarct (ASPECTS, Perfusion Imaging (CTP))

large artery occlusion (CTA, MRA, NIHSS>8, LAMS>4)

19
Q

How is further brain injury prevented after a stroke?

A

blood pressure (not too high and not too low)

glucose (hyperglycemia worsens stroke)

infection (prevent pneumonia, dysphagia screen, NPO)

temperature (euthermia, brain cooling ICTUS trial, works well on animals puts humans at risk for infections, don’t do it in clinics)

20
Q

What examples of stroke prevention?

A

diet: low fat, low salt
exercise: >30 minutes, 3-4 times per week
smoking cessation: cuts stroke risk in half
stop heavy consumption
hypertension (top risk factor for stroke)
diabetes: goal euglycemia
hyperlipidemia: stains prevent stroke

21
Q

What is carotid atherosclerosis?

A

artery-artery embolism
fatty streak –> fibrous plaque –> plaque rupture –> thrombosis

carotid disease stenosis >50%

treatment: carotid endarterectomy or stent

22
Q

What is intracranial atherosclerosis?

A

treatment: medical management

angioplasty/stenting only for patients refractory to medical management

23
Q

What is carotid or vertebral dissection?

A

subintimal hematoma of carotid of vertebral artery

associations: trauma, connective tissue disease, atherosclerosis

angiogram: string sign, smooth tapered occlusion

treatment: antiplatelet or anticoagulation

24
Q

What is a small vessel lacunar stroke?

A

microvascular disease: lipohyalinosis or microatheroma

caused by long standing hypertension, diabetes

treatment: antiplatelet (controlling blood pressure, diabetes)

25
Q

What are cardioembolic stroke?

A

15-20% of ischemic strokes

clots forms in heart, embolizes to brain

26
Q

What is atrial fibrillation?

A

atrium (on top) is contracting irrhythmically

causes formation of clots and stroke

27
Q

What is anticoagulation indicated for?

A

atrial fibrillation, left ventricular thrombus, mechanical valve

28
Q

What are antiplatelets indicated for?

A

for all TIAs or Ischemic stroke unless anticoagulation indicated

29
Q

What are the types of hemorrhagic stroke?

A

epidural hemorrhage (on top of dura)

subdural hemorrhage (subdural space)

subarachnoid hemorrhage (pia mater)

intracerebral hemorrhage (inside brain)

30
Q

What is an intracerebral hemorrhage?

A

hemorrhage into brain parenchyma (blood vessel bursts and leaks blood to the brain)

neurological deficits similar to ischemic stroke, cannot distinguish by clinical presentation

headache

altered level of consciousness

31
Q

What are causes of intracerebral hemorrhage?

A

hypertension
amyloid angiopathy
vascular malformation
brain tumor
coagulation related
brain trauma
drug (amphetamine, cocaine)
vasculitis

32
Q

What are treatments of intracerebral hemorrhages?

A

treat underlying causes

blood pressure control

correct coagulation of abnormal

intracranial pressure management

seizures

33
Q

What are subarachnoid hemorrhages?

A

hemorrhage into subcortical space, can become subdural, intracerebral, or intraventricular

sudden onset worse headache of life

neck stiffness

altered level of consciousness

cranial nerve III palsy

graded by Hunt + Hess scale

34
Q

What is the cause of subarachnoid hemorrhages?

A

intracranial aneurysm rupture

NEURO 210 (23 decks)

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