Patho- Vascular disease Flashcards
What are the four main sites a blood can accumulate in the skull?
Extradural- Between bone and dura
Subdural- Separated dura from arachnoid
Subarachnoid- SA space
In brain itself
What can cause an extradural hemorrhage?
Skull fracture etc
What can cause a subdural hemorrhage?
Torn cerebral veins- more common in the elderly
What can cause a SA hemorrhage?
Ruptured CoW- Berry aneurysm etc
What are the two broad categories of intracranial hemorrhage?
Spontaneous
Traumatic
What are some forms of spontaneous hemorrhage?
Intracerebral hemorrhage
Cerebellar hemorrhage
SA hemorrhage
Hemorrhagic infarct
How does an intracerebral hemorrhage tend to present?
Stroke
How does a hemorrhagic infarct tend to present?
Stroke
What are some symptoms of a cerebellar hemorrhage?
Headache
Loss of consciousness/coma
Nystagmus/ocular palsy
Acute hydrocephalus
What are some risk factors for a SAH?
Smoking
Hypertension
Kidney Disease
Men aged 30-40
What causes SAH?
Berry aneurysm rupture
Arteriovenous malformation
Where are Berry aneurysms found?
Branching of CoW
What does a AVM look like on imaging?
Storm cloud
What are some symptoms of a SAH?
Sudden devastating headache Loss of consciousness Vomiting Neck stiffness/pain Photophobia Positive Kernig's sign Papilloedema Bloody CSF
What is Kernig’s sign?
Knee + hip at 90 degrees then extend knee. Get pain/stiffness
What is the differential for a SAH?
Migraine
How do you diagnose a SAH?
Immediate CT- bright white in SA space/ventricles
LP for blood if CT equivocal
What will you see in the CSF with SAH?
Yellow colour
What must you not be/have to have a LP done in SAH?
No focal deficits or papilloedema
How do you treat a SAH?
Bed rest and support Treat hypertension Nimodipine Dexamethasone- for oedema Surgery to treat aneurysm
What are some complications of a SAH?
Obstructive hydrocephalus- Shunt or LP drain
Cerebral ischemia- develops 3-12 days after
Arterial spasm
Rebleeding- doesn’t stop
Hyponatremia- transient, give Na, don’t fluid restrict
Seizures
What are some forms of traumatic hemorrhage?
Extradural hematoma Subdural hematoma SAH Intracerebral hemorrhage Contusions
Where does a extradural hematoma occur?
Between the dura mater and the skull
What is the most common cause of an extradural hematoma?
Trauma to the pterion damaging the middle cerebral artery.
What are some symptoms of an extradural hematoma?
Rapid onset of symptoms over minutes of hours
Brief unconsciousness followed by lucid interval then coma.
Ipsilateral dilated pupil
Contralateral hemiparesis
Brain herniation/coning- Resp arrest
What does an extradural hematoma look like on imaging?
Biconvex
What is a subdural hematoma?
Collection of blood in the subdural space (between mater and arachnoid) due to ruptured bridging veins
What group usually gets subdural hematomas?
Elderly
What tends to cause subdural hematomas?
Mild trauma damaging bridging veins in the elderly.
What are some symptoms of a subdural hematoma?
Can take weeks to develop Fluctuating symptoms Headache Drowsiness COnfusion Hemiparesis Epilepsy Coninc
How do you treat a subdural hematoma?
Immediate CT
Monitor carefully
What condition can brain bleeds cause?
Stroke
What is a stroke?
Sudden disturbance of cerebral function of vascular origin that causes death or lasts over 24h.
Rapid (minutes to hours) development of clinical symptoms and/or focal (1 area) loss of brain function with symptoms lasting >24h or death that is vascular in origin.
What are the two broad types of stroke?
Infarct
Hemorrhage
What can cause an infarct stroke?
Thrombosis
Embolism
Where do embolisms arise from?
Carotids
Heart
Aorta
What are some risk factors for an infarct stroke?
Atheroma Hypertension Obesity DM Neck artery disease Smoking
Where can a bleed occuring cause a stroke?
Cerebral hemispheres
SAH
What two kinds of cerebral hemisphere bleed can cause a stroke?
Primary intracerebral hemorrhage
Secondary intracerebral hemorrhage
What can cause a primary intracerebral hemorrhage?
Hypertension
What can cause secondary intracerebral hemorrhage?
AV malformation
Aneurysm
Tumour
What are the three severities of stroke?
TIA
Minor
COmplete
What is a minor stroke?
Patient recovers without major deficit in ~week.
What is a complete stroke?
Maximum deficits occur within 6 hours.
What is a TIA?
Sudden focal deficit taking seconds to hours to recover.
Often reoccur and herald an ischemic stroke
What are some signs of a TIA?
Preserved consciousness
Focal losses: Amaurosis fugax- transient loss of vision in one eye
Transient global amnesia
How do you diagnose a TIA?
ABCD2- score out of 7
Describe ABCD2
Age >60 +1 BP >140/90 +1 Clinical features: Unilateral features +2 or Speech disturbances without weakness +1 Duration: 10-59min +1 or >60min +2 Diabetes +1
How does a right side stroke general present?
Side neglect
Artistic loss
Affects left side of body
How does a left side stroke generally present?
Often affects language
Affects right side of the body
What are the five major places for a stroke to occur?
Total anterior circulation syndrome (TACS)
Partial anterior circulation syndrome (PACS)
Lacunar syndrome (LACS)
Posterior circulation (vertebrobasilar) syndromes (POCS)
Large medullary syndrome
WHat are some symptoms of a Total anterior circulation syndrome (TACS)?
Hemiplegia involving at least two of face, arm and leg +/- hemisensory loss • Homonymous hemianopia • Cortical signs (dysphasia, neglect) • Drowsiness/unconsciousness • Complete hemiparesis • Hemisensory loss • Incontinence • Forced deviation of eye towards the side of the stroke
What are some symptoms of a Partial anterior circulation syndrome (PACS)?
2/3 of:
Hemiplegia involving at least two of face, arm and leg +/- hemisensory loss
Homonymous hemianopia
Cortical signs (dysphasia, neglect)
What is lacunar syndrome (LACS)?
Small, discrete infarcts around the internal capsule, thalamus and basal ganglia. Often multiple. Occlusion of single deep penetrating artery.
What are some symptoms of Posterior circulation (vertebrobasilar) syndromes (POCS)?
Signs and symptoms of brainstem damage:
• Severe truncal ataxia (midline vermis lesion)
• Limb clumsiness (signs ipsilateral to cerebellar hemisphere damage)
• Gaze palsies
• Respiratory rhythm disturbance
• Hemiparesis (contralateral)
What are some signs of large medullary syndrome?
Ipsilateral face paralysis or pain Severe vertigo Vomiting Dysphagia Dysphonia Ataxia Contralateral limb sensory loss Horner's syndrome
How do you diagnose a stroke?
Rosier score
Describe the rosier score
Loss of consciousness or syncope -1 Seizures -1 Asymmetrical facial weakness +1 Asymmetrical arm weakness +1 Asymmetrical leg weakness +1 Speech disturbance +1 Visual field defect +1
What does a Rosier score of =0 suggest?
Stroke is unlikely but don’t rule out
What does a Rosier score of >0 suggest?
Stroke is likely
What are some risk factors for stroke?
Hypertension Smoking Obesity Alcohol High cholesterol Raised heamatocrit Diabetes Carotid stenosis
What are some differentials for a stroke?
Seizure Sepsis Metabolic SOL Functional- symptoms but no patho
How do you treat a stroke?
CT to differentiate infarct or hemorrhage
Infarct- give thrombolysis
What thrombolysis should be used for stroke?
Alteplase 10% IV bolus over 2 minutes
How would a stroke present on CT?
Hyperacute ischemia- Loss of grey/white differentiation
What is the long term treatment for a stroke?
Antihypertensive
Antiplatelets- unless thrombolysed
Anticoag is have AF
What antiplatelets should be used in stroke?
Aspirin 300mg for 14 days then Clopidogrel 75mg and Aspirin 75mg
