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Clinical Med > post midterm 5:cerebro > Flashcards

post midterm 5:cerebro Flashcards

1
Q

what are the 3 Major Types of Ischemic Cerebrovascular Events?

A

1) Thrombosis-clot in blood vessel
2) Embolism-from somewhere else, can be clot or fat infectious air etc
3) Hemorrhage

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2
Q

what is TIA? will it show up on MRI?

people with TIA are more prone to what?

A

Time-limited episodes of neurologic dysfunction
Up to 50% with TIA have MRI evidence of brain ischemia
Longer events (> 2 hours) increase the likelihood for tissue ischemia (even if there is full clinical recovery)
A potent predictor of stroke (10-15% in next 90 days)
50% of strokes within 2 days
Risk of cardiac event ~ 2.5% in 90 days
Risk of death ~ 2.5% in 90 days

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3
Q

what is a stroke? what are some risk factors?

A 
Persistent neurological deficit due to cerebrovascular disease
3d most common cause of death in US
Traditional risk factors:
-Hypertension
-Hyperlipidemia
-Smoking
-Diabetes
-Alcohol (heavy use)
-Pro-thrombotic medications (eg estrogens)
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4
Q

what happens if the vertebrobasilar system is affected?

A 
"the D's"
Diplopia, visual loss
Dizziness, vertigo
Dysarthria
Dysphagia
Ataxia
Weakness (one or both sides)
	Corticospinal tracts
Crossed numbness
Spinothalamic tracts
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5
Q

what can you get with Bilateral Occipital Infarction

A
  • Cortical blindness
  • Korsakoff’s amnesia
    • Memory defecits
    • Confabulation
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6
Q

what are Small-Vessel (Lacunar) Strokes? what are they assoc with?

A
  • Strongly associated with hypertension
  • Good prognosis for recovery
  • **Pure motor stroke
  • Pure sensory stroke
  • Dysarthria/clumsy hand
  • Ataxic hemiparesis (weak lower extrem; arm and leg incoordination)
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7
Q

what are some possible causes of stroke?

A

> Embolism
-Clot from a proximal atherosclerotic vessel
-Cardiogenic embolism (atrial fibrillation, post-MI, endocarditis)
Local vessel thrombus formation
Low flow in a diseased vessel due to hypotension, vasospasm, hyperviscosity, vasculitis
Arterial dissection
Consider other causes including non-ischemic events (e.g. seizure) in the differential diagnosis (TIA)

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8
Q

what are some characteristics found in embolic stroke? what is typically the source of emboli?

A

Abrupt onset of maximal deficit
-Associated headache
In a Younger patient:
Atrial fibrillation (may be presenting finding), may not know they have heart issues
*Source of emboli most often is the heart

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9
Q

when is it beneficial to give thrombolytics during stroke?

A

within 3 hours

*higher risk of Intracranial hemorrhage

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10
Q

how do you treat a stroke?

A

-Rule out hemorrhage
-Heparin anticoagulation if not contraindicated
Long term:
*Anti-platelet
*Anticoagulation

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11
Q

what is the tx protocol for stenosed carotids when symptomatic vs asymptomatic pts?

A 
High grade (≥ 70%) stenosis with symptoms (stroke/TIA) studies favor surgery
-otherwise, even if stenosed, if no symptoms, benefits may outweigh risks...
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12
Q

what are the current USPTF screening rec for carotid stenosis?

A

The US Preventive Services Task Force recommends AGAINST screening for asymptomatic carotid artery stenosis in the general adult population.

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13
Q

what is carotid stenting vs Endarterectomy and what are the risks and benefits?

A

stenting=higher risk for stroke, lower risk of heart attack

endarterectomy= higher risk of heart attack, lower risk of stroke

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14
Q

T/F: Potential for recovery of neurologic function exists in Intracerebral Hemorrhage

A

true because blood flow often preserved

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15
Q

what are some clinical signs you see with Hemorrhagic Stroke?

A 
-Gradual onset of deficit (hypertensive bleeds) or maximal at onset (subarachnoid hemorrhage)
Onset often during activity 
*Headache (50%)
Meningeal signs 
*Change in level of consciousness
Nausea, vomiting (>50%) 		
**Photophobia, painful eye movements
*Seizures (1/3 in 3 days)
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16
Q

what are some risk factors Hemorrhagic Stroke?

A

-Underlying HTN (longstanding)
-Older age
-Tumor
-Brain AVM
-High alcohol intake
-Stimulant drug use (amphetamines, cocaine)
Consider in young patient

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17
Q

what are some favorable factors for good prognosis of Hemorrhagic Stroke?

A

Level of consciousness at presentation
Size of bleed
Age

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18
Q

what side effects will someone have with Thalamic Hemorrhage (Hypertensive Intracerebral Hemorrhage)

A

Contralateral motor/sensory deficits
Paralysis of vertical gaze
Eyes deviated towards affected side
Pupils unequal, light reflex absent

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19
Q

what side effects will someone have with cerebellar Hemorrhage (Hypertensive Intracerebral Hemorrhage)

A 
Vertigo, ataxia
Occipital headache
Lateral gaze paralysis
Facial weakness 
Late, abrupt deterioration/death
Surgical decompression possible
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20
Q

what is the Most common cause of spontaneous subarachnoid bleed?

A

Intracranial Aneurysms, majority near circle of willis

21
Q

intracranial aneurysms are associated with what other inherited tissue disorders?

A 
connective tissue disorders 
    Autosomal dominant polycystic kidney disease
	Ehlers-Danlos Type IV
	Neurofibromatosis
	Marfan’s syndrome

**Family history of intracranial aneurysm inc risk

22
Q

what clinical symptoms do you see in cavernous sinus syndrome

A 
Unilateral ophthalmoplegia (III nerve)
Unreactive pupil (III nerve)
Facial pain (V nerve)
Chiasmal syndrome (medial extension)
With rupture:
	Pulsating exophthalmos
	Orbital venous congestion
23
Q

T/F: Small intracranial aneurysms are relatively common and rarely rupture

A

true

24
Q

list some Clinical Features of Ruptured Aneurysm:

A

Sudden, violent headache
Nausea, vomiting are common
Collapse, but usually retain consciousness
- Death may occur within minutes
- 12% die before reaching medical attention
*Lateralizing neurologic findings unusual=unlike in strokes

25
Q

what are some dx tests for Ruptured Intracranial Aneurysm

A

Preretinal/subhyaloid hemorrhages (25% of cases)
Nuchal rigidity (after several hours)
*Cranial CT (95% sensitive initially -> only 50% after 1 week)
**MRI not sensitive for acute hemorrhage
*CSF xanthochromia (yellow color from hemoglobin breakdown)

26
Q

what are some ways to tx Ruptured Intracranial Aneurysm?

A

Control of BP, quiet environment
- Calcium channel blocker to control spasm
Surgery or embolization to stabilize aneurysm

27
Q

What is best predictor of acute prognosis for Ruptured Intracranial Aneurysm?

A

Best predictor of acute prognosis is condition on arrival at hospital
**Significant longterm morbidity in 35% of survivors

28
Q

what are some pros of MRI vs CT scan?

A 
MRI:
(+)  Most sensitive for detection of parenchymal abnormalities and masses 
-Mass (tumor, abscess)
-Ischemia/infarct (stroke)
-Inflammation, edema (encephalitis)
-Demyelination (MS, PML)
(+) No ionizing radiation
29
Q

what are some pros of CT vs MRI scan?

A

(+) Most sensitive for detection of acute bleeding
Subdural hematoma, aneurysm rupture, hemorrhagic infarct
(+) Better tolerated than MRI for many patients

Quicker results!

30
Q

what happens during amaurosis fugax? how long does it last?

A

Duration: 1-15 min
Onset: dimming or curtain of darkness
Total or partial field loss
Positive phenomena: flashing lights, shimmering vision, streaks or jagged lines (30%)

31
Q

what are some differentials for amaurosis fugax?

A 
Internal carotid TIA
Temporal arteritis
Impending CRV occlusion
Embolism to CRA
Transient hypotension
Hematologic disorders (hyperviscosity)
Migraine
Hypoglycemia
Seizures
32
Q

amaurosis fugax can be a predictor of what?

A

A predictor of significant carotid disease and of subsequent TIA, stroke, and retinal infarction

33
Q

describe cholesterol emboli in retina?

A

Yellow-orange Hollenhorst plaques, at bifurcations,often asymptomatic

-Predict cardiovascular mortality (6%/year), retinal ischemia (2%/year) and stroke (6%/year)

34
Q

describe calcific emboli in retina? where do they come from and are they symptomatic?

A

Arise mainly from heart, sometimes proximal lesions

White, opaque, frequently symptomatic

35
Q

describe Platelet/Fibrin Emboli

in retina? where do they come from and are they symptomatic?

A

Arise from heart or proximal-vessel atheromata
Gray-white, long, smooth; high rate of occlusion and
visual symptoms

36
Q

list some possible causes of CRAO

A

Embolism
Carotid, aortic atherosclerosis
Cardiac thrombi, valvular sources

Inflammation
***Vasculitis (GCA)

Thrombosis
Central retinal artery atherosclerosis
Ophthalmic artery and internal carotid artery

Hyperviscosity / hypercoagulable states
Multiple myeloma
Polycythemia, Leukemia, Thrombocytosis, Sickle disease
Antiphospholipid antibody-thrombosis syndromes
Antithrombin deficiencies

37
Q

what causes ocular ischemia and what pop do you see it in?

A

Marker of severe ipsilateral (or bilateral) carotid disease:
Male: Female 2:1
Older age (mean age 65)
Result of chronic hypoperfusion

38
Q

what are some symptoms of ocular ischemic syndrome?

A

Unilateral visual blurring or blindness, usually slow progression
Vision varies (20/40 to count fingers)
Amaurosis fugax in 5%
Ocular or eyebrow pain; “facial angina”
Slower time to recovery after exposure to bright lights

39
Q

what will you see in the retina/eye with ocular ischemia?

A

Retinal artery narrowing
Dilation of retinal veins
Retinal hemorrhages and microaneurysms
Cotton wool spots
Retinal, disc, anterior segment neovascularization
Neovascularization of iris → increased IOP
Consider ocular ischemic syndrome when seen in non-diabetics
Cherry red spot

40
Q

what are some clinical symptoms of Increased Intracranial Pressure

A

Mental status change

Headache

Dizziness, Vomiting

Coma, Respiratory arrest

41
Q

what are some Ocular Manifestations of Increased Intracranial Pressure?

A

Papilledema

Abducens nerve palsy

Bilateral exopthalmos

Pupillary abnormalities

42
Q

how do those with subarachnoid heme present?

A

Thunderclap HA – sudden onset, maximal intensity achieved rapidly
Duration hours – days
Emesis may occur
Neuro exam often normal
**Exam findings vary from grossly abnormal to normal
Retinal, vitreous or subhyaloid hemorrhages
Nuchal rigidity (meningeal irritation)

–Focal neurological defect(s) depending upon location of bleed
3d, 6th nerve palsy
Motor, speech, etc. defects

–Initial diagnostic study: CT w/o contrast

43
Q

what usually causes epidural hematoma?

A

Bleeding between the skull and dura, usually from rupture of middle meningeal artery by head trauma

44
Q

describe the clinical presentation of epidural hematoma?

A

Bleeding between the skull and dura, usually from rupture of middle meningeal artery by head trauma

45
Q

how do you tx epidural hematoma?

A

Treatment is urgent “burr hole” to evacuate hematoma

46
Q

what is a subdural hematoma? what increases your risk for it? what causes it usually?

A

Hemorrhage from small bridging veins into subdural space
Trauma
Risks include: advanced age, anticoagulation, alcoholism

47
Q

how/when do subdural hematomas present?

A

Subacute and Chronic SDH present weeks or months after initial trauma, often with subtle manifestations
Headache
Delerium
Focal neurologic deficits

48
Q

what should be normal opening pressure for LP?

A

200 mm H20

Clinical Med (10 decks)

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