vascular Flashcards
1
Q
Epidural Hematoma -TX
A
_immediate evacuation
2
Q
Epidural hematoma
A
- Middle meningeal artery, lucid interval, often associated with bone break -Herniation->CNIII compression (ipsilateral pupillary dilation/ “down and out” ; PCA-> ipsilateral visual cortex/ contraletral VF ; Duret-> compression of contraleteral cerebral peduncle-_ipsilateral hemiparesis ( false localizing sign)
3
Q
Subdural Hematoma
A
-Bridging veins -Can be fatal -Midline shift -
4
Q
Supratentorial herniation
A
-Uncal -Central (transtentorial) -Cingulate (subfalcine) -Transcervical
5
Q
Infratentorial herniation
A
-Upward ( cerebellar or transtentorial) -Tonsillar ( downward cerebellar)
6
Q
Cingulate Herniation
A
-ACA -LEG WEAKNESS
7
Q
Transtentorial Herniation
A
-Reticular-altered level of consciousness -Corticospinal tract- decorticate posturing; rostral-caudal deterioration
8
Q
Uncal Herniation
A
-Cerebral peduncle-hemiparesis ( ipsi) -CNIII-pupil dilation; down and out; ipsi -PCA- visual field loss contra
9
Q
Subarachnoid Hemorrhage- cause and risk factors
A
- Ruptured berry aneurysm -ACOM>MCA>PCOM>basilar - for non-traumatic cases, the pathology is rupture of a berry aneurysm. risk factors drug use (cocaine, amphetamines, cigarettes, alcohol) polycystic kidney disease and fibromuscular dysplasia.
- “worst headache of my life”
10
Q
Subarachnoid Hemorrhage-complications
A
- Vasospasm -TX with nimodipine (CCB)
11
Q
diagnosis of SAH
A
-95% CT will show; Sometimes need LP and this shows xonthochromia and persistent bleeding…not to be confused with a traumatic tap!
12
Q
SAH-TX
A
-clipping or endovascular coiling -CLinical depends on level of consciousness; want to treat earlier
13
Q
Parenchymal/ Intracerebral
A
-putamen, pons, cerebellum, and thalamus -cerebellum needs surgical intervention (occlusion of the 4th ventricle, hydrocephalus) -RF: HTN! ASTAB/ASTAB; old-cerebral amyloidosis bleeding into ischemia, tumor, AVM, cavernomas,trauma
14
Q
Ischemic Stroke
A
-Strokes of Large, named arteries -Lacunar Stroke Syndrome -BStem stroke syndromes -Cerebellar stroke syndromes -Cerebellar strokes - Watershed and embolic strokes -Venous infarcts
15
Q
Named Arteries: ACA
A
-contra motor/sensory;leg>face/arm - Frontal lobe, behavior, akinetic mutism - trans motor aphasia (L) /neglect (r) -urinary incontinence
16
Q
Named Arteries: MCA
A
-Contra motor/sensory ; face/arm>Leg -Aphasia (L);neglect (R) -Eyes deviate towards lesion -b/l homonymous hemianopsia
17
Q
Named Arteries: PCA
A
-contra hemianopsia, alexia w/o agraphia for L sided. pts may be unaware of loss -Large- contra motor/sensory
18
Q
Lacunar Strokes
A
- Small vessels -Subcortical white matter, BG/Internal capsule,Thalamus, Pons, Cerebellum -HTN! -Changes in small arteries-hyalonosis
19
Q
Lacunar Strokes-Clinical
A
-Pure Motor:internal capsule -Pure Sensory: thalamus Ataxic hemiparesis Clumsy-hand/dysarthria * not so much higher cortical function
20
Q
Brainstem Strokes
A
-Crossed findings -CN ipsi & M +S contra -Brainstem disease include dizziness/vertigo, ataxia, nausea, imbalance, double vision, nystagmus, dysarthria, and dysphagia. - reticular problems can cause comatose
21
Q
WALLENBERGSyndrome
A
- Occlusion of vertebral artery or PICA -lateral medullary syndrome - Clinical 1.dysphagia, hoarseness, dizziness, nausea, and vomiting,nystagmus, problem with gait/balance. Hiccups ( tx-thorazine) 2. Pain & temp loss in contra body, ipsi face 3. Horner’s syndrome
22
Q
Cerebellar Strokes
A
-ipsi ataxia -n/v, vertigo,dysarthria,and nystagmus. -lateral-ataxia of ipsi arm/leg; medial= axial muscle/gait /balance -Usually ok; unless swells ( day 3-5) and then need to drain if 4th ventricle occlusion
23
Q
Waterhshed/ Embolic Strokes
A
-hypoperfusion(hypotension, CHF, carotid stenosis) -ACA/MCA weakness of proximal arm/leg muscles but ok distal strength. (“man in barrel”) -From other arteries or other areas
24
Q
Venous Infarcts- what? RF? treatment? radiologic signs?
A
-Depends on part of brain effected -Signs of ^ICP-HA/seizures -RF: hyper-coagulable states ( genetic, postpartum, infections, and meds) -Tx-heparin -Cord sign/empty delta
25
Amaurosis fugax
temporary monocular blindness bc of temporary occlusion of the retinal artery
26
Locked-In syndrome
-Aware and awake can only move eyes. lesion of ventral pons -Tip of basilar
27
Vertebral Artery dissection
-Tear into wall from chiropractic procedure (other neck trauma, RF of connective tissue disorder) -Clot into wall layers not lumen -String sign
28
Dense MCA sign
-Clot in MCA; early stroke
29
tPA
-within 3 (4.5 hrs) -CI:minor/resolving deficits, pts w/ glucose \<50mg/dL, recent trauma/surgery, hemorrhage, BP \> 185/110, INR \>1.7, Platelet count less than 100,000
30
Tx- Lupus anticoagulant
Warfarin
31
Acute Stroke Workup
- DWI and ADC map -Post stroke Mana usually R sided stroke
32
MRI & contrast
- T1 -Indicates breakdown of BBB
33
Psychiatric symptoms of ischemic stroke
-Depression
34
CADASIL
Cerebral Autosomal Dominate Ateriopathy with Subcortical Infarcts and Leukoencephalopathy= pt with migraines, dementia, and multiple lacunar strokes
35
MELAS
- mitochondrial encephalopathy with lactic acidoses and stroke -A mitochondrial disorder (maternal inheritance) with stroke-like episodes often in the occipital region. Presents with seizures and dementia in adolescence.
36
Sickle Cell
-An autosomal recessive disease of caused by a mutation of hemoglobin found in people of African ancestry. - Predisposes to stroke
37
2ndary stroke prevention
- high dose statin regardless f lipid profile -BP 120/80\*\*\* -HgBA1c-DM?treat - Smoking cessation, dietary modification, exercise
38
Anticogulation or antiplatelet?
Transesophageal chocardiogram Is there a clot in the heart? If yes, start anticoagulation EKG, cardiac monitoring Is there atrial fibrillation? If yes, start anticoagulation. If there is no indication for anticoagulation, use an antiplatelet agent (ASA, ASA/dipyridamole (Aggrenox), Clopidogrel (Plavix). Clopidogrel is more effective in preventing heart attacks than ASA. Anticoagulants are Dabigatran (Pradaxa) or Warfarin.
39
TIA
Patients with TIAs should be treated as per stroke patients. In high-risk patients with certain clinical features of the TIA (unilateral weakness or speech disturbance), the 90-day stroke risk is nearly 20%.
40
Carotid Endarectomy
Carotid Doppler/MRA Is there carotid stenosis (usually \>70%) If yes, carotid endarectomy (preferably within two weeks).
41
Global cerebral anoxia
From cardiac arrest There is diffuse edema with sulcal effacement, bilateral uncal herniation, diffuse compression of the entire ventricular system. "reversal sign on CT"
42
Young stroke patients
Hypercoag/rheum work-up antithrombin III deficiency, protein C and S deficiency, activated protein C resistance/factor V Leiden mutation, and prothrombin gene mutation. Most of these present with strokes before the age of 30, and they usually cause venous infarctions.
43
Antiphospholipid syndrome
can be screened for by testing lupus anticoagulant and anticardiolipin antibodies. Patients are often women, and may report spontaneous abortions. The treatment is with warfarin.
44
ASA -Distribution
Lateral costicospinal tract; Medial leminiscus Caudal medulla -hypoglossal nerve
45
ASA-stroke
Contra hemiparesis- lower limbs Dec contralateral propioception Ipsilateral hypoglossal dysfunction ( tongue deviates ipsilaterally)
46
PICA-distribution
Lateral medulla- vestibular nuclei, lateral spinothalamic tract, spinal trigeminal nucleus, nucleus ambiguous, sympathetic fibers, inferior cerebellar peduncle
47
PICA-Stroke
-Vomiting, vertigo, nystagmus -Limbs/face- decreased pain, temp, sensation -Dysphagia, hoarseness, Dec gag reflex -Ipsi Horner's -Ataxia, dysmetria
48
AICA-distribution
-Lateral pons-vestibular nuclei, facial nucleus, spinal trigeminal nucleus, cochlear nuclei, sympathetic fibers -MIddle and inferior cerebellar peduncles
49
AICA stroke
-Vomiting, vertigo, nystagmus -Paralysis face -Dec lacrimation/salivation -Dec taste from anterior 2/3 tongue -Dec corneal reflex FACe-dec pain, temp; ipsi dec hearing, ipsi horner's
50
PCA-distribution
-Occipital cortex, visual cortex
51
PCA-stroke
-Contra hemianopsia w/macular sparing
52
# reversed
\_immediate evacuation
Epidural Hematoma -TX
53
# reversed
- MCA, lucid interval, often associated with bone break -Herniation-\>CNIII compression (ipsilateral pupillary dilation/ "down and out" ; PCA-\> ipsilateral visual cortex/ contraletral VF ; Duret-\> compression of contraleteral cerebral peduncle-\_ipsilateral hemiparesis ( false localizing sign)
Epidural hematoma
54
# reversed
-Bridging veins -Can be fatal -Midline shift -
Subdural Hematoma
55
# reversed
-Uncal -Central (transtentorial) -Cingulate (subfalcine) -Transcervical
Supratentorial herniation
56
# reversed
-Upward ( cerebellar or transtentorial) -Tonsillar ( downward cerebellar)
Infratentorial herniation
57
# reversed
-ACA -LEG WEAKNESS
Cingulate Herniation
58
# reversed
-Reticular-altered level of consciousness -Corticospinal tract- decorticate posturing; rostral-caudal deterioration
Transtentorial Herniation
59
# reversed
-Cerebral peduncle-hemiparesis ( ipsi) -CNIII-pupil dilation; down and out; ipsi -PCA- visual field loss contra
Uncal Herniation
60
# reversed
-Ruptured berry aneurysm -ACOM\>MCA\>PCOM\>basilar -80% in anterior circ -Esp alcoholics, old -May need intervention -Can be incidental finding
Subarachnoid Hemorrhage
61
# reversed
- Vasospasm -TX with nimodipine (CCB)
Subarachnoid Hemorrhage-complications
62
# reversed
-drugs, polycystic kidney disease, fibromuscular dysplasia. -95% CT will show; Sometimes need LP and this shows xonthochromia
RF SAH
63
# reversed
-clipping or endovascular coiling -CLinical depends on level of consciousness; want to treat earlier
SAH-TX
64
# reversed
-putamen, pons, cerebellum, and thalamus -cerebellum needs surgical intervention (occlusion of the 4th ventricle, hydrocephalus) -RF: HTN! ASTAB/ASTAB; old-cerebral amyloidosis bleeding into ischemia, tumor, AVM, cavernomas,trauma
Parenchymal/ Intracerebral
65
# reversed
-Strokes of Large, named arteries -Lacunar Stroke Syndrome -BStem stroke syndromes -Cerebellar stroke syndromes -Cerebellar strokes - Watershed and embolic strokes -Venous infarcts
Ischemic Stroke
66
# reversed
-contra motor/sensory;leg\>face/arm - Frontal lobe, behavior, akinetic mutism - trans motor aphasia (L) /neglect (r) -urinary incontinence
Named Arteries: ACA
67
# reversed
-Contra motor/sensory ; face/arm\>Leg -Aphasia (L);neglect (R) -Eyes deviate towards lesion -Contra hemianopsia
Named Arteries: MCA
68
# reversed
-contra hemianopsia, alexia w/o agraphia for L sided. pts may be unaware of loss -Large- contra motor/sensory
Named Arteries: PCA
69
# reversed
- Small vessels -Subcortical white matter, BG/Internal capsule,Thalamus, Pons, Cerebellum -HTN! -Changes in small arteries-hyalonosis
Lacunar Strokes
70
# reversed
-Pure Motor:internal capsule -Pure Sensory: thalamus Ataxic hemiparesis Clumsy-hand/dysarthria \* not so much higher cortical function
Lacunar Strokes-Clinical
71
# reversed
-Crossed findings -CN ipsi & M +S contra -Brainstem disease include dizziness/vertigo, ataxia, nausea, imbalance, double vision, nystagmus, dysarthria, and dysphagia. - reticular problems can cause comatose
Brainstem Strokes
72
# reversed
- Occlusion of vertebral artery or PICA -lateral medullary syndrome - Clinical 1.dysphagia, hoarseness, dizziness, nausea, and vomiting,nystagmus, problem with gait/balance. Hiccups ( tx-thorazine) 2. Pain & temp loss in contra body, ipsi face 3. Horner's syndrome
WALLENBERGSyndrome
73
# reversed
-ipsi ataxia -n/v, vertigo,dysarthria,and nystagmus. -lateral-ataxia of ipsi arm/leg; medial= axial muscle/gait /balance -Usually ok; unless swells ( day 3-5) and then need to drain if 4th ventricle occlusion
Cerebellar Strokes
74
# reversed
-hypoperfusion(hypotension, CHF, carotid stenosis) -ACA/MCA weakness of proximal arm/leg muscles but ok distal strength. ("man in barrel") -From other arteries or other areas
Waterhshed/ Embolic Strokes
75
# reversed
-Depends on part of brain effected -Signs of ^ICP-HA/seizures -RF: hyper-coagulable states ( genetic, postpartum, infections, and meds) -Tx-heparin -Cord sign/empty delta
Venous Infarcts
76
# reversed
temporary monocular blindness bc of temporary occlusion of the retinal artery
Amaurosis fugax
77
# reversed
-Aware and awake can only move eyes. lesion of ventral pons -Tip of basilar
Locked-In syndrome
78
# reversed
-Tear into wall from chiropractic procedure (other neck trauma, RF of connective tissue disorder) -Clot into wall layers not lumen -String sign
Vertebral Artery dissection
79
# reversed
-Clot in MCA; early stroke
Dense MCA sign
80
# reversed
-within 3 (4.5 hrs) -CI:minor/resolving deficits, pts w/ glucose 185/110, INR \>1.7, Platelet
tPA
81
# reversed
Warfarin
Tx- Lupus anticoagulant
82
# reversed
- DWI and ADC map -Post stroke Mana usually R sided stroke
Acute Stroke Workup
83
# reversed
- T1 -Indicates breakdown of BBB
MRI & contrast
84
# reversed
-Depression
Psychiatric symptoms of ischemic stroke
85
# reversed
AD disease -pt with migraines, dementia, and multiple lacunar strokes
CADASIL
86
# reversed
- mitochondrial encephalopathy with lactic acidoses and stroke -A mitochondrial disorder (maternal inheritance) with stroke-like episodes often in the occipital region. Presents with seizures and dementia in adolescence.
MELAS
87
# reversed
-An autosomal recessive disease of caused by a mutation of hemoglobin found in people of African ancestry. - Predisposes to stroke
Sickle Cell
88
# reversed
- high dose statin regardless f lipid profile -BP 120/80\*\*\* -HgBA1c-DM?treat - Smoking cessation, dietary modification, exercise
2ndary stroke prevention
89
# reversed
Transesophageal chocardiogram Is there a clot in the heart? If yes, start anticoagulation EKG, cardiac monitoring Is there atrial fibrillation? If yes, start anticoagulation. If there is no indication for anticoagulation, use an antiplatelet agent (ASA, ASA/dipyridamole (Aggrenox), Clopidogrel (Plavix). Clopidogrel is more effective in preventing heart attacks than ASA. Anticoagulants are Dabigatran (Pradaxa) or Warfarin.
Anticogulation or antiplatelet?
90
# reversed
Patients with TIAs should be treated as per stroke patients. In high-risk patients with certain clinical features of the TIA (unilateral weakness or speech disturbance), the 90-day stroke risk is nearly 20%.
TIA
91
# reversed
Carotid Doppler/MRA Is there carotid stenosis (usually \>70%) If yes, carotid endarectomy (preferably within two weeks).
Carotid Endarectomy
92
# reversed
From cardiac arrest There is diffuse edema with sulcal effacement, bilateral uncal herniation, diffuse compression of the entire ventricular system. "reversal sign on CT"
Global cerebral anoxia
93
# reversed
Hypercoag/rheum work-up antithrombin III deficiency, protein C and S deficiency, activated protein C resistance/factor V Leiden mutation, and prothrombin gene mutation. Most of these present with strokes before the age of 30, and they usually cause venous infarctions.
Young stroke patients
94
# reversed
can be screened for by testing lupus anticoagulant and anticardiolipin antibodies. Patients are often women, and may report spontaneous abortions. The treatment is with warfarin.
Antiphospholipid syndrome
95
# reversed
Lateral costicospinal tract; Medial leminiscus Caudal medulla -hypoglossal nerve
ASA -Distribution
96
# reversed
Contra hemiparesis- lower limbs Dec contralateral propioception Ipsilateral hypoglossal dysfunction ( tongue deviates ipsilaterally)
ASA-stroke
97
# reversed
Lateral medulla- vestibular nuclei, lateral spinothalamic tract, spinal trigeminal nucleus, nucleus ambiguous, sympathetic fibers, inferior cerebellar peduncle
PICA-distribution
98
# reversed
-Vomiting, vertigo, nystagmus -Limbs/face- decreased pain, temp, sensation -Dysphagia, hoarseness, Dec gag reflex -Ipsi Horner's -Ataxia, dysmetria
PICA-Stroke
99
# reversed
-Lateral pons-vestibular nuclei, facial nucleus, spinal trigeminal nucleus, cochlear nuclei, sympathetic fibers -MIddle and inferior cerebellar peduncles
AICA-distribution
100
# reversed
-Vomiting, vertigo, nystagmus -Paralysis face -Dec lacrimation/salivation -Dec taste from anterior 2/3 tongue -Dec corneal reflex FACe-dec pain, temp; ipsi dec hearing, ipsi horner's
AICA stroke
101
# reversed
-Occipital cortex, visual cortex
PCA-distribution
102
# reversed
-Contra hemianopsia w/macular sparing
PCA-stroke
