Vascular: CVD

Question 1

Etiology + DDx of TIA/stroke

Answer 1

TIA/Amourosis Fugax/stroke by etiology:
Thrombosis (thrombus in carotid, vertebral, intracranial arteries causing stenosis/occlusion).
Cardioembolic: e.g. afib, MI, valvular disease.
Intracranial hemorrhage.
Small vessel occlusion.
Non-vascular patho: e.g. tumor.

DDx: seizure, migraine, tumor.

Question 2

Describe amourosis fugax, MCA syndrome, ACA syndrome.

Answer 2

Amourosis fugax: transient blindness due to occlusion of ophthalmic artery.
MCA: contralateral weakness and sensory loss to face and arm.
ACA: Contralateral leg paresis and sensory loss.

Question 3

RF for stroke

Answer 3

DM, HTN, CAD, hyperlipidemia, afib, smoking

Question 4

Appropriate investigations for stroke pts

Answer 4

Risk of future stroke is highest immediately following TIA or minor initial stroke so investigate early.
CT brain: look for ischemic infarct/hemorrhage, look at carotid/vertebral arteries for lesions.

CT angiogram: gold standard for defining arterial lesions. Reveals trickle flow. Cannot discern thickness of plaque. 1/200 risk of stroke with test.

Carotid duplex US: use plaque imaging, flow velocity and color doppler to determine degree of stenosis. Not reliable in very high grade stenosis. Note cannot assess carotids above mandible.

Find source of emboli: ECG for MI, holter for afib, DM/dyslipidemia w/u, echo for valvular disease.

Question 5

When to give tPA/contraindications to tPA

Answer 5

Give tPA if: pt seen early (within 4.5 hrs of onset), deficit still present, CT negative for hemorrhage.

Contraindications: Improving or minor symptoms, seizure at onset, symptoms of SAH/pericarditis/MI. ICH hx,pregnancy, recent major surgery, recent hemorrhage, recent LP, high BP, hemorrhage on CT, high INR/PTT

Question 6

Medical vs surgical therapy for carotid occlusion disease

Answer 6

Medical: antiplatelet drugs (ASA, clopidogrel), statins (lower lipids, stabilize plaque), BP control (avoid excessive lowering in order to maintain perfusion to brain), mgmt of RF (DM, smoking, physical activity, HTN).

Surgical: carotid endarterectomy for revascularization. Indicated if symptomatic stenosis with >50% blockage following TIA ipsilateral to carotid lesion. Or, asymptomatic stenosis >80% in low surgical risk pt.

Question 7

Potential complications of endarterectomy

Answer 7

1-5% mortality.

Injury to vagus, recurrent laryngeal, sympathetic plexus, hypoglossal nerves.