Neuro vascular etc HYs Flashcards
The most common complication of aneurysmal subarachnoid hemorrhage is __, which typically occurs 3-12 days after the initial insult and can cause delayed cerebral ischemia
vasospasm
CT looks normal
Transient ischemic attacks resulting in left leg weakness and vision loss in the right eye are likely due to emboli originating from the
right internal carotid artery
____ artery occlusion causes vertigo/nystagmus, ipsilateral cerebellar signs, loss of pain/temperature sensation in the ipsilateral face and contralateral body, bulbar weakness, and ipsilateral Horner syndrome.
Posterior inferior cerebellar
lateral medullary (Wallenberg) syndrome
7 Upper motor signs
Upper motor neuron signs include abnormal plantar flexion (Babinski sign), spastic paralysis, increased muscle tone, clasp-knife rigidity, hyperreflexia, pronator drift, and pyramidal weakness (weakness more pronounced in lower extremity flexors and upper extremity extensors).
Inadequate blood supply to the brain leads to ischemic stroke. The first microscopic changes are typically seen 12-24 hours after irreversible ischemic injury and include intense ____ and ____.
1–3 days:
3–7 days:
1–2 weeks:
2+ weeks:
eosinophilic staining of the neuronal cytoplasm (red neurons)
nuclear fragmentation (pyknotic nuclei, loss of Nissl substance)
1–3 days: Neutrophilic infiltration
3–7 days: Macrophage/microglia infiltration & phagocytosis begins
1–2 weeks: Reactive gliosis & vascular proliferation around the necrotic area (Liquefactive necrosis)
2+ weeks: Glial scar formation. Cystic area surrounded by dense glial fibers (>1 month)
An aneurysm of the internal carotid artery can laterally impinge on the ____.
This can cause ipsilateral nasal hemianopia by damaging the optic nerve fiber from the temporal portion of the retina.
optic chiasm
ACA strokes affect what
Contralateral Lower extremity
MCA stokes affect what
Contralateral Upper extremity and Face
what is Gertsmann syndrome
what structure is affected and what supplies it?
Agraphia, Acalcula, Left-right disorientation, Finger Agnosia
angular gyrus of the dominant parietal lobe, a brain region supplied by the middle cerebral artery.
*angular gyrus lesions can also have aphasia and alexia
Ischemic injury to the _____, which is supplied by the posterior inferior cerebellar artery, can result in Wallenberg syndrome.
dorsolateral medulla
Patients typically present with:
Contralateral hemiparesis (pyramids/CST dmg),
Contralateral propioception/vibration/ touch loss (medial lemniscal pathway/ Dorsal column dmg),
ipsilateral tongue paralysis towards lesion (hypoglossal nucleus).
an ischemic stroke syndrome caused by occlusion of the ______.
anterior spinal artery (paramedian br.)
or
vertebral arteries
Medial medullary syndrome
The basal ganglia are supplied by the _____, which are deep, small vessel branches off the middle cerebral arteries. Typically affected due to long standing HTN.
lenticulostriate arteries
deep in the brain
_____ of the major cerebral arteries are affected in lobar hemorrhages (occipital & parietal).
Tend to occur in the elderly due to amyloid angiopathy.
Cortical branches
Ischemic injury to the ____ can lead to locked-in syndrome, a condition in which patients are unable to move or speak (due to interruption of the corticospinal and corticobulbar tracts) but retain consciousness, sensation, eye opening, and vertical eye movements.
bilateral ventral pons
appears as hyperattenuated, or bright, lesions on noncontrast head CT
Acute bleeding
Deep intraparenchymal hemorrhage is most commonly caused by _______ of the small penetrating branches of the cerebral arteries.
This is in contrast to rupture of _______, which typically cause subarachnoid hemorrhage.
hypertensive vasculopathy (Charcot-Bouchard aneurysm rupture)
saccular aneurysms
Wernicke’s area is located in the auditory association cortex within the posterior portion of the ____ temporal gyrus in the ____ temporal lobe.
superior
dominant
The middle cerebral artery supplies Broca’s area ( ___ division) and Wernicke’s area ( ___ division).
superior
inferior
symmetric, bilateral wedge-shaped strips of necrosis over the cerebral convexity are characteristic of
global cerebral ischemia
Watershed areas affected
The cells that are typically affected first by hypoxia are the CA1 pyramidal neurons of the ____, which can be damaged by ischemia in as little as 3 minutes.
hippocampus
The ___ cells and _____ neurons are also highly susceptible to damage if ischemia lasts for 5-10 minutes
because of their high metabolic demand and unique neurochemical characteristics (inability to repolarize after anoxic depolarization)
cerebellar Purkinje
neocortex pyramidal
Cytotoxic (early) edema less than 24 hours after cerebral ischemia/stroke is due to the accumulation of _____ in hypoxic cells
= raising intracranial pressured = brain herniation
intracellular Na+ and water
due to the failure of ATP-dependent ion transporters
Vasogenic edema follows _____ hours after cerebral ischemia when the release of inflammatory mediators disrupts the ____ of the blood-brain barrier, allowing ___ and water to enter the _____.
Can cause persistent cerebral edema for weeks
24-48
tight junctions
proteins (eg, albumin)
interstitial space
Cavernous hemangiomas are vascular malformations that occur most commonly within the brain parenchyma; they carry an increased risk of ___ and ___.
intracerebral hemorrhage
seizure
Intraventricular hemorrhage (IVH) is a common complication of prematurity (< 32) and/or with birth weight (<3 lb 5 oz).
Signs are _____, seizures, coma.
bulging anterior fontanelle
IVH in preterm infants usually originates from the germinal matrix
Intraventricular hemorrhage in preterm infants usually originates from the _____, a highly cellular and vascularized layer in the subventricular zone
This area contains fragile, thin-walled vessels lacking ____ making them more susceptible to hemorrhage.
germinal matrix
glial fibers
______ (aka loss of conjugate lateral gaze) is caused by damage to the medial longitudinal fasciculus, which can occur with occlusion of the ___ artery.
Internuclear ophthalmoplegia
pontine
Weakness of the face, arm, and leg is classically caused by contralateral motor cortex or ____ infarction
internal capsule
Damage to the oculomotor nerve (CN III) can lead to impaired extraocular movements with a ____ eye
down-and-out
Resting tremor is typically associated with parkinsonism due to damage of the _____ and its projections to the striatum.
substantia nigra
The locus ceruleus is a paired brainstem nucleus located in the posterior ____ near the lateral floor of the ____ and functions as the principal site for ___ synthesis in the brain.
rostral pons
fourth ventricle
norepinephrine
______ are produced in the posterior hypothalamus and play an important role in arousal and wakefulness.
Histamine and orexin
Norepinephrine is converted to epinephrine primarily in the ____
adrenal medullae.
Dopamine is produced in the _____ area and substantia nigra pars compacta located in the ___.
ventral tegmental
midbrain
The major dopaminergic pathways in the brain include
mesolimbic and mesocortical pathways (regulate ___ & ___)
nigrostriatal pathway (regulates coordination of ___)
tuberoinfundibular pathway (inhibits ____ secretion).
cognition and behavior
voluntary movements
prolactin
_______ is the most common cause of spontaneous and/or RECURRENT lobar hemorrhage, particularly in the ELDERLY.
The most common sites of hemorrhage include the ______
Cerebral amyloid angiopathy
occipital and parietal lobes
- HTN = DEEP brain
- amyloid = parietal/occipital
Fever, Proptosis, decreased sensation in the upper face, plus CN3,4,6 deficits indicates a ____ lesion
Cavernous sinus
CNS injury is associated with ___ & ____
This process leads to the formation of a glial scar, which compensates for the volume loss that occurs after neuronal death.
Astrocyte hypertrophy/glial hyperplasia
Proliferation (gliosis).
Glial scar (Months to years) = Astrocytes
Transient global amnesia is a self-limited syndrome characterized by the sudden onset of prominent anterograde amnesia accompanied by repetitive questioning where is the dysfunction located?
Transient dysfunction of the hippocampus
pure motor hemiparesis and a small cavitary lesion in the internal capsule, characteristic of a
lacunar infarct.
lipohyalinosis, microatheroma formation, and hardening/thickening of the vessel wall (hypertensive arteriolar SCLEROSIS) found in what kind of infarcts
Lacunar (image 8)
pure motor hemiparesis
or
ataxia-hemiplegia syndrome (ipsilateral limb ataxia out of proportion to motor deficit) caused by
Posterior limb of the internal capsule and/or
basal pons lesions
Dysarthria-clumsy hand syndrome (dysarthria and dysphagia with clumsiness of one hand) caused by
Genu/anterior limb of the internal capsule and/or
basal pons lesions
Ventroposterolateral or ventroposteromedial thalamus cause
pure sensory stroke
List 2 complications of Subarachnoid Hemorrhage
Vasospasm (give nimodipine) 3-12 days later
Hydrocephalus (impaired absorption from granulations)
Brain ____ malformation is the most common cause of intracranial hemorrhage in children/ non-neonate infants and tends to be a single lesion.
arteriovenous
___ artery atherosclerosis and cardiac embolism may cause acute ischemic stroke, which typically presents with sudden neurologic deficits that are maximal at symptom onset.
Carotid
____ rupture is usually due to chronic hypertension and typically causes hemorrhage involving deep brain structures ( basal ganglia, cerebellar nuclei, thalamus, pons).
Charcot-Bouchard aneurysm (image 1)
On CT, subarachnoid hemorrhage appears as hyperattenuation of the ___ and basal cisterns.
sulci (Image 25)
Cerebral ____ is the most common cause of spontaneous lobar hemorrhage, particularly in the elderly. The most common sites of hemorrhage include the occipital and parietal lobes
amyloid angiopathy
Head CT reveals multiple, small lobar hemorrhages of varying ages in the occipital and parietal areas with a medium-size acute bleed in the left parietooccipital lobe.
Diagnosis?
Cerebral amyloid angiopathy
The first sign of ____ is a fixed, dilated pupil on the side of the lesion.
uncal herniation
*Paralysis of the oculomotor muscles occurs later and leads to ptosis and a down-and-out position of the ipsilateral eye.
A fixed, dilated pupil on the side of the lesion. Contralateral or ipsilateral hemiparesis (Cerebral Peduncle) and contralateral homonymous hemianopsia (PCA) with macular sparing may also occur.
uncal herniation
An Epidural Hematoma can cause an ___ herniation of the cingulate gyrus/ Falx cerebri leading to compression of the ACA
subfalcine
An Epidural Hematoma on the Temporal lobe can cause an ___ herniation leading to compression of CN 3
Uncal
through tentorium cerebelli
the combination of left leg weakness and vision loss in the right eye (amaurosis fugax) suggests a lesion in the right ____ artery.
internal carotid
transient episodes of focal neurologic impairment that occur due to localbrain ischemia; tissue infarction does not occur, and brain imaging is normal.
Transient ischemic attacks (TIAs)
used for thrombolysis in patients with acute, potentially debilitating, ischemic stroke, which would present with persistent neurologic deficits. They are NOT indicated as this patient’s symptoms resolved without intervention.
Tissue plasminogen activator TPA (alteplase)
An aneurysm of the ____ artery can laterally impinge on the optic chiasm (Nasal Hemianopia)
internal carotid
Blood Between dura mater & arachnoid mater
Subdural Hematoma
Blood Between arachnoid mater & pia mater
Subarachnoid Hemorrhage
Blood in the basal cistern and nuchal rigidity + HA
Subarachnoid Hemorrhage
Lacunes are small cavitary infarcts located within the basal ganglia, posterior limb of the internal capsule, pons, and cerebellum. The infarcts result from occlusion of the _____ arteries that supply these deep brain structures.
(small penetrating arteries) lenticulostriate
image 12
Infarcts occur most commonly in the setting of chronic uncontrolled hypertension or diabetes mellitus.
Lacunar infarcts (Lenticulostriate branches of MCA)
Lipohyalinosis and microatheromas are believed to be the primary causes of ____ infarcts.
lacunar
- Lipohyalinosis due to leakage of plasma proteins through damaged endothelium causes hyaline thickening of the vascular wall, collagenous sclerosis, and accumulation of FOAMY MQs.
- Microatheromas result from atherosclerotic accumulation of lipid-laden macrophages within the INTIMAL layer of a penetrating artery near its origin off the parent vessel.
On autopsy, the symmetric, bilateral wedge-shaped strips of necrosis over the cerebral convexity are characteristic of
global cerebral ischemia.
Image 13
*This patient with a history of drug use developed fever and new-onset aortic regurgitation, which are suggestive of endocarditis. His pulmonary edema (crackles) and hypotension are due to subsequent cardiogenic shock.
It is characterized by:
Neck, torso, shoulder, and pelvic girdle pain and morning stiffness.
Monocular vision loss is a common complication
*Fatigue, fever and weight loss may also occur.
Polymyalgia rheumatica
due to Temporal arteritis–Large Vessel
Characterized by:
Dysphagia, no Gag-reflex, hoarseness (Nucleus ambigus lesion)
Diplopia, Nystagmus, Vertigo, Vomiting (Vestibular Nuclei lesion)
Loss of pain/temperature sensation in the ipsilateral face (Spinal Trigeminal Nuclei lesion)
Loss of pain/temperature sensation in the contralateral body (STT lesion)
Ipsilateral cerebellar signs: ataxia, dysmetria (Inf. Cerebellar Peduncle lesion)
Ipsilateral Horner syndrome: miosis, ptosis, anhidrosis (Descending Hypothalamic Spinal tract lesion)
Lateral Medullary Syndrome (Wallenberg)
PICA lesion
___ stroke cause contralateral weakness with clasp-knife spastic rigidity, hyperreflexia, and a positive Babinski sign.
internal capsule
Occlusion of the ____ typically results in contralateral hemiparesis and hemisensory loss of the face and upper limb with relative preservation of lower limb function. If the occluded artery is in the dominant (usually left) hemisphere, aphasia may also occur.
middle cerebral artery (MCA)
