Stroke and Cerebrovascular Disorders

Question 1

What is it called if you have an infarct block your retinal artery?

Answer 1

Retinal stroke

Question 2

What causes a lacunar stroke?

Answer 2

Small artery thrombosis with two main causes:

1. Atherosclerosis
2. Lipohyalinosis - fibrinoid necrosis + lipid

Question 3

How do cardiac emboli show up on CT scan?

Answer 3

Usually with multiple emboli all over the brain -> embolization from Afib or mural thrombosis can affect multiple brain areas

Question 4

What are the nonmodifiable risk factors for stroke?

Answer 4

1. Age > 55
2. Male sex
3. Hispanic and blacks
4. Family history

Question 5

What are the modifiable risk factors for stroke?

Answer 5

Atherosclerosis risk factors:

1. Hypertension
2. Diabetes
3. Dyslipidemia
4. Smoking
5. Elevated homocysteine
6. Alcohol
7. Obesity
8. Sedentary lifestyle

Question 6

What will a stroke of the left cerebral hemisphere do to gaze preference?

Answer 6

Makes gaze preference go to left -> left frontal eyefield will be knocked out, so right becomes dominant in turning gaze to left

Question 7

What is one sign which really points more towards brainstem lesion than cerebral lesion?

Answer 7

Decreased consciousness

Question 8

Where will blood easily be seen in CT of a subarachnoid hemorrhage?

Answer 8

The perimesencephalic cisterns of the brain, i.e. prepontine cistern

Question 9

What happens in the ischemic areas of the brain which makes them more susceptible to loss of blood flow? What is another cause of this

Answer 9

There is a loss of cerebral autoregulation -> S-shaped curve which maintains cerebral blood flow at varying perfusion pressures is lost, making areas much more susceptible to hypoperfusion or hyperperfusion

Also occurs in chronic hypertension

Question 10

What scale standardizes measures of severity of stroke?

Answer 10

NIH stroke scale -> can be used between providers

Question 11

How do you tell the difference between an ischemic and a hemorrhage stroke?

Answer 11

Via a CT of head without contrast -> cannot tell the difference between the two clinically

-if ischemic stroke is obvious, it’s probably an old stroke because it will not appear for a few hours

Question 12

What other labs should you order on a patient with a stroke?

Answer 12

CBC, PT/PTT, troponins, SaO2, EKG

-> testing for cardiac origin or other problems

Question 13

What is the door to treatment goal for the ER, and what is the latest you should administer tPA? Why?

Answer 13

ER - door to treatment = 60 minutes

tPA - 3 hours, 4.5 hours in select patients
-> odds ratio for improvement is not better after 3 hours

Question 14

What are the absolute contraindications to tPA?

Answer 14

Head trauma / stroke in past 3 months
Previous history of hemorrhage
BP > 185 systolic or 110 diastolic
Elevated aPTT or PT, current anticoagulation
Low blood glucose
CT suggests multilobar infarction
Tumor or intracranial / intraspinal surgery in last 3 months

Question 15

What are the relative contraindications of tPA?

Answer 15

Pregnancy
Recent GI hemorrhage
Recent MI
Only minor symptoms

Question 16

What drugs are used to rapidly achieve the blood pressure goals of tPA therapy? Why is this important?

Answer 16

Labetalol (pregnant organist), nicardipine (nice card), clevidipine (clover)

-> hydralazine should be avoided because it may cause vasodilation and worsen cerebral edema

Important because high blood pressure predisposes to bleeding

Question 17

How should you treat high blood pressure following stroke?

Answer 17

Usually recovered on its own, can just observe for 1-2 weeks to see if it comes down

Question 18

What is standard of care for treatment of ischemic infarct now?

Answer 18

tPA + stentriever -> little piece of mesh to pull out the clot

Question 19

What is a very common persistent symptom following a stroke?

Answer 19

Depression (40% of people)

Question 20

What drugs should be started for secondary prevention following a stroke?

Answer 20

1. Antihypertensive agents - ACE inhibitor / diuretic
2. Statin therapy - regardless of LDL
3. Antiplatelet agents - aspirin, clopidogrel, or aspirin / dipyridamole (phosphodiesterase inhibitor) -> annotate this

Question 21

Where do embolic clots normally form in atrial fibrillation and how is it treated to prevent stroke? Is aspirin effective?

Answer 21

Normally in left auricle - antiplatelet agents like aspirin are not sufficient, need anticoagulants

• > Warfarin to increase INR to 2-3
• > direct oral anticoagulants like: Dabigatran, Rivoroxaban, Apixaban, etc

Question 22

What condition accounts for a major percentage of anterior circulation strokes and TIAs, and how is it treated?

Answer 22

Carotid artery stenosis -> treat via carotid endarterectomy

Question 23

What is the part of the brain where the infarct starts and is already dead called? The part that can be saved?

Answer 23

Starts - “core”
Can be saved - “penumbra”

Time is brain