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PT 680 Clinical Medicine > Stroke - Guest Lecture > Flashcards

Stroke - Guest Lecture Flashcards

1
Q

a brain attack in which there is damage resulting from an alteration in cerebral blood flow

A

stroke

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2
Q

what are the 2 types of stroke and what are their %

A
  • ischemic: loss of blood flow - 87%
  • hemmorhagic: 10% intracerebral and 3% subarachnoid hemorrhages
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3
Q

causes no permanent damage visible on MRI and whose sx resolve 100%

A

transient cerebral ischemia (TIA)

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4
Q

relative lack of O2 in arterial blood generally leading to altered metabolism and if not reversed, leads to cell death

A

hypoxia

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5
Q

complete deprivation of O2 supply

A

anoxia

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6
Q

potentially reversible tissue dysfunction secondary to hypoxia (however it may also result from organic poison, severe hypoglycemia); is always pathological

A

ischemia

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7
Q

tissues are lacking something

A

ischemia

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8
Q

ischemia can result in necrosis in vulnerable brain regions (ie hippocampus) in as little as

A

2 minutes

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9
Q

irreversible tissue death that is the result of ischemia

A

infarction

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10
Q

brain tissue destined to die; all dead

A

ischaemic core

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11
Q

salvageable brain area; not all is dead, can potentially save this area

A

penumbra

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12
Q

what is the 5th leading cause of death in the US and is leading cause of long term disability

A

stroke

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13
Q

how often does someone die of stroke in US, accounting for 1/20 deaths

A

4 minutes

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14
Q

how many adults over 20 have had a stroke already and how much is this expected to increase by 2030

A

7.2 million
3.4 million

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15
Q

how many stroke occur in the US per year and how many are new strokes

A

800,000
610,000

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16
Q

how much do strokes cost the US/year

A

34 billion

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17
Q

what percent of strokes occur in people under 50

A

10%

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18
Q

build up of plaque in arteries

A

atherosclerosis (build up of fat, cholesterol)

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19
Q

a blood clot that breaks off and travels

A

embolism

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20
Q

what are sources of emboli

A
  • carotid (artery to artery embolism)
  • cardioembolic (atrial fib, vegetations, low EF/LV thrombus, paradoxical embolism (PFO), hypercoagutable state)
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21
Q

most common cause of clots in the heart and causes a rhythm problem; most common irregular heart rhythm problem

A

artial fibulation

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22
Q

clot build up in the heart; may be sterile thrombus or infectious

A

vegetations

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23
Q

most common ischemic stroke

A

lacunar infarcts

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24
Q

small infarcts that affect the deeper parts of the brain

A

lacunar infarcts

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25
Q

what structures do lacunar infarcts affect

A

basal ganglia, thalamus, white matter

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26
Q

what % of all strokes are lacunar

A

20%

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27
Q

occurs due to occlusion of deep penetrating branches of major cerebral arteries

A

lacunar infarcts

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28
Q

what are lacunar infarcts associated with

A

hypertension, DM

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29
Q

involves small arteries and arterioles

A

hypertensive small vessel disease

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30
Q

types/affected hypertensive small vessel disease

A

athersclerosis
arteriosclerosis
maroaneurysms

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31
Q

thickened eosinophilic walls (lipohyalinosis)

A

arteriosclerosis

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32
Q

order of sensitivity to hypoxic ischemic encephalopathy

A

cerebral cortex and striatum –> thalamus –> brainstem

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33
Q

what area will have decreased blood flow first in brain with clogged arteries

A

the area furthest away from clot

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34
Q

what type of metabolism is the brain

A

aerobic

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35
Q

the brain lacks significant energy reserves so it required a continuous supply of well ____ _blood

A

oxygenated

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36
Q

how much blood and O2 does the brain require and how much does the brain weigh

A

20% cardiac output
15% O2 consumption at rest
brain is 2% total body weight

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37
Q

what brain structures are vulnerable to damage based on their high energy demands and metabolism

A
  • purkinje cells of cerebellum
  • pyramidal cells of CA1 - sommer’s sector of hippocampus
  • middle layers of cerebral cortex - laminar necrosis (3 and 5)
  • brain stem nuclei in infants
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38
Q

what area of the brain (gray or white) is at the highest level of hypoxia/metabolic poison

A

gray matter

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39
Q

inflammation of blood vessel walls; causes arteries to squeeze down

A

vasculitis

40
Q

what are the 3 layers of an arterial wall

A

endothelial intima
smooth muscle media
connective tissue adventitia

41
Q

cause of vasculitis

A

unknown, often not infectious

42
Q

what is vasciulitis divided into

A
  • large vessel (aorta and its main branches)
  • medium vessel (muscular arteries)
  • small vessel (arterioles, capillaries, venules)
43
Q

74 y/o pt presents with history of HTN, smoking and diabetes. he presents with L arm and leg weakness. MRI shoes lacunar stroke, what is likely cause
- atheroembolic
- carioembolic
- septic emboli
- small vessel ischemia

A

small vessel ischemia

44
Q

risk factors for intraparenchymal hemorrhage

A
  • hypertensive hemorrhage
  • vascular malformations
  • amyloid angiopathy
  • hemorrhagic transformation of infarcts
  • hemorrhagic tumors
  • anticoagulation
45
Q

locations of intraparenchymcal hypertensive hemorrhage

A

basal ganglia
thalamus
pons
cerebellum
cerebral hemispheres (lobar)

46
Q

tangle of abnormal arteries interposed between a feeding artery and draining veins

A

arteriovenous malformation (AVM)

47
Q

arteries most to least at risk for AVM

A

MCA > ACA > PCA

48
Q

cluster of cavernous vessels without intervening stroma; just veins are involved

A

cerebral cavernous malformation

49
Q

epilepsy or recurrent HA common signs; annual risk of bleeding is 1%; familial forms are common in those of Mexican-american heritage; autosomal dominant (CCM1-3 genes in chromosome 3 and 7)

A

cerebral cavernous malformation

50
Q

may produce lobar hemorrhage; most cases are due to deposition of beta-amyloid (associated with AD) in leptomeningeal and cortical small arteries; proteins causing bleeding in the brain

A

cerebral amyloid angiopathy

51
Q

brain tumors that are prone to hemorrhage

A
  • gliomas (GBM/oligo)
  • metastatic: melanoma, renal cell carcinoma, thyroid carcinoma, choriocarcinoma, lung CA
52
Q

3rd most common cerebrovascular lesion (after cerebral infarction and hypertensive hemorrhage); rupture of a berry aneurysm is the most common cause

A

non-traumatic subarachnoid hemorrhage (SAH)

53
Q

is the most frequent intracranial arterial aneuryrsm

A

berry aneurysm (aka saccular or congenital anneurysm)

54
Q

where to aneurysms tend to occur most often

A

at vessel branch points in circle of willis

55
Q

individuals with two first degree relatives who have _______ should be screened with cerebral vascular imaging

A

intracranial aneurysms

56
Q

list s/s of stroke

A

vertigo, fatigue/depressed level of consciousness, dysarthria, aphasia, dysphagia, apraxia, agnosia, gaze preference, ataxia, neglect, disconjugate gaze

57
Q

room spinning

A

vertigo

58
Q

slurred speech

A

dysarthria

59
Q

trouble producing speech, cannot say what they want, frustrated

A

expressive aphasia (Broca’s)

60
Q

say words but don’t make any sense, cannot follow commands

A

receptive aphasia (wernickes)

61
Q

difficulty swallowing

A

dysphagia

62
Q

cannot perform purposeful movements; inability to use voluntary use of strength

A

apraxia

63
Q

difficulty recognizing things

A

agnosia

64
Q

with gaze preference, do the eyes look toward or away from the side of the stroke

A

toward

65
Q

loss of coordination but limbs are still strong

A

ataxia

66
Q

unable to acknowledge one side of the body, pt doesn’t realize they have a problem

A

anosognosia (neglect)

67
Q

can acknowledge each side individually, but when on both sides simultaneously, they will not be able to see/feel impaired side

A

extinction (neglect)

68
Q

how to test for disconjugate gaze and how to interpret

A

test by coverign one eye at a time for 30 seconds
- brain problem: blurry vision that goes away when pt covers 1 eye
- eye problem: blurry vision that stays blurry when cover 1 eye

69
Q

for every _____ that the brain is starved for blood, 2 million neurons, 14 billion synapse and 12 kilometers of myelinated fibers are destroyed

A

1 minute

70
Q

for every _____ in delay to reperfusion decreases the likelihood of a good outcome by 10%

A

30 minutes

71
Q

what are the indications for reperfusion via systemic IV thrombolysis

A
  • age >/= 18
  • clinical diagnosis of ischemic stroke
  • clearly defined set of sx with onset less than 4/5 hours prior to treatment
  • CT scan shows no evidence of intracranial hemorrhage
72
Q

a drug to restore blood flow; only for ischemic stroke

A

IV thrombolysis

73
Q

on a perfusion scan, what does the purple and green coloring indicate

A

green = penumbrum (sick of dead brain)
purple = dead brain (core)

74
Q

barriers to recovery following stroke

A
  • post-stroke depression/anxiety
  • pain (spasticity, shoulder subluxation, central post stroke pain, disuse and abnormal postures)
  • falls
  • fatigue
  • changes in lifestyle
  • recurrent stroke
75
Q

non-modifiable risk factors of stroke

A

age
gender
race
eclampsia/pre-eclampsia
history of TIA/stroke

76
Q

genetic risk factors for stroke

A

hypercoaguable state
fabry disease
sickle cell
T21
CADASIL

77
Q

modifable risk factors for stroke

A

hypertension
dyslipidemia
diabetes
obesity
obstructive sleep apnea
tobacco use
A-fib
medication/iatrogenic
drug/alcohol abuse
vascular disease (CAD/PAD)

78
Q

what is the most important modifiable risk factor for stroke

A

hypertension

79
Q

what is the target BP reduction in hypertension

A

< 130/80

80
Q

_____ with intensive lipid-lowering effects is recommended to reduce the risk of stroke and CV events among pts with ischemic stroke or TIA presumed to be of atherosclerotic origin; has good benefits but medication often leaves pt with severe muscle pain that is out of proportion

A

statin therapy

81
Q

for patients with a prior history of stroke or TIA a goal of HgBA1c of ___ is resonable

A

7%

82
Q

what percentage of patients with a stroke or TIA have sleep disordered breathing

A

50-75%

83
Q

the risk for stroke in an asymptomatic carotid disease (CAD) is ______ as symptomatic CAD

A

not as high

84
Q

pts with aysmptomatic carotid stenosis should be prescribed what

A

daily aspirin and statin

85
Q

angioplasty and/or stenting is considered investigational and should only be considered when

A

failure of medical therapy
intracranial surgical interventions

86
Q
  • may consider CEA in asymptomatic pts with > 70% stenosis if the risk of perioperative MI/stroke/death is <3%; CAS may be considered in this setting but effectiveness compared to best medical management is not clear
  • consider CEA or CAS in symptomatic pts with > 70% stensosis by non-invasive imaging or > 50% by cath based imaging
A

carotid revascularization

87
Q

that is the optimal medical therapy for all pts with carotid A stenosis and a TIA/stroke

A

antiplatelet therapy
statin therapy
risk factor modifcation

88
Q

risk factors specific to women

A
  • pregnancy, preeclampsia, gestational diabetes, TOC use and hormone replacement
  • migraine with aura, diabetes, A-fib, psychosocial stress
89
Q

family risk factors

A

those with a parent who suffered a stroke under age 65 were at 3x higher risk for stroke

90
Q

conditions associated with increased risk

A

sickle cell disease
T21
fabry disease
MELAS
CADASIL
intrinsic hypercoaguable state
autosomal dominant polycystic kidney disease

91
Q

3 antiplatelet agents

A

aspirin
cilostazol
clopidogrel

92
Q

for primary prevention in those with 10 years risk > 10%, may also be considered in those with CKD
- for patients with bio-prosthetic heart valve
initial agent for secondary prevention without extenuating circumstances (allergy, severe CKD, PUD)

A

aspirin

93
Q

for primary prevention in those with peripheral arterial disease or in some cases with aspirin

A

cilostazol

94
Q

may be considered for secondary prevention in pts who fail aspirin therapy; need to consider hypo/non-responders

A

clopidogrel

95
Q
  • nonvalvular A-fib with chads2vasc >/=2
  • mitral valve stenosis and an embolic event or L artrial thrombus
  • those with heart failure and ambolic event
  • potentially those with hypercoaguable state
  • evaluation for those with cryptogenic stroke and ESUS
A

anticoagulation

96
Q

primary or secondary prevention in valvular A-fib and those with mechanical aortic or mitral valves

A

warfarin

PT 680 Clinical Medicine (18 decks)

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