Vascular/NCC Flashcards
Anterior choroidal -
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)
carotid anatomy
Atherosclerosis =no increase risk carotid dissection
-C4: CC to ECA, ICA
CARASIL
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
CADASIL
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
(other genetic stroke disorders)
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
MELAS
mitochondrial encephalopathy with lactic acidosis and stroke like episodes
-transfer RNA gene (mt)
Familial moyamoya
-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)
cerebrovascular fibromuscular dysplasia
alternating beading of intracranial vessels due to skip areas of stenosis
ACA
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
ABCD2 score
Age 60, DM, BP>140/90
Duration: 1 pt if 10-59 min, 2 pts if >60 min
HLD not included
brainstem localization/respiratory patterns
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
AICA
lateral pons, inner ear (labyrinthine A branch), middle cerebellar peduncle-anterior inferior cerebellum
ipsilateral hearing loss vs PICA
CVST
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
PICA
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
vert dissection
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
amarousis fugax
most common - retinal A from ophthalmic A from ICA
artery of Percheron
Varient where supplies medial thalamus bilaterally
-off P1 of PCA
MCA
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
Thalamus supply
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
cerebellum
superior cerebellum: leve midbrain: SCA + superior colliculus/pretectum (dorsal, quadrigeminal plate)
inferior cerebellum: level medulla: PICA
lacunes
lipohyalinosis -occlusion small penetrating branches (not microhemorrhages)
Dejerine-rossey
- post thalamus stroke pain syndrome - hypersensitivity to pain
medial medullary
occlusion vert
-contralateral A/L and spares face
-contralateral loss position and vibration
-ipsilateral tongue weak
aneurysmal rupture
Posterior circulation higher risk rupture
-Marfans, Ehlers Danlos
-ACA most common
PCA infarct
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
TPA contraindications
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
ASPECTS
-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
carotid stenosis CEA/CAS
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
RCVS
-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
primary CNS angiitis
-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
vascular malformations
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
blood on MRI
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
cerebral edema
-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
herniation syndromes
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):
ICP crisis
-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
states of consciousness
unresponsiveness wakefulness - return of sleep-wake cycles in previous comatose pt - vegetative state
coma - reflex responses only
sodium nitroprusside
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
epidural vs SDH
SDH: does not respect suture lines - banana shape
epidural: respects suture; lemon shaped (biconvex)
-MMA-foramen spinosum
SAH
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
fat embolization
axillary, thorax, conjunctiva petechial hemorrhage
-petechial hemorrhages in brain after bone fractures
-CT usually normal
vs. coup/contrecoup - CTH with blood
GBS
-ABG not indicator of intubation b/c drop later in resp failure
central pontine myolinolysis
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
AC reversal
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
cardiac arrest
**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
decorticate vs decerebrate
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
malignant hyperthermia
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]
ICH
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
dexmedetomidine
alpha2 agonist (precedex)
-no resp depression, can arouse
