Sketchy Path: Neuro - "Ischemic and Hemorrhagic Stroke"

Question 1

Thrombotic strokes form by _______________.

Answer 1

rupture of atherosclerotic plaques on cerebral or carotid arteries

Question 2

Ischemic strokes can be caused by what three things?

Answer 2

• Thrombus
• Embolus
• Hypoxia (hypoxemia, hypotension, hypoperfusion

(These are represented by the bird poop – embolic –and gold paint on the model’s forehead –thrombotic –and blue cadaver next to brain jar.)

Question 3

Most TIAs resolve in ______________.

Answer 3

fifteen minutes or less (like the clock with one quarter painted black)

Question 4

The first step in evaluating a suspected stroke is _______________.

Answer 4

a non-contrast CT of the head (like the black cat kicking the blood on the ground)

Question 5

The most sensitive test for detecting ischemic changes in the acute setting is _____________.

Answer 5

MRI DWI (like the magnet above Da Vinci’s head pulling the weights)

Question 6

Ischemic strokes generally present as _____________.

Answer 6

wedge-shaped white marks on brain imaging (like the wedge-shaped feather in Da Vinci’s hat)

Question 7

Review the timeline of pathologic changes in ischemic brain tissue.

Answer 7

• 12-24 hours: red neurons (like the red spots on the Da Vinci sketch
• 1 day: neutrophils and proteolysis (EMTs with stretcher and dripping ink)
• 3 days: macrophages (cage to the right of EMTs)
• 1 week: astrocytes with gliosis (star-flyer to the right of the trashcan)

Question 8

Reactive inflammation after strokes can cause _____________.

Answer 8

cerebral edema (like the swollen head hot air balloon above the EMTs)

Question 9

____________ help new blood vessels form.

Answer 9

Astrocytes (like the red strings connecting the star-flyer to the ceiling)

Question 10

Ultimately, ____________ form at the site of ischemic strokes.

Answer 10

liquefactive necrosis (surrounded by gliosis)

Question 11

Atherosclerotic thrombi can form on large, medium, and small cerebral vessels. Review the sites of each.

Answer 11

• Large: carotid, circle of Willis, vertebral arteries

* Medium: basal ganglia, midbrain

Question 12

Medium vessel thrombi can lead to ___________ infarctions.

Answer 12

lacunar (like the lakes in the painting behind the model with the basal ganglia tree)

Question 13

Risk factors for lacunar infarctions include ______________.

Answer 13

diabetes and HTN (like the jar of candy and the exploding volcano)

Question 14

What is lipohyalinosis?

Answer 14

Endothelial injury leads to swelling of the endothelium and thus narrowing of the vessel. This leads to

Question 15

What symptoms suggest lacunar infarction?

Answer 15

Focused strokes: 
•Pure motor
•Pure sensory
•Mixed sensorimotor affecting a select part of the body
•Dysarthria

Question 16

Embolic strokes usually follow _____________.

Answer 16

atrial fibrillation or MIs (like the a fib window or the broken lute on the beam)

Also, PFOs can let DVTs pass into the brain (like the bird jumping through the hole).

Question 17

How does the symptom onset differ in thrombotic vs. embolic strokes?

Answer 17

• Embolic: sudden, due to rapid occlusion of vessel from clot
• Thrombotic: less sudden, due to accumulation of platelets at rupture site

Question 18

When should tPA be given?

Answer 18

Optimally within 3 hours, but benefits have been shown to be within 4.5 hours (like the kid on the left with three fingers and the kid on the right with 5)

Question 19

What is reperfusion injury after a stroke?

Answer 19

In an ischemic stroke, the endothelium distal to the clot can get damaged. When tPA is given, the stroke can convert to a hemorrhagic stroke if the endothelium is excessively damaged.

(Think of the kid with the red hat at the tPA arts and crafts table.)

Question 20

Those with __________ are more prone to develop global hypoxic stroke.

Answer 20

hypertension

Those with HTN have a higher baseline cerebral perfusion due to increased blood pressure. They thus have a lower threshold for global stroke.

Question 21

Although global hypoxic strokes affect the entire brain, the __________________ are most susceptible to early loss.

Answer 21

pyramidal cells of the hippocampus (seahorse with pyramidal fins), Purkinje cells of the cerebellum, and watershed areas (coral reaching each other beneath the depiction of the frog with feet symbolizing watershed areas)

Question 22

The most common factor predicting hemorrhagic stroke is _______________.

Answer 22

HTN (like the guy blowing off steam near the John the Baptist painting with red paint on its head)

Question 23

________________ can cause recurrent hemorrhagic stroke in elderly adults.

Answer 23

Amyloidopathy (like the multiple red amyloid chains on the head of the HTN guy)

Question 24

Other than HTN and amyloidosis, what two things can cause hemorrhagic stroke?

Answer 24

• Tumors (stars on pot on his head)

* Vasculitis (red candles)

Question 25

Small aneurysms in the basal ganglia and internal capsule that are prone to rupture are called _____________.

Answer 25

Charcot-Bouchard aneurysms (like the sHARpe bush with red berries next to the basal ganglia bush)

Question 26

How are hemorrhagic strokes treated?

Answer 26

• Lower HTN

* Treat cerebral edema if it arises