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Cheng-Ching > Vascular/NCC > Flashcards

Vascular/NCC Flashcards

1
Q

Anterior choroidal -

A

off ICA branch - posterior limb internal capsule and caudate TAIL
(anterior limb internal capsule=recurrent A Heubner)
Homonymous hemianopsia - LGN in thalamus
(Like MCA but normal speech)

(posterior choroidal A off PCA)

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2
Q

carotid anatomy

A

Atherosclerosis =no increase risk carotid dissection

-C4: CC to ECA, ICA

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3
Q

CARASIL

A

cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy - HTRA1 mutation on 10q26.13; lacunar ischemia (hemorrhage)
-like CADASIL plus premature alopecia, back pain, spondylosis
-NO MIGRAINE vs CADASIL

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4
Q

CADASIL

A

Missense mutation in gene NOTCH3 on chromosome 19q13.1
granular osmiophilic material in basal laminal cutaneous arrterioles and CNS arteries
-p/w migraine with aura, stroke, dementia, FHx stroke, dementia
-Dx: genetic testing or skin biopsy
MRI: anterior temporal lobes

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5
Q

(other genetic stroke disorders)

A

Fabry - alpha galactosidase , build up ceramide trihexoside
-sm fiber neuropathy hands + feet, worse with heat
-strokes dolieoctasia

COL4A1-laucnar ischemia or hemorrhage; extensive white matter involved; also with aneurysms, CKD, muscle cramps

Deficiency of ADA2-associated polyarteritis nodosa vasculopathy-ADA2 on 22q11.1-HSM, recurrent fevers, small vessel vasculitis

Retinal vasculopathy with cerebral leukodystrophy (RCVL)-TREX1-ischemic strokes - visual loss, retinal microangiopathy, kidney/liver disease

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6
Q

MELAS

A

mitochondrial encephalopathy with lactic acidosis and stroke like episodes

-transfer RNA gene (mt)

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7
Q

Familial moyamoya

A

-nonathero intracranial stenosis in ICAs
- puff of smoke angio with useless collaterals;
-histo: intimal thickening of fibrous tissue, no inflammatory cells/atheromas

SPARES white matter vs. other genetic stroke disordres
(AD or AR-ACTA2, MTCP1, RNF213 genes)

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8
Q

cerebrovascular fibromuscular dysplasia

A

alternating beading of intracranial vessels due to skip areas of stenosis

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9
Q

ACA

A

A1 segment/Acomm occlusion (if normal circle of Willis)= no deficits, b/c proximal to Acomm which communicates with BL ACAs

distal to Acomm-leg weak, urinary incontinence, medial micturition-paracentral lobule, paratonic rigidity, +/- eye deiviation to lesion

Recurrent artery Heubner-ACA branch
Head caudate-inferior
Ant limb internal capsule
anterior globus pallidus
Nuc accumbens, basal Nuc Meynert

-ACA most common site for aneurysm

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10
Q

ABCD2 score

A

Age 60, DM, BP>140/90
Duration: 1 pt if 10-59 min, 2 pts if >60 min
HLD not included

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11
Q

brainstem localization/respiratory patterns

A

top of basilar - midbrain, thalamus, temp, occipital - impaired consciousness, pupil abnormalities

Locked in - basilar occlusion-base of Pons-no horizontal movements, quadriplegia, preserved consciousness
-apneustic breathing-respiratory pause at inspiration + expiration (lateral tegmentum) - pons has a pause

Medulla: ataxic breathing -irregular -upper medulla

BL hemisphere/diencephlon: cheyne-stokes -intact brainstem -cycle hyperpnea + apnea

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12
Q

AICA

A

lateral pons, inner ear (labyrinthine A branch), middle cerebellar peduncle-anterior inferior cerebellum
ipsilateral hearing loss vs PICA

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13
Q

CVST

A

seizures-40%
HA-90%
-middle ear infection, mastoiditis-transverse sinus thrombosis

Deep veins: internal cerebral, thalamostriate/septal, basal vein Rosenthal->** vein of Galen +inferior saggital sinus->straight sinus**
-infarct straight sinus - thalamic infarcts

superior saggital sinus (parasaggital cortex)->confluence of sinuses->meets straight sinus (drains Galen)->transverse sinus (cavernous/superior petrosal)->sigmoid sinus-> internal jugular vein

ophthalmic vein ->cavernous sinus
->superior petrosal->transverse sinus
cavernous sinus->inferior petrosal
->sigmoid sinus/jugular bulb

scalps veins->emissary veins->dural venous sinus

anastomoses along Sylvian fissues
superior anastomotic vein of Trolard-sylvian V to superior saggital
-**inferior anastomotic vein of Labbe **-temporal lobe->sylvian V to transverse sinus

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14
Q

PICA

A

Wallenberg- PICA-off vert
-ipsilat: face sense-CN V
-vestibular nuclei CN VIII-nystagmus, vertigo
-STT-pain/temp contralateral body
sympathetics - Horner’s
-nuc tractus solitarius-loss taste

inferior cerebellum-lateralpulsion, ataxia

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15
Q

vert dissection

A

C1-C2
-vert runs through transverse foramina at C5-C6 + C2
Dx: MRA TOF-flow at dissection
MRI fat suppression-eval vessel wall-nonocclusive dissection

gold standard-angio-but no info about vessel wall
-dont need TTE b/c thrombus from dissection
Tx: AP or AC, endovascular open vessel

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16
Q

amarousis fugax

A

most common - retinal A from ophthalmic A from ICA

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17
Q

artery of Percheron

A

Varient where supplies medial thalamus bilaterally
-off P1 of PCA

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18
Q

MCA

A

lenticulostriate branches - putamen, GPe/GPi, caudate head/body (caudate tail=anterior choroidal off ICA)
-no supply to thalamus

superficial brances: frontal, parietal, temporal lobe, * insula*
LCA lenticulostriate/MCA watershed
strip down corona radiata - internal watershed

homonymous hemianopsia b/c hit optic radiations

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19
Q

Thalamus supply

A

tuberothalamic A- Pcomm- anterior-(ventral anterior nuc) (Tubero Top)

paramedian / thalamoperforating A- P1 - medial (dorsomedial nuc)

thalamogeniculate - P2 - lateral (ventral lateral nuc)

posterior choroidal- P2 - posterior-pulvinar nuc

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20
Q

cerebellum

A

superior cerebellum: leve midbrain: SCA + superior colliculus/pretectum (dorsal, quadrigeminal plate)
inferior cerebellum: level medulla: PICA

21
Q

lacunes

A

lipohyalinosis -occlusion small penetrating branches (not microhemorrhages)

22
Q

Dejerine-rossey

A
  • post thalamus stroke pain syndrome - hypersensitivity to pain
23
Q

medial medullary

A

occlusion vert
-contralateral A/L and spares face
-contralateral loss position and vibration
-ipsilateral tongue weak

24
Q

aneurysmal rupture

A

Posterior circulation higher risk rupture
-Marfans, Ehlers Danlos

-ACA most common

25
Q

PCA infarct

A

L occipital-alexia, anomia, achromotapsia (color anomia)

Alexia WITH agraphia - L angular gyrus

Alexia without agraphia - L PCA - spares angular gyrus; involves splenium corpus callosum

Gerstmann - L angular gyrus - agraphia, finger agnosia, acalculia and right left confusion

Midbrain PCA branches:
Benedikt’s syndrome -paramedian midbrain- mesencephalic tegmentum-**ventral midbrain*
-Benedikt involved red nucleus =contra lat choreoathetosis, ataxia + ipsi CN III

vs Claude, brachium conjunctivum, CN III
-ipsi CN III, contralateral tremor + ataxia, no choreoathetosis

26
Q

TPA contraindications

A

absolute contraindications:
-glucose<50
head trauma/stroke in last 3 months, prior ICH, neoplasm, AVM, aneurysm
SBP>185 or DBP>110
Sx SAH
arterial puncture at noncompressible site < 7 days
-active internal bleeding, plt <100,000
-heparin within 48 hrs+elevated aPTT
-CT infarct >1/3 hemisphere
-INR >1.7 or PT >15 sec

relative contraindications:
-Major surgery or serious trauma within prior 14 days
-GI tract hemorrhage, recent MI,
pregnancy, minor/improving stroke Sx

-can’t give TPA >3 hours if: NIHSS>25, age>80

27
Q

ASPECTS

A

-two Axial cuts-one high and one at BG/thalamus
-10 total: 4 deep-caudate, IC, lentiform (putamen/GP), insular
6 cortical

No stroke=10 full points; 0=full MCA

7 or less: increased dependent and death

28
Q

carotid stenosis CEA/CAS

A

symptomatic stenosis 50-69%: CEA better outcomes for men

CAS: higher risk stroke
-better if neck surgery, prior radiation, contralateral carotid occlusion, contralat CN X paralysis

CEA: higher risk MI

29
Q

RCVS

A

-thunderclap then can have persistent HA
-small cortical SAH
-beading on angiogram
-vessels should normalize after 3 months-angio confirms Dx
-Tx: CCB, mag
-more common in women (~PRES)
-no vessel wall inflammation

30
Q

primary CNS angiitis

A

-beading on angiogram
-small and medium vessels
-women=men affected
-definitive Dx: brain biopsy with wall inflammation, but poorly sensitive
MRI: GAD+ meninges or pareynchyma

Tx: steroids +/- cyclophosphamide

31
Q

vascular malformations

A

Dural AVF: meningeal/dural A branches, drain into venous sinus
-if cortical venous drainage vs dural venous sinus, highest risk hemorrhage
-acquired - CVST, arterialization draining veins
-cranial or spinal, no brain or capillary in between
-Sx of high venous pressure -pulsatile tinnitus
MRI: thick worms

AVM: pial arterial supply + nidus that draws draining veins and arteries congenital draining vessel
-high pressure blood in low pressure
-brain in between; no capillary beds in between, (no stroke if embolize AVM)
-hemorrhage

cavernous malformation - popcorn with dark rim
-low pressure capillary malformation
-no smooth muscle/elastic fiber, thin walled vessels
-seizures

developmental venous anomaly=venous angioma-caput medusa/palm tree sign
-Asx

31
Q

blood on MRI

A

I B hyperacute <12 hours
I D acute
B D early subacute 2-7 days
B B late subacute 1 week-1 month
D D chronic

32
Q

cerebral edema

A

-interstitial edema - (transependymal)-low attenuation periventricular changes around the lateral ventricles-acute obstructive hydrocephalus-causes hydrostatic pressure

cytotoxic -cell death->failure Na+/K+ ATPase pumps ->alters permeability cell membrane->intracellular accumulation fluid
-also with changes in serum osmolality

vasogenic - extravasation of fluid

DDx - high altitude, lead intoxication

33
Q

herniation syndromes

A

uncal - contralateral hemiparesis if ipsilateral CSF
- or if displacement against contralateral Kernohan’s notch->compress contralateral CST->ipsilateral hemiparesis
-uncal - compresses PCA in tentorial notch
-specific to uncal hernation

no ipsilateral pupil + contra hemiparesis + PCA infarct:
-subfalcine (cingulate gyrus)
- tonsillar (medulla, 4th ventricle),
-central transtentorial (diencephalon down on midbrain)
-transcalvarial (through bony defect in skull):

34
Q

ICP crisis

A

-normal **5-15 mm Hg ** / 7.5-20 cm H2O
-hyperventilation: reduce pCo2 ->hypocapnia -> cerebral vasocontriction

-mannitol-BOLUS -target serum osm <320 mOsm/L - depletes K, Mg, phos

Hypertonic saline - continuous infusion-sodium 150 target

Propofol-can reduce ICP; causes hypotension, hyperTG, infection, lactic acidosis, HLD

Pentobarbital - Tx

ICP waveforms: Lundberg A - plateau waves - intracranial HTN - amplitude 50-100
B waves, C waves normal

35
Q

states of consciousness

A

unresponsiveness wakefulness - return of sleep-wake cycles in previous comatose pt - vegetative state

coma - reflex responses only

36
Q

sodium nitroprusside

A

produces NO and cyanide
-increases ICP, decreases MAP-> can decrease cerebral perfusion pressure
-Tx cyanide toxicity-> sodium thiosulfate (converts to thiocyanate) or methemoglobin
-not if renal disease
-thiocyanate toxicity: pupillary constriction, tinnitus, seizures, Tx: dialysis

37
Q

epidural vs SDH

A

SDH: does not respect suture lines - banana shape

epidural: respects suture; lemon shaped (biconvex)
-MMA-foramen spinosum

38
Q

SAH

A

ABCs first
vasospasm - 3-15 days, peak 6-8 days
-triple H therapy once aneurysm secured: hypervolemia, HTN, hemodilution
-nimodipine x21 days

Hunt Hess score: CLINICAL
1. ASx/minimal HA, slight nuchal rigid
2. moderate-severe HA, nuchal rigid, CN palsy only
3. drowsy/confused, moving all 4, mild neuro deficit
4. stupor, severe hemiparesis
5. deep coma, posturing

Fisher - CT
1. no SAH
2. thin blood
3. thick blood
4.ICH or IVH clots

39
Q

fat embolization

A

axillary, thorax, conjunctiva petechial hemorrhage
-petechial hemorrhages in brain after bone fractures
-CT usually normal
vs. coup/contrecoup - CTH with blood

40
Q

GBS

A

-ABG not indicator of intubation b/c drop later in resp failure

41
Q

central pontine myolinolysis

A

correct mo faster than 12 Na+ per day
-Sx 3-10 days after correction
-myelin destruction in ventral pons (or deep matter cortex), spares axons, bodies
-burns, liver transplant

42
Q

AC reversal

A

warfarin - prothrombin complex concentrate PCC (Kcentra) fastest and less complications vs FFP; IV vit K

heparin- protamine sulfate

dabigatran - direct thrombin inhibitor - idarucizumab

factor Xa inhibitors - DOACs - PCC

43
Q

cardiac arrest

A

**24-72 hrs: best predictor- absent BL N20 response on SSEPs with median N stim OR no pupils (cortical potentials N19-P22)
>72 hours: no corneals, no eye movements

EEG-2 uV 10 cm apart x 30 min

44
Q

decorticate vs decerebrate

A

decort: above red nuc, disinhibits red nucleus, and activates rubrospinal path

decerebrate: at red nuc/superior colliculi, above vestibular nuc

below vestibular nuc: flaccid response, no extensor posturing

45
Q

malignant hyperthermia

A

AD defect Ry R-release Ca into SR when given halogenated anesthetics-depolarizing (succinylcholine)
-central core disease - congenital myopathy - increased risk malignant hyperthermia

-dantrolene only for malignant hyperthermia

[NMS - Tx-bromocriptine, dantrolene]

46
Q

ICH

A

30 day outcome - die at 30 days if 5 pts; no die at 30 days if 0 points
-GCS -
-ICH volume - >30 cc=1 pt
-intraventricular hemorrhage
-infratentorial
-age: >80=1 pt

47
Q

dexmedetomidine

A

alpha2 agonist (precedex)
-no resp depression, can arouse

Cheng-Ching (17 decks)

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