Vascular Flashcards
54 year-old woman developed a headache and rapid-onset of left hemiparesis.
Hypertensive basal ganglia hemorrhage
CT: hemorrhage in R putamen
Intraparenchymal hemorrhagic stroke
-
Chronic HTN → rupture of small arteries
- Unlike stroke which is immediate, progresses over 30-90 mins
- Risk factors:
- HTN
- Aspirin
- Old age
- Cerebral amyloid angiopathy
- Smoking, alcohol, cocaine
- Symptoms
- Decreased consciousness → coma, headache, nausea/vomiting
- Contralateral hemiplegia and sensory deficit (due to mass effect), aphasia, neglect, visual disturbances
- Common sites
- Basal ganglia (putamen)
- Pons
- Cerebellum
- Thalamus
60 year-old man was found down, not moving right side.
Hypertensive basal ganglia hemorrhage → intraventricular extension
CT: large hemorrhage in left thalamus with intraventricular extension
A 65 year-old man collapsed while outside and remained comatose.
Pontine hemorrhage
CT: hemorrhage in the pons
- Usually a devastating and fatal event
- Due to rupture of penetrating vessels from the basilar artery
- Symptoms
- Quadraplegia, rigidity, decerebrate postering
- Comatose with few brainstem reflees
- Pinpoint pupils
- Prognosis
- Patients do not survive
A 56 year-old presented with nausea and vommiting followed by an intense headache and loss of consciousness.
Cerebellar hemorrhage
CT: hemorrhage in cerebellum with extension into 4th ventricle
- Signs and symptoms
- Headache, gait ataxia, vertigo/dizziness, vomiting
- “Fatal gastroenteritis” = nausea/vomiting due to unrecognized cerebellar pathology
- Complications
-
Obstructive hydrocephalus due to occlusion of 4th ventricle = EMERGENCY
- Do frequent neuro checks and imaging
- Monitor respiratory and circulatory status
-
Obstructive hydrocephalus due to occlusion of 4th ventricle = EMERGENCY
- Treatment
- Mannitol, hyperventilation
- Hematomas < 3cm can be monitored clinically and radiographically
- Hematomas > 3cm require surgical evacuation via drainage
4 separate elderly patients with the sudden onset of headache and focal neurological deficits.
Lobar hemorrhage
- Hemorrhages within lobes of brain adjacent to the cortex
- __Most common in parietal and occipital
- Basal ganglia, brainstem, cerebellum are spared
- Epidemiology
- Elderly w/o HTN
- ApoE2 or APE4 allele
- Associated with cerebral amyloid angiopathy (CAA)
- Abnormal accumulation of amyloid protein in arterioles of the cortex and meninges
- Congo red stain of amyloid protein
- Treatment
- AVOID antiplatelet + anticoagulant
A 76 year-old woman with left sided weakness and neglect (left).
A 68 year-old with visual hallucinations in her left visual field (right).
Hemorrhagic conversion of ischemic stroke
CT: Hemorrhage within R MCA infarct (left)
CT: Hemorrhage withing R PCA infarct (right)
-
Ischemic strokes can convert to hemorrhage after tPA
- Risk of hemorrhage on tPA is 6%
- Risk factors:
- Deviation from tPA protocol
- Large strokes
- Old age
- Hyperglycemia
A 76 year-old woman presented with a headache and deficits in her right visual field.
Hemorrhage into tumor
- Brain tumors often hemorrhage into the nectrotic center of the tumor
- Common bleeding tumors:
- Medulloblastomas
- Oligodendrogliomas
- Craniopharyngiomas
- Vestibular schwannomas
- Ependymomas
- Pituitary adenomas
- Choroid plexus carcinoma
A 46 year-old woman presented a seizure and scan (left) was performed. 4 months later he was found unconscious in bed and scan (right) was performed.
Hemorrhagic metastatic tumor
- Metastatic tumors that bleed:
- Melenoma
- Renal cell carcinoma
- Choriocarcinoma
- Thyroid cancer
- However, lung and breast cancer are more common and therefore most metastatic bleeds are due to these cancers!
- Metastatic vs. primary tumor is hard to tell on imaging
- Cerebellar tumors are mostly metastatic though!
A 61 year-old man developed right-sided leg weakness, urinary incontinence, mutism.
Left ACA infarct
- ACA supplies:
- Medial frontal lobe + anterior parietal lobe
- Corpus callosum
- Cingulate gyrus
- Signs
- Contralateral weakness and sensory loss of legs
- Urinary incontinence - disruption of micturition inhibition center
- Disinhibition, abulia (can’t make deciscions)
- Left side
- Transcortical motor aphasia
- Right side
- Hemineglect
A 67 year-old man developed severe left-sided weakness and neglect.
Right MCA infarct
- Signs
- Contralateral weakness, sensory loss, homonymous hemianopsia
- Eyes deviate to side of the lesion
- Left side
- Global aphasia
- Right side
- Hemineglect
59 year-old man developed sudden-onset of left-sided weakness (left).
65 year-old woman suddenly lost consciousness with left-sided weakness (right).
Dense MCA sign (left)
Dense basilar sign (right)
- Most cases of ischemic stroke will show a normal brain on non-con CT
- Large artery thrombosis can reveal clot of the artery as a hyperdense focality on CT scan
A 76 year-old woman presented with the sudden onset of left-sided weakness and neglect syndrome.
Ischemic stroke of right MCA
- Earliest sign of stroke will show blurring of white-gray matter
- These changes start at 6-12 hours
A 55 year-old man was brought to the hospital by his wife after he “stopped making sense.”
Inferior division MCA stroke
- Supplies posterior frontal lobe + anterior parietal lobe + lateral temporal lobe
- Signs
- Contralateral visual deficit (occipital)
- Contralateral cortical sensory loss (parietal)
- Left
- Wernicke’s (receptive) aphasia
- Right
- Hemineglect
A 79 year-old man presented with trouble seeing and reading…
PCA infarct
- Supplies inferior medial temporal lobe + occipital lobe
- Small penetrating branches supply parts of the midbrain + thalamus
- Signs
-
Contralateral homonymous hemianopsia with macular sparing
- There is collateral supply from the MCA
- Alexia without agraphia (splenium of corpus callosum)
- Sensory deficit (thalamus)
- Upper nerve palsies, vertical gaze impairment, coma (midbrain)
-
Contralateral homonymous hemianopsia with macular sparing
A 59 year-old man was admitted after falling down the stairs. He could not see, but denied any visual complaints.
Bilateral PCA stroke
- Cortical blindness in patients with damage to both occipital lobes
-
Anton’s syndrome = damage to both occipital lobes
- Denial of blindness
-
Balint’s syndrome = damage to both posterior parietal lobes
- Optic ataxia = impairment of hand-eye coordination
- Oculomotor apraxia = can’t guide eye movements
- Simultanagnosia = can’t perceive more than one object at a time in one’s visual field
A 67 year-old man presented with sudden aphasia.
Cardioembolic stroke
- There are multiple small infarcts of different ages in different vascular territories
- 20% of ischemic strokes are cardioembolic
- Most common cause is a-fib
- Left atrial appendage can have thrombus formation
- Risk factors = CHF, endocarditis, CAD, intracardiac tumors, prior MI
- Diagnosis
- TEE to determine if there is thrombus
- EKG to determine if there is a-fib
- Treatment
- Lifetime warfarin
- INR 2-3
- Alternatives: dabigatran, apixaban, rivaroxaban
- Do not have to check INR
- Lifetime warfarin
An 89 year-old woman had a prior history of alexia without agraphia and an expressive aphasia.
Remot PCA and MCA stroke
A 57 year-old man with an stroke several years prior.
Wallerian degeneration
- Red arrow = atrophy of right cerebral peduncle due to Wallerian degeneration after cortical infarct
- Damage to cortical motor tracts will lead to degeneration of corticospinal tract throughout CNS
A 57 year-old man suffered a stroke many years prior.
Hydrocephalus ex Vacuo
- Image: old infarct in R MCA with dilation of lateral ventricles (red arrow)
- Infarcts → necrosis → destruction of brain tissue → enlargement of adjacent ventricles
3 patients presented with the sudden onset of ataxia, vertigo, and nausea.
3 cerebellar infarcts
- Case 1 = SCA infarct
- Supplies upper lateral pons + superior cerebellum and vermis + cerebellar hemispheres
- Case 2 = AICA infarct
- Supplies lower lateral pons + middle cerebellar peduncle + anterior cerebellum
- Case 3 = PICA infarct
- Supplies lateral medulla + inferior cerebellum and vermis
A 50 year-old man was found down, seemingly comatose. On exam several days later he was noticed to have vertical eye movements.
Basilar artery infarct
- Occlusion of basilar artery can infarct entire pons
-
Locked-in syndrome
- No voluntary movements other than vertical eye movements (controlled by midbrain)
A 85 year-old female was found down at home and was nonresponsive on exam.
Brain dead
Guidelines for brain death determination:
- Establish irreversible and proximate cause of coma
- Achieve normal systolic blood pressure
- Perform 2 neuro exams confirming absense of brainstem reflexes
- Perform apnea test
A 35 year-old female presented with a severe headache and right-sided weakness.
Thrombosis of inferior sagittal sinus
- Red arrow = no flow in deep venous system
- Signs and symptoms
- Unlike arterial stroke, no specific pattern of injury with venous infarctions
- Focal neuro deficits depend on part of brain that is damaged
- More indolent presentation
- Seizures, headaches, signs of increased ICP
- Unlike arterial stroke, no specific pattern of injury with venous infarctions
- Risk factors
- Hypercoaguable state, pregnancy, infection, medications
- Smoking + oral contraceptives
- Treatment
- Immediate heparin (even if bleeding)
- Oral anticoagulation for 3-4 months
A 34 year-old female presented with a headache and seizures.
Venous thrombosis
- Image:
- “Cord sign” - hyperintensity in R central sulcus
- “Empty delta sign” - absense of contrast flow in superior sagittal sinus
A 56 year-old presented with the sudden onset of right-sided weakness.
Watershed stroke
- Caused by hypoperfusion of brain from systemic hypotension, CHF, carotid stenosis
- Signs
- ”Man in a barrel” = weakness of proximal arm and legs with preservation of distal strength
A 69 year-old man presented with the sudden onset of right-sided weakness.
ICA thromboembolism
- Image:
- Left - plaques in left ICA
- Right - infarction in territory of ACA and MCA
- 30% of ischemic stroke is due to artery-artery thromboembolism
- Aortic arch, common carotid, ICA, vertebral
- Carotid bifurcation is most common source
- Management
- US, MRA or CTA of ICA
- Treatment
-
Carotid endarterectomy or stenting
- Second ischemic stroke is most common complication
- Reperfusion injury = headache, seizures, neuro deficits
-
Carotid endarterectomy or stenting
A 65 year-old man presented with left hand weakness.
Acute infarction of R motor cortex (hand homunculus)
A 23 year-old woman developed neck pain and dizziness, vertigo, dysarthria, abnormal facial sensation, and a Horner’s syndrome after strenuous exercise.
Right vertebral artery dissection
- Image:
- Left - vertebral artery dissection (red arrow)
- Right - narrowing of arterial lumen (red arrow)
- Signs and symptoms
- Similar to carotid artery dissection
- Neck pain
- Horner’s syndrome (sympathetic pathway affected)
- Risk factors
- Connective tissue disorders
- Trauma to neck
- Treatment
- Anticoagulation or antiplatelet
- Stents, artery ligation
A 66 year-old man presented with the sudden onset of left-sided weakness and neglect syndrome.
Right MCA infarct
- Interventional procedures
- Mechanical clot removal
- Direct delivery of thrombolytics
A 56 year-old man developed the sudden onset of left sided weakness. He became obtunded over the next several days, and underwent a life-saving procedure.
Right MCA infarct followed by hemicraniectomy
- Massice infarctions of MCA can cause swelling, herniation, and death
- Cytotoxic edema = swelling of infarct
- The BBB remains intact and therefore glucocorticoids will not work!
- Edema caused by intracellular accumulation of sodium and water (defect in Na/K pump)
- Vasogenic edema = swelling of CNS neoplasms
- Cytotoxic edema = swelling of infarct
- Treatment
- Mannitol, hyperventilation
- Hemicraniectomy in emergencies
A 45 year-old man with developed headaches and cognitive impairment. He also had several small strokes. A similar thing happened to his father.
CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)
- Image:
- Left - hyperintensity in white matter of temporal lobes
- Right - hyperintensity of external capsule
-
Most common hereditary stroke disorder
- NOTCH3 gene mutation
- Degeneration of smooth muscle cells in blood vessels
- Diagnosis
- Skin biopsy
- Signs and symptoms
- History of confusional migraines
- Multiple lacunar strokes (middle age) in absence of other stroke risk factors
- Eventual dementia
- Treatment
- Antiplatelets
A 99 year-old female was found unresponsive in her bed. She was comatose on arrival and died several days later.
Right MCA infaract, left chronic subdural hematoma
- There is equal and opposite mass effect and therefore no midline shift
A 67 year-old presented with mild cognitive impairment.
Microvascular disease
- Images: confluent hyperintensities in subcortical white matter and pons
- Lesions are indistinguishable from MS!
- White matter lesions are throughout as opposed to periventricular in MS
- Most common in old people
- Risk factors
- Smoking
- Diabetes
- HLD
