Stoke And Hemorrhage Flashcards
Normal value for protein in CSF
15-60
Protein content in CSF in presence of bacterial infection
Very high
Normal glucose numbers in CSF
45-100
Glucose presence in CSF in presence of bacterial infection
Low because bacteria eats it all
Normal white blood cell count in CSF
0-5
White blood cell count in CSF in bacterial infection
Very high (mostly neutrophils)
Protein count in CSF of viral infection
Increased
Glucose levels in CSF in viral infection
Normal to slightly decreased
Protein levels in CSF in fungal infection
Increased
WBC of CSF in viral infection
Increased
WBC of CSF in fungal infections
Increased
What does yellow CSF mean
Suspect brain hemorrhage
What will change in CSF in the case of autoimmune disease?
High protein (IgG)
Presence of blood in CSF
Hemorrhage
Worst headache of my life
Subarachnoid hemorrhage
Historically, this has been associated with all clinical manifestations of a sudden loss of neurological function
Stroke
What can cause malfunction or death of neurons?
Any reduction of brain perfusion
Reduction of the flow rate by 60% in brain
Causes neurons to stop generating electrical signals
Reduction of the flow rate to about 20% in the brain for more than a few minutes
Initiates processes that result in necrosis of the involved brain tissue
A necrotic region of tissue in brain
Infarct
An abrupt incident of vascular insufficiency is called
Stroke
What can cause stroke like consequences
Bleeding into or immediately adjacent to the brain
Loss of blood supply to an area of the brain resulting in a loss of neurological function
Stroke
Stroke and age
Incidence increases with age
Stroke and gender
More common in men
Types of stroke
- occlusive (ischemic) 70-80%
- hemorrhagic (not due to trauma)
Thrombotic or emboli strokes
Occlusive (ischemic)
Intracerebral hemorrhage or subarachnoid hemorrhage can cause what
Stroke
What kind of stroke is from a comprised artery or blood loss?
Hemorrhagic
What kind of stroke happens from any occlusion of arteries
Occlusive
What is the most important factor of a stroke
The location, not necessarily the size
Risk factors of stroke
- HTN
- smoking
- abdominal obesity
- poor diet
- lack of exercise
- diabetes
- excess alcohol
- stress and depression
- heart disorders
- presence of blood fat molecules called apolipoproteins (LDL)
Preventable risk factors of stroke
- smoking
- alcohol excess
- obesity
- lack of exercise
- heart disease
- type II diabetes
- stress and depression
The region surrounding the area of permanent tissue damage
Penumbra
Area that will survive if you treat rapidly and appropriately
Penumbra
Re perfection over the penumbra
May salvage this region and reduce the neurologic deficits suffered by the patient
Time to treat penumbra
Up to 3 hours
Close forms locally over an atherosclerotic lesion, often has prodromes - vasospasms and partial occlusion aka transient ischemic attack (TIA)
Thrombotic occlusive stroke
Blockage by thrombi formed elsewhere. The thrombus detaches, travels and lodges in an artery. Often without prodromes
Embolic occlusive (ischemic) stroke
hypoxia due to insufficient blood supply. Hypotension/hypovolemia. Affects vulnerable sites. Caused by systemic conditions. No occluded artery but blood supply is still insufficient
Watershed infarct (stroke)
What are the most common causes of subarachnoid hemorrhage
Aneurysm rupture, arteriovenous malformation
-superficial artery bursts in the subarachnoid space
Types of hemorrhagic stroke
Subarachnoid hemorrhage
Intracerebral hemorrhage
Most common intracerebral hemorrhage causes
Hypertension
Arteriovenous malformation
Why are strokes so bad for brain
Brain does not have collateral arteries to save compromised arteries, areas near end of blood supply gets affected first, if severe, whole brain suffers
Classification of the U of New England cerebrovasular disease classification advantages
- takes into account pathological features of stroke
- relatively less complicated
Advantages of the may clinic stroke classification chart
Takes into account also the clinical feature of the stroke
Takes into account the size of the vessels involved
How are strokes clinically classified as?
Focal or diffuse
Focal stroke
Due to artery occlusion to relatively small hemorrhage
- particular area of brain is affected
- patient presents with neural deficits at multiple sites
Diffuse stroke
The whole or multiple regions of the brain are affected
-patient is usually unconscious
What type of stroke is the patient usually unconscious?
Diffuse
How are strokes pathophysiologically classified as?
- ischemic
- hemorrhagic
This type of stroke leads to decreased oxygenation of brain tissue (hypoxia), which can progress to tissue necrosis (infarction)
Ischemic (reduced blood supply)
This type of stroke results from a rupture of a blood vessel
Hemorrhagic
Overlap of types of stroke
If you have a hemorrhagic stroke, you will have parts of the brain that are ischemic
Hemorrhagic stroke in brain parenchyma
Rupture of a small artery. Leads to accumulation of blood within the brain and compression of adjacent tissue
Hemorrhagic stroke in subarachnoid space
Rupture of a superficial artery (most often aneurysm). Again, the collected blood compresses the brain underneath
Clinical presentation of ischemia and hemorrhage
Lead to virtually the same clinical presentation. The only difference is the mechanism
What does a severe headache indicate when figuring out the type of stroke that it is
Hemorrhagic stroke
Vascular event with symptoms similar to stroke
Transient ischemic attack
What is the crucial difference between a TIA and stroke
The deficits associated with TIA persist only a few minutes to a few hours and are followed by an essentially complete recovery
What are TIAs usually caused by
Minute emboli
TIA example: amaurosis fugax
- transient monocular blindness
- caused by emboli that detach from a plaque in the internal carotid artery, enter the ophthalmic artery, and render the retina temporarily ischemic
Why is amaurosis fugax clinically important?
Often precede a stroke
Infection of the brain caused by a platelet thrombus that develops over a disrupted atherosclerotic plaque in a cerebral artery
Thrombotic stroke (ischemic)
Thrombus has formed elsewhere, detaches, travels to a more distal location where it lodges and occluded the vessel
Embolic stroke (ischemic)
Sources of emboli
- left atrium of the heart
- carotid arteries
- paradoxycal embolus
Venous embolus that passes through a patent foramen ovale and lodges in a cerebral artery
Paradoxycal embolus
-this type is not arterial, so it has to go to the heart and the brain
When is an emboli in the left atrium of the heart more common
When someone has atrial fib
Common locations of ischemic strokes
- MCA
- internal carotid artery near the bifurcation
- basilar artery
What is the most common location for an ischemic stroke
MCA
Gross and microscopic findings of ischemic stroke
- swelling of brain
- loss of demarcation between gray and white
- breakdown of myelin
- gliosis as a reaction to injury
What is necrosis of the brain tissue called
Liquefaction necrosis
Main symptoms of a stroke involving the MCA
- Contralateral hemiparesis and sensory loss predominantly in the face and upper extremity
- aphasia (wernicke and broca)
What are the areas that are controlled by parts of hte brain supplied by MCA?
- hip, neck, trunk, head
- upper extremities
- eye, nose, lips, teeth, gums, jaw, tongue
- face
- pharynx
- intrrabdominal
What kind of stroke has symptoms that are pure motor or pure sensory?
Lacunae stroke (MCA stroke)
- monoparesis
- isolated sensory loss
Main symptoms involving the anterior cerebral artery
- contralateral hemiparesis predominantly in lower extremity
- contralateral sensory loss predominantly in the lower extremity
- urinary inontinecn
What does the part of the brain control that is supplied by the anterior cerebral artery (ACC)?
Lower extremities and geneital
Stroke involving the vertebral artery
- posterior inferior cerebellar artery (PICA)
- lateral medullary syndrome (Wallenberg)
Strokes involving the basilar artery
- AICA
- SCA
Main symptoms of strokes involving the vertebral-basilar system
- vertigo (ataxia)
- ipsilateral sensory loss in the face
- contralateral hemiparesis and sensory loss in the trunk and limbs
- posterior cerebral arteries
What is the give away point for someone with a vertebral-basilar stroke
Vertigo, ataxia
What does the PICA supply?
- inferior surface of the cerebellar hemisphere
- lateral medulla
- its occlusion causes lateral medullary syndrome (Wallenberg syndrome)
Lateral medullary syndrome (Wallenberg syndrome)
- ataxia, vertigo
- sensory deficits affecting the trunk and extremities on the opposite side of the infarction and cranial nerves on the same side with the infarct
- loss of pain and temperature sensation on the contralateral side of the body and ipsilateral side of the face
- swallowing difficulty (dysphagia) and slurred speech
- hornets syndrome-miosis, ptosis, anhydrosis
Main symptoms of strokes involving posterior cerebral artery
Gaze paralysis -paralysis of cranial nerve III Visual fields defects -hemianopsia-eyes deviate toward the side of the lesion to compensate -EYES LOOK TOWARDS THE LESION -Contralateral sensory loss
What is a giveaway for strokes involving posterior cerebral artery
Eyes look towards the lesion
Locations of intracranial hematoma
- epidural
- subdural
- subarachnoid
Cause of epidural hematoma
Rupture of a meningeal artery
-blow to the head
Cause of subdural hematoma
Rupture of a bridging vein
-accident-head hits hard surface and the brain moves abruptly in the skull
Causes of subarachnoid hematoma
Most often aneurysm rupture
-worst head of my life
Arterial bleed creates a blood filled space between the bone and the dura mater
Epidural hematoma
Pathophysiology of epidural hematoma
Temporal or parietal skull fracture tears middle meningeal artery
-vessel lies between the dura and the inner table of the bone
Presentation of epidural hematoma
Short (or no) loss of consciousness, lucid interval, neurological deterioration, death
What causes death in epidural hematoma
Intracranial pressure increases, leading to herniation and death
Diagnosis of epidural hematoma
Head CT scan is the imaging test of choice. Hematoma rarely crosses the suture line because the dura is firmly attached at these sites. Lens shaped mass
Treatment for epidural hematoma
Creating burr holes to relieve pressure
Subdural rupture of bridging veins between dura and arachnoid matter
Subdural hematoma
Why does venous bleeding in subdural hematoma make a difference?
Less pressure leads to slow expansion of hematoma with a delayed onset of symptoms (days to weeks)
Predisposing factors of subdural hematoma
Brain atrophy, shaking, whiplash
Subdural hematoma often seen in
- shaken baby syndrome
- alcoholics
- elderly
Causes of subarachnoid hemorrhage
- ruptured berry aneurysm (malformation)
- congenital atrivenous malformation
- trauma
Clinical presentation of subarachnoid hemorrhage
- sudden onset-worst headache of my life
- sluctuating level of consciousness
- CN III paralysis
Diagnosis of subarachnoid hemorrhage
- bloody or xanthochromic (yellow) spinal tap
- crescent shaped hemorrhage in CT, crosses suture lines
- cerebral compression and displacement of temporal lobe, tentorial herniation
Treatment of choice for subarachnoid hemorrhage
Removal of hematoma by craniotomy
What is the significance of the lack of neurologic deficit in someone with a subarachnoid hemorrhage?
Could progress to stroke
