Stroke Flashcards
stroke is the ____ most common cause of death in the US
3rd
after heart disease and cancer
Most important modifiable risk factors for stroke (5)
hypertension AF DM cigarette smoking hyperlipidemia
AF increases risk of stroke by
6x
RHD increases risk of stroke by
18x
Diabetes increases stroke compared to nondiabetics by
2x as much
in the case of CAD, the level of ___ has the most impact on the incidence of stroke
LDL
characteristic of atherothrombotic vs cardioembolic stroke is the occurrence during sleep
atherothrombotic
preferential location of atheromatous plaques (IVMPA) (5)
(1) in the internal carotid artety; at its origin from the common carotid;
(2) in the cervical part of the vertebral arteries and at their junction to form the basilarartery;
(3) in the stem or at the main bifurcation of the middle
cerebral arteries;
(4) in the proximal posterior cerebral arteries as they wind around the midbrain; and
(5) in the proximalanterior cerebral arteries
Most typical sign of CVD
hemiplegia
For embolic strokes, the most important risk factors are (2)
structural cardiac disease and arrhythmias (AF)
TIAs are generally cosidered as more closley aligned with
embolic or atherothrombotic stroke
atherothrombotic
True or False
It is unusual for the cerebellar and ophthalmic arteries to show atheromatous involvement
True
It is high degree of stenosis usually above ____ % of the original lumen compromised or a residual lumen of less than approximately __mm of the carotid artery that is most likely to be associated with strokes in the distal territory of the vessel
90% and less than 2mm
CHADS2
Congestive Heart Failure Hypertension Age (<65,0; 65-74,1; >75,2) Vascular disease 1 Diabetes Female Stroke or TIA (2)
CHA2DS2-VASC
Congestive Heart Failure - 1 Hypertension - 1 Age (<65=0; 65-74=1; >75=2) Diabetes - 1 Stroke or TIA - 2 Coronary or peripheral vascular disease - 1 Female - 1
How many percent of infarcts that follow TIAs occur within a month? how many percent within a year?
20% of infarcts that follow TIAs occur within a month
50% within a year
True of False
Blindness in amaurosis fugax or TMB is painless
True
p787
Vascular factors in Ischemic infarcts
Anastomosis in occlusion of ICA (neck) via _____ (1)
Occlusion of vertebral artery
_____________(3)
ICA - from the ECA via ophthalmic artery
vertebral artery - anastomotic vessels via deep cervical, thyrocervical, or occipital arteries
Over a range of mean
blood pressures of approximately ____ to ____ mm Hg, the small pial vessels are able to dilate and to constrict in order to maintain cerebral blood flow (CBF) in a relatively narrow range.
50 to 150 mm Hg
CBF in which it causes infarction regardless of duration
10-12ml/100g/min
critical level of hypoperfusion that abolishes function and leads to tissue damage
12-23ml/100g/min
Changes at the previously mentioned critical level of hypoperfusion
EEG changes: slow and isoelectric
K - increases
ATP - depleted
reversible if circulation is quickly restored
Temperature and reduction of metabolic requirements
reduction of 2 to 3C reduces metabolic requirements of neurons and increases tolerance to hypoxia by ____%
25 to 30%
Stroke Trial ATC
Antiplatelet Trialists’ Collaboration
pts with symptomatic atherosclerosis on ASA 50-1500mg/day
23% odds reduction in the composite outcome of MI, vascular death, stroke
Stroke Trial CATS
Canadian American Ticlopidine Study
pts with thromboembolic strokes were randomized to ticlopidine 250mg BID vs placebo
ticlopidine reduces the risk of composite outcome of MI, stroke and vascular death by 30%
Stroke Trial TASS
Ticlopidine Aspirin Stroke Study
pts with recent TIA or ischemic stroke were randomized to ticlopidine 250mg BID vs ASA 1300mg/d
Ticlopidine reduced the risk of stroke or death at 3 years by 12% relative to ASA
Stroke Trial CAPRIE
Clopidogrel versus ASA at Risk of Ischemic Events
clopidogrel showed slightly reduced vascular complications rates compared to ASA, driven mostly by reductions in the rate of vascular complications in PAD pts
primary outcome: composite cluster of ischemic stroke MI vascular death
borderline clinical signiifcance RR 8.7% clopid vs ASA
with h/o PAD: RR 23.8%
Stroke Trial MATCH
Management of Atherothrombosis with Clopidogrel in High Risk Patients with TIA or Stroke
Aspirin and clopidogrel compared with clopidogrel alone after recent ischemic stroke or TIA in high risk patients
SA 75mg + clopid 75mg is no more effective than clopid 75 for secondary prevention of vascular complications with a siginificant higher risk of major and minor bleeding
Stroke Trial CHARISMA
Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization Management and Avoidance
(Clopidogrel and ASA vs ASA alone for the prevention of Atherothrombotic events
Clopidogrel +ASA is not superior to ASA for preventing vascular complications and death, but may be considered in pts with symptomatic atherothrombosis. that is offset by a nonsignificant absolute risk increase of 0.4% for sever bleeding especially in those multiple vascular risk factors
Stroke Trial SPS3
Secondary Prevention of Small Subcortical Strokes 3
pts with lacunar infarcts within 180 days were randomized to clopid 75+ASA 325mg vs ASA 325 mg
ffup of 3.4 yrs rate of recurrent stroke was not significantly different between groups
Stroke Trial CSPS
Cilostazol Stroke Prevention Study
pts with cerebral infarctions in the past 6 months were randomized to cilostazol 100mg BID vs placebo
reduction of recurrent ischemic stroke in cilostazol group by 41.7%
Stroke Trial TOSS 1
Trial of Cilostazol in Symptomatic Intracranial Arterial Stenosis
progression of symptomatic intracranial stenosis by MRA was significantly lower with cilostazol and ASA compared with ASA alone
Stroke Trial CSPS 2
Cilostazol Stroke Prevention Study 2
pts with cerebral infarctions were randomized to cilostazol 100mg BID vs ASA 81mg
primary outcome of non-inferiority
hemorrhagic events occurred less but headache, tachycardia and diarrhea were more frequent in cilostazol group
Stroke TOSS 2
Trial of Cilostazol in Symptomatic Intracranial Arterial Stenosis
pts with acute ischemic stroke within 2 weekssecondary to stenosis of MCA and basilar artery were randomized to cilostazol 100mg BID + asa vs Clopid + ASA
no significant difference in the rate of progression between groups
less hemorrhagic complications seen in cilostzol treated grp
Stroke Trial ESPS 1
European Stroke Prevention Study 1
pts with ischemic strokes were randomized to dipyridamole + ASA vs placebo
combination DP + ASA reduces the risk of stroke and detah by 33%
Stroke Trial ESPS 2
European Stroke Prevention Study 2
Dipyridamole and ASA in the secondary prevention of stroke
ASA 25 mg BID and dipyridamole 400mg in a modified realease form at a dose 200 mg twice daily have each been shown to be equally effective for the secondary prevention of ischemic stroke and TIA compared to placebo and the combination of the two is superior to either agent alone with no significant increase in death
Stroke Trial ESPRIT
European/Australasian Stroke Prevention in Reversible Ischemia Trial
Aspirin plus Dipyridamole versus Aspirin Alone after Cerebral Ischemic of Arterial Origin (ESPRIT)
Aspirin 30 -325 mg plus dipyridamole220 mg bid compared to ASpirin monotherapy significantly lowers the incidence of stroke, MI, death, from vascular causes and major bleeds and is equally safe in pts with h/o of ischemic stroke or TIA in the last 6 months
Stroke Trial PROFESS
Prevention Regimen for Effectively Avoiding Second Stroke
Although telmisartan reduces mena BP in recurrent stroke pts, it does not affect disability or cognitive dysfunction at 30 months compared to placebo
ASA + dipyridamole vs clopidogrel cofers no similar benefits, but significantly increases major hemorrhagic complications
Stroke Trial TACIP
Triflusal Aspirin Cerebral Infarction Prevention
pts with tia or ischemic strokes
triflusal 600mg/day vs ASA 325
similar efficacy between groups in in combined endpoint of stroke,MI and vascular death
Stroke Trial TAPIRSS
Triflusal versus Aspirin in the Prevention of Infarction: A Randomized Stroke Study
pts with recent TIA or ischemic strokes were randomized to triiflusal 600mg/day vs ASA 325 mg/day
no significant difference in combined endpoint of stroke, MI, vascular death
Stroke Trial WARSS
Warfarin Aspirin Recurrent Stroke Study
there was no benefit from warfarin INR 1.4 -2.8 compared to ASA 325mg daily for secondary prevention of ischemic, non cardioembolic stroke or death
Stroke Trial WASID
Warfarin Aspirin in Symptomatic Intracranial Disease
for symptomatic intracranial stenosis 50-99% warfarin increased the risk of adverse events without any vascular cause other than stroke compared to Asa 1300mg
T/F
Migraine headaches are not a component of Binswanger Disease
True
recurrent small strokes beginning in early adulthood culminate in a subcortical dementia
imaging: large confluent cerebral white matter changes
mutation: missense change on chromosome 19 of the NOTCH 3 gene
CADASIL
Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and leukoencephalopathy
different vasculopathy, migraine not part of the syndrome
NOTCH gene is normal
inheritance is a recessive trait from a mutation in HTAR1 gene
resulting in fragmentation and duplication of the internal elastic lamina of cerebral vessels with narrowing of their lumens
CARASIL
T/F
Levels of protein C and S and of antithrombin are temporarily depressed after stroke
True
Adams p833
so that any detected abnormalities must be confirmed months later and in the absence of anticoagulation
Genetic disorder which cause arterial or venous infarction with maternal type of inheritance
MELAS (mitochondrial)
most common sites of ICH
- putamen and int capsule 50%
- central white matter of temporal parietal frontal lobes
- thalamus
- cerebellar hem
- pons
the _____ sign the appearance of contrast within the hemorrhage during CT angiography is associated with a high rate of hematoma expansion
spot sign
how many weeks before the surrounding edema in ICH begins to recede and the density of hematoma decreases
2-3 weeks
hypertensive vascular lesions that lead to arteriolar rupture
changes in arterial wall referred to as segmental lipohyalinosis and the formation of false aneurysm (microaneurysm) named as
Charcot Bouchard aneurysms
aspirin can prevent stroke due to AF by how many percent
24
warfarin reduces stroke in AF by how many percent
64
warfarin compared with aspirin reduced stroke by
38
identify trial
among patients intolerant with warfarin, dual antiplatelet therapy using clopidogrel and aspirin is better than aspirin alone but there was increased bleeding with DAPT
ACTIVE-A
Mortality rate in patients with clots of 60mL or larger and an initial Glasgow Coma Scale score of 8 or less
Mortality is 90%
Mortality rate for ICH score of 4
97%
ICH score for the following GCS 5-12 >30ml age <80 with intravetricular hemorrhage
ICH score 3, mortality rate of 72%
T/F
In patient with ICH who survive, there can be as surprising degree of restoration of function because in contrast to infarction, the hemorrhage has to some extent pushed brain tissue aside rather than destroy it
True
goals in management of patients with large ICH
PCO2
osmolality
Na
PCO2 25-30mmHg
Osmolality 295 to 305 mOsm/L
Na 145 to 150 mEq