Nervous System-Vascular disease and Cephalgia Flashcards by Leslie Vargas

What are the two common places that a clot can come from that goes to the brain

Heart
Carotids

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What are the disorders that encompasses cerebrovascular disease?

ischemic and hemorrhagic stroke, aneurysmal subarachnoid hemorrhage, and arteriovenous malformations

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85% of strokes are _______ and 15% are _________

thrombotic, hemorrhagic

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What is the issue in thrombotic stroke?

there is a lot of inflammation

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What can help you identify where in the brain a patient may be having problems with perfusion?

knowing the blood supply to different areas of the brain

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What is the blood supply to the brain carried by?

two internal carotid arteries and two vertebral arteries which anastomose at the base of the brain to form the circle of willis

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Carotids supply the _________ portion of the brain while the vertebrobasilar system suppplies the ________ of the brain

anterior, posterior

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What does cerebral autoregulation allow the brain to mantain?

constant cerebral flow despite changes in the systemic arterial pressure

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What is the mean arterial pressure range that autoregulation is efficient within?

60-140 mmHg

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What happens if the MAP is below 60?

cerebral flow can be severely compromised

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What happens if MAP rises beyond the upper limit of autoregulation?

cerebral flow increases rapidly and overstretches the cerebral vasculature

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What are the three major metabolic factors affecting cerebral blood flow?

CO2
Hydrogen ion
Oxygen concentration

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What does an increase in CO2 provide a stimulus for?

vasodilation

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What does an increase in H ion concentration do?

increases cerebral blood flow, serving to wash away the neurally depressive acid material

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A _______ oxygen concentration increases cerebral blood flow

decreased

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What is a stroke?

the syndrome of acute focal neurologic deficit from a vascular disorder that injures brain tissue

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What are the two main types of strokes and their definitions

Ischemic
-Interruption of blood flow in a cerebral vessel (87% of all strokes)
Hemorrhagic
-Bleeding into brain tissue
-Blood vessel rupture
-Hypertension, aneurysm, injury

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What are the mechanisms of Ischemic CVA?

Large artery atherosclerotic disease (thrombotic and embolic (not including cardiac) – 20%
Small vessel or penetrating artery disease (lacunar) – 25%
Cardiogenic embolism – 20%
Cryptogenic (undetermined) – 30%

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What are modifiable factors for stroke?

-HTN
-Hyperlipidemia
-smoking
-diabetes
-HD (a fib, wall motion defects)
- Carotid artery disease
-coagulation disorders
- obesity/inactivity
-heavy alcohol use
-cocaine use

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What are unmodifiable factors for stroke?

-age
-gender
-race
-hereditary

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What is cerebral ischemia caused by?

cerebrovascular obstruction by thrombosis or emboli

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What are the two major types of types of ischemic cerebrovascular disease?

TIA and CVA

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What is the difference between TIA and CVA?

TIA- ischemia w/o infarction its brain angina but its not painful

CVA- infarction has occurred and the amount of infarction depends on location and collateral circulation and how quickly do we intervene.

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Ischemic CVA may be further subdivided _____ and _____

etiology, location

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In an evolving CVA, there is a central core of dead or dying cells surrounded by an ischemic band of minimally perfused cells called the _____________

penumbra

What is the goal of stroke management?

to save the penumbra

Why is the penumbra maintained in ischemia CVA?

because of small amounts of perfusion

What is the survival of cells in the penumbra dependent on?

timely return of adequate circulation, volume of toxic material released by dying cells and the degree of edema

What happens if the cells in the penumbra are affected adversely?

the core of ischemic tissue enlarges and the volume of surrounding ischemic tissue increases

What is an TIA?

(Transient Ischemic Attack) is a brief episode of neurologic dysfunction resulting from focal cerebral ischemia not associated with infarction

T/F TIA is infarction

False, not infarction

What is TIA secondary to?

thrombus or embolus

TIA is analogous to brain angina in that there is a temporary disturbance in ______ which reverses before infarction occurs

focal perfusion

“A zone of penumbra without central infarction” is this CVA or TIA?

TIA

Ischemia CVA results there is ______ of the brain tissue. cell death occurs.

infarction

Ischemic CVA may be divided into categories:

Large vessel and small vessel, and can be thrombotic or embolic

What is the most common type of CVA?

Large vessel

What is the most common cause of large vessel CVA?

Atherosclerotic disease Plaques found frequently at arterial bifurcation

Large vessel CVA often affects the ________ and may result in _______, _______,_____ and _______

cortex, aphasia, visual field deficits, motor and sensory changes

T/F in large vessel TIA, symptoms usually develop gradually over minutes to hours and may wax and wane in severity

True

In which population is large vessel TIA most often seen in?

older individuals with evidence of atherosclerotic heart or peripheral arterial disease

A patient presents with small vessel TIA. Where would these infarcts be located?

in deeper, non-cortical portions of the brain or in brainstem

What does small vessel TIA result from?

occlusion of the smaller penetrating branches of the large cerebral arteries

Small vessel TIA commonly occurs in the setting of which two diseases?

chornic HTN, DM

Does small vessel TIA usually cause cortical defects?

no, instead it result in motor or sensory hemiplegia, or dysarthria

What imaging is ordered if a patient has small vessel TIA?

MRI because it cannot be seen on a CT scan

What does Embolic CVA usually affect?

the larger proximal cerebral vessels and often lodges at bifurcations (most frequent is middle cerebral artery)

Where do most cerebral emboli originate from?

thrombus in the left heart but they may also come from a plaque in the carotid arteries

In contrast to thrombotic stroke, in embolic CVA there is no ______________ disease in the occluded vessel

intrinsic vascular

T/F Embolic CVA typically does not have a a sudden onset with immediate maximum deficit

False, it DOES

What are the various cardiac conditions predispose to emboli formation?

Atrial fibrillation Rheumatic heart disease Recent MI Ventricular aneurysm Bacterial endocarditis

What is hemorrhagic CVA caused by?

spontaneous rupture of an intracerebral vessel

T/F Hemorrhagic CVA occurs suddenly and is not as common

True

What does Hemorrhagic CVA cause ?

focal hematoma, edema, compression of the brain contents

What are the two types of Hemorrhagic CVA?

1. intracerebral (directly into the brain parenchyma) 2. subarachnoid (bleeding into the space between the pia mater and the arachnoid mater) depending on which artery ruptured and where it was located

What are the most common predisposing factor of Hemorrhagic CVA?

advancing age and HTN

What does the symptoms of Hemorrhagic CVA depend upon?

which vessel is involved

The manifestations of a CVA are determined by:

1. cerebral artery affected 2. the area of brain tissue that is supplied by the vessel 3. adequacy of collateral circulation

In CVA, everything ______ to the thrombus is at risk for infarction

distal

With cephalgia(headache), brain ________ and most ______ tissue is ________ to pain. What are the two types of cephalgia pains?

Brain parenchyma, meningeal tissue, insensitive 1. Infratentorial pain (occipital) is carried by cervical nerve roots 2. Supratentorial pain (frontal, temporal, parietal) is carried by the trigeminal nerve

What are cephalgia classifications?

Migraine Cluster Tension Chronic Daily Headache -15 days or more per month -?transformed migraine, ?evolved tension

What is cephalgia related to ?

overuse of symptomatic medications, psychiatric disorders

Which population are migraine most common in?

women

Etiology of migraines

1. fam hx/genetic 2. hormonal etiology

What are the two types of migraines?

Without aura (85%) With aura (can be anything, visual, auditory, any type of sensory changes)

What are the S/S of migraines?

Severe unilateral head pain (throbbing/pulsating) Photophobia Phonophobia Nausea/vomiting

What are the 4 stages of migraines?

– pro-drome, aura, headache, post-drome Aura stops and then the headache starts but not the case for everyone Postdrome- fatigue not feeling good

What is the patho for migraines?

-poorly understood -theory: activation of the trigeminal nerve -Activation of the trigeminal sensory fibers may lead to the release of neuropeptides, which in turn cause painful neurogenic inflammation within the meningeal vasculature characterized by vasodilation -Estrogen is thought to play a major role in the pattern of migraine attacks

What population is cluster headaches typically seen in?

males

_______ occur in clusters over weeks or months with long period of remission between. Episodes may last from 15 minutes to 3 hours

cluster headahces

What is the patho for cluster headhaces?

-Activation of the trigeminal nerve and the cranial autonomic parasympathetic reflexes are thought to explain the pain and autonomic symptoms -The hypothalamus is also believed to play a key role -MRI imaging has demonstrated dilated intracranial arteries on the affected side

T/F a cluster headache is common

False, it is uncommon

A cluster headahce is typically seen in ______

males

Cluster headaches occur over weeks or months with long periods of _______ in between. Episodes may last from ______ minutes to _____ hours.

remission 15, 3

What is thought to explain the pain and autonomic symptoms of cluster headaches? and which area of the brain is thought the play a key role?

-activation of trigeminal nerve and cranial autonomic parasympathetic reflexes -hypothalamus

In a cluster headache, MRI imaging has demonstrated _____________ on the affected side

dilated intracranial arteries

What is a cluster headache frequently associated with?

1. Restlessness or agitation 2. Ipsilateral conjunctival injection or lacrimation 3. Ipsilateral nasal congestion or rhinorrhea 4. Ipsilateral eyelid edema, facial swelling

What is the most commonly occurring headache with a hatband distribution?

tension-type headache

Newer theories suggest that tension type headaches are a form of ________. These are _________ or ________ withdrawal headaches

migraine analgesic, caffeine