Week 8 Flashcards
1
Q
Give me the exact definition of stroke
A
Blocked or ruptured blood vessel in the brain causing a failure of neuronal function, leading to some deficit in brain function
2
Q
4 causes of stroke
A
Blockage with thrombus or coke
Disease of vessel walk
Disturbance of normal properties of blood
Rupture of vessel wall (haemorrhage)
3
Q
What are the two types of strokes?
A
Infarction
Haemorrhage
4
Q
What’s haemorrhage vs ischaemic stroke?
A
Haemorrhage/blood leaks into brain tissue
Clot blocks blood supply to an area of the brian
5
Q
3 diseases that can block blood vessels?
A
Small artery diease
Large artery disease
Clot coming from the heart
6
Q
Areas of bifurcation eg carotid vessels tend to be areas of what , and therefore what
A
Shear force, lots of turbulence, so atheroma’s develop
7
Q
What could happen after an atheroma develops
A
Clot forms on top and then the clot breaks eg and can go up internal carotid
Eh area of plaque around bifurcation
8
Q
An example of large vessel disease causing stroke?
A
Carotid diseas
9
Q
Cardioembolic stroke is due to what
A
A large vessel occlusion.
10
Q
Commonest cause being cardioembolic stroke
A
Atrial fibrillation eg clot forms in atrial appendage, clot to cerebral vessels
11
Q
Penumbra is what
A
Reversible injured brain tissue around ischemic core
Just not getting enough oxygen and glucose to function, that’s all
12
Q
How soon after penumbra forms does the tissue die
A
24-36 hours after the stroke
13
Q
Commonest cause of small vessel disease?
A
Lacunar stroke
14
Q
Which vessel blocked in lacunar stroke?
A
Well.. it’s the large vessels, they have little tiny branches going off deep into the brain tissue, and it’s these that are blocked. Just affects small part of brain therefore
15
Q
What are lacunar strokes associated with?
A
Hypertension
Thickening of the wall of tiny vessels, making the lumen smaller
16
Q
Rarer cause of large vessel stroke is carotid dissection, explain
A
Where the lining of the blood vessel tears and a thrombus forms
Could be due to trauma, or be idiopathic
17
Q
What does carotid dissection look like on an angiogram?
A
Lumen kinda tapers, just kinda looks thin
18
Q
Aortic arch plaque could lead to what
A
Brain infarctkon
19
Q
Valve disease could lead to what
A
Brain imfarction
20
Q
Left ventricle thrombi
A
Stroke
21
Q
Intracranial stenosis could lead to what
A
Stroke
22
Q
3 big risk factors for stroke?
A
Hypertension
Smoking
Waist to hip
23
Q
Is diet a risk for stroke
A
Yah
24
Q
Is physical activity a risk for stroke
A
Yah
25
Is: alcohol, stress/depression, diabetes, cardiac causes, risk for stroke?
Yah
26
Smoking is a risk factor for stroke
Yah
27
Ratio of ApoB to ApoA is responsible for risk for stroke?
Yah
28
Rough percentage of large vessel cause of stroke
About 20%
29
How many strokes are cryptogenic/no cause found?
30%
30
Haemorrhage mostly happens within big or small vessels
Small
31
Haemorrhage is often due to what (2)
Hypertension mostly!!!
Or amyloid
But also excess alcohol? Hypo cholesterolaemia, haemorrhagic transformation
32
What’s amyloid when referring to blood vessels, when referring to stroke
Where the vessels become glass-like, fracture easily, haemorrhage occurs easily
33
Is high cholesterol is associated with haemorrhage of blood vessels
No bro
It’s actually LOW cholesterol that’s associated with haemorrhage
34
Primary haemorrhage vs what in strokes
Occurring in tissue already damaged by an ischaemic event
35
Penumbra is getting blood supply (to not die)
Yes from collateral flow
36
Why is it important to know if penumbra?
Treatment is either: protect penumbra, or restore blood supply
37
Transient ischemic attack?
Transient ischaemia,
Ischaemia results from the failure of cerebral blood flow to part of the brain
38
Ischaemia results in varying degrees of what (2)
Hypoxia
Hypoglycaemia
39
In Ischaemia, there are two parts:
Ischemic core
Ischemic penumbra
40
Lack of oxygen: cells can die, or…
Use anaerobic metabolism for a while
41
Hypoxia = penumbra
Anoxia = ?
Infarction, leading to necrosis
42
Is stoke just penumbra or can you have ahayqwwb
A completed strike is infarction from anoxia
43
Once completed stroke, where does further damage come from?
Oedema, damage from swelling, water bursts from cells
44
Oedema does what to the brain
Kinda like squashes it
45
Surgical procedures if oedema in the brain?
Ask the surgeons to consider removing a flap of skull to allow brain to swell out the way- prevents mortality (but doesn’t restore function obvs)
46
When cells in penumbra switch to anaerobic metabolism, what’s released
Lactic acid
47
What could release of lactic acid in the brain do
Potential to destroy cells by disrupting the normal acid base balance
48
What happens when ATP reliant ion transport pumps fail
Membrane becomes depolarises
Influx of calcium and efflux potassium
So intracellular calcium high= excitatory amino acid glutamate = stimulates something = even more calcium
Excess calcium entry = Ischaemic cascade, excitotoxicity
49
After excititoxicity, (ischaemic cascade) what happens? (3)
Cell membrane broken down by phospholipases
More permeable so More Ions and harmful chemicals enter cell
Mitochondria break down, realising apoptotic factors into cell
Cells undergo apoptosis
50
What happens after ischaemic cascade, and then apoptosis, and therefore necrosis, =
It releases glutamate and toxins,
Toxins poison nearby neurons and glutamate overexcites them
51
Why does release of toxins after necrosis, resulting in loss of vascular structural integrity due to neurons being poisoned, lead to cerebral oedema?
Due to breakdown of protective blood brain barrier
So secondary progression of bleeding
52
How quickly does the excititoxicity occur?
Within minutes
53
Oxidative stress occurs how quickly?
Just over an hour ish
54
Post ischaemic inflammation and oedema following necrosis in a stroke, occurs over what time frame
Over two weeks
55
Disruption of blood supply can be caused by: (4)
Thrombus formation or embolus eg with atrial fibrillation
Atherosclerosis
Shock
Vasculitis
56
TIA is basically what
Neurological dysfunction secondary to ischaemia without infarction
57
What’s a crescendo TIA?
Two or more TIAs within a week
58
Presentation of a stroke: (sudden) (4)
Weakness of limbs
Fascial weakness
Speech disturbance
Visual or sensory loss
FAST
Face, arm, speech, time
59
Is the combined contraceptive pill a risk factor for stroke?
Yes
60
Angina, myo infarct and peripheral vascular disease is a risk factor for stroke
Yah
61
What’s the ROSIER tool for recognition of stroke in the emergency room
Based on clinical features and duration
62
For ROSIER tool, stroke is likely if the patient scores anything above what
0
63
NICe management of stroke: (4)
Admit patient to a specialist stroke centre
Exclude hypoglycaemia
Immediate CT brain scan to exclude primary intracerebral haemorrhage
Aspirin 300mg stat (after the CT) and continued for 2 weeks
64
What can be used after the CT brain scan has excluded intracranial haemorrhage
Thrombolysis with alteplase
65
What’s alteplase
A tissue plasminogen activator, that rapidly breaks down clots
66
Treatment of hypertension is what acronym
ABCD
67
Explain treatment of hypertension acronym
ABCD
Angiotensin receptor blocker/ Angiotensin converting enzyme - end in sartan
Beta blockers - end in lol
Calcium channel blockers - end in dipine
Diuretics - end in pril
68
When might a thrombectomy be offered?
If an occlusion is confirmed on imaging, depending on time and location
Not used after 24 hrs since onset of symptoms
69
Why should blood pressure not be lowered during a stroke
Cuz this risks reducing perfusion to the brajb
70
Management of TIA
Start aspirin 300mg daily
And secondary prevention measures for cardiovascular disease
71
What specialist imaging for strokes?
Diffusion-weighted MRI/ CT is alternative
Carotid ultrasound for carotid stenosis
72
If carotid stenosis is suspected
Do carotid stenting
73
Endarterectomy is for what
Removing plaques
74
(4) secondary prevention of stroke? L
1) clopidrogrel 75mg once daily
75
Ace inhibitors do what
Well remember that angiotensin 2 constricts blood vessejs
76
What do we see in basilar artery strokes?
People can be very very sleepy, and find it difficult to keep awake
77
Effects post basilar artery stroke?
Heart beat and breathing affected
78
Coordination maintained by what part of the brain?
Cerebellum
79
What does the carotid system supply?
Most of the hemispheres, and cortical deep white matter
80
The vertebro-basilar system supplies the what
Brain stem, cerebellum and occipital loves
81
What’s the sensory sign of stroke?
Loss of feeling
82
What’s gaze palsy a sign of?
Stoke
83
Hemianopia is a sign of what
Stroke
84
In stroke most symptoms are what
Loss of something
85
Sudden loss of feeling with stroke is different to migraine how?
Migraine is mainly just pins and needles
86
What happens if the anterior cerebral artery is occluded? (3)
Paralysis of contra lateral foot and leg
Sensory loss over contra-lateral toes, foot and leg
Impairment of gait and stance
87
Why could a small lacunae stroke have a big affect?
Major deficit of all fibres tightly packed together like flowers in a vase
88
Posterior circulation of the brain is with with artery
Basilar
89
Nausea, vomiting, are common in a posterior circulation stroke
Yah
90
Pons is what
Motor
91
Carotid bruits is associated with stroke
True
92
Angina is associated with not only heart attacks, but what:
Stroke
93
Previous TIA is a risk factor for what
Stroke
94
Aortic aneurysm is a risk factor what what
Stroke
95
Cocaine and alcohol abuse is a risk factor for what vascular thingy
Stroje
96
Lots of haemorrhages are associated with what
Poor blood pressure r control
97
Stroke incidence increases dramatically when blood pressure rises above what
160
98
Hypertension is particularly associated with what type of stroke
Small vessel/ lacunar stroke
99
Does diabetes increase incidence of stroke?
Yes
3 fold
100
Smokers have a two fold increased risk of ischaemic stroke
True
101
A high LDL can result in excessive amounts of what within the arterial wall
Cholesterol
102
Is high LDL a risk of actor for stroke?
Not in itself, but in conjunction with hypertension, cigarette smoking, bad
103
Small amounts of alcohol decrease risk of stroke
True
104
Heavy drinking increases risk of stroke
True
105
Obesity is a risk factor not only for vascular disease, but also
Stroke
106
AF is risk factor for stroke
Yah
107
Guess three purposes of treatment of stroke
Protect damaged brain before ischaemia becomes cell death
Get rid of the clot
Prevent the clot happening in the first place
108
Benefit of thrombolysis is time dependant?
Yes
Within 90 minutes please
109
At what time would harm increase over benefit for thrombolysis? (We don’t actually treat)
Past 4 and a half hours
110
Why not thrombolyse a patient if too longer after eg after 4 1/2 hours?
High risk that they’d bleed into tissue
111
Do you get a headache with stroke?
Not generally
112
Get patients, admitted with ischaemic stroke, thrombolysised within what time frame?
30 mins of arrival
113
What imaging in emergency department for stroke?
CT scan
114
Why would perfusion CT be helpful if stroke in emergency department?
See if any tissue is viable
115
Why are MRIs good in stroke treatment?
Can see good levels of infarcts
116
What’s alteplase
Thrombolytic agent
117
Glasgow Coma Scale asses what
Impairment of conscious level in response to defined stimuli
118
Highest possible score in Glasgow coma scale?
15
= fully conscious
119
Lowest possible score in the Glasgow Coma Scale?
3
(Coma or dead)
120
What score is dead on Glasgow coma scale?
3
121
What does the Glasgow coma scale rate on?
Motor responsiveness, verbal performance, and eye opening
122
Could you literally put the thrombolysis in the artery eg basilar artery which has high mortality
Yah
Intra-arterial procedure
Put line in through groin, up into the basilar artery
123
Where’s the sinotubular junction?
Defining point for where the aortic ‘root’ finishes
124
Where does the ‘ascending aorta’ end?
At the brachiocephalic artery
125
The aortic arch is what
The bit with the three arteries: starts at Brachiocephalic, the left carotid, and ends just after the left subclavian
126
How many sinuses in the sinus of valsalva?
3
127
Where do the coronary arteries come from?
Sinus if valsalva of aorta
128
How many coronary sinuses are there out of the three sinuses of valsalva of the aorta?
2
There is one non-coronary artery
129
What’s the junction between the sinus of valsalva and the ascending aorta called?
Sinotubular junction
130
We measure the aortic root at three levels. What are they?
Sinotubular junction diameter
Sinus of valsalva diameter
Annulus diameter
131
What’s the sinus of valsalva?
Abnormal dilatation of the aortic root
132
What’s the annulus?
Where the aortic valve leaflets hinge/ gets attached to the myocardium
133
The three leaflets/cusps of the aortic valance corresponds to a different sinus of valsalva
Yes
Eg right coronary cusp > right sinus of valsalva (and for left)
And. Eg
Non coronary cusp to non coronary sinus
134
Basic histology of aorta:
Tunica intima
Tunica media
Tunica adventitia
135
What is the tunica Adventitia?
Thin connective tissue layer
136
What does the collagen in the tunica Adventitia do?
Prevents elastic arteries from stretching beyond their physiological limits during systole
137
5 big risk factors for atherosclerosis?
Hypertension
Hypercholesteroleamia
Smoking
Diabetes
Genetics
138
Atherosclerosis timeline?
Takes decades
139
4 things that atherosclerosis can lead to
Myo infarct
Stroke
Peripheral vascular disease
Aneurysm
140
What’s an aneurysm
Localised enlargement of an artery
Caused by weakening of a vessel walk
141
What are the 3 types of anywrysms ?
True
False
Diseecting
142
Two sub types of true aneurysm?
Saccular (1 side)
Fusiform (both sides)
143
False aneurysm
Rupture of walk of aorta- contained by adventitia or surrounding soft tissue
144
What type of aneurysm could occur in inflammation eg endocarditis?
False
145
Marfans is collagen abnormality, lead to what aneurysm?
Trie
146
What infections could lead to an aneurysm?
Mycotic/ syphillis
147
Bicuspid aortic valve could lead to what
True aneurysm
148
Why has a pseudo aneurysm have a high chance of rupture
Cuz walls are thinner
149
5 signs and symptoms of aortic aneurysms
Breathlessness
Pulsating mass
Back pain
Dysphagia and hoarseness swallowing problems
Symptoms of dissection (sharp chest pain radiating to back)
150
Why dysphagia and hoarseness in thoracic aneurysms?
Cuz compressing
151
Two tests of choice for investigating thoracic aneurysms
Ct angiogram aorta to diagnose
MRI aorta to diagnose and follow up
152
Why MRI aorta follow up test for aneurysms?
Because….. no radiation
153
What’s aortic dissection?
Tear in the inner wall of the aorta
Blood forces the walls apart
154
Are aortic dissections usually chronic or acute?
Acute usually
But also could be chronic
155
5 risk factors for dissection
Hypertension
Atherosclerosis
Marfan’s syndrome
Bicuspid aortic valve
Trauma
156
How could dissection = myo infarct
Because could involve coronary arteries
157
How would dissection = stroke
If carotid arteiee
158
What is cardiac tamponade??????????????
Pressure on heart when blood or fluid builds up in space between heart muscle and pericardium
159
Aortic regurgitation could be caused by dilation of what part of the aorta
Ascending
160
Type A (Stanford) is any aortic dissection that what
Involves ascending aorta, regardless of the site of origin
161
Stanford , what’s type B dissection.
Doesn’t involve ascending aorta
162
DeBakey classification of aortic dissection… type 3 is not involving ascending aorta…
What’s type 1 vs type 2?
Type 1= originates in ascending aorta, and is more
Type 2= ONLY ascending aorta
163
How might an aortic dissection. Present?
Collapse maybe due to tamponade
Sharp pain, radiating to the back
Stroke if carotid arteries are involved
164
Examination of carotid arteries
Reduced or absent peripheral pulses
Hypertension/hypotension
BP mismatch
Diastolic murmur -aortic regurgitation
Pulmonary oedema
165
What scan confirms diagnosis of aortic dissection?
CT angiogram aorta
166
ECG of aortic dissection might show what
ST elevation
Ischaemia indicating coronary involvement
167
What might CXR show in aortic dissection?
Widened mediastinum
168
What is the test of choice for diagnosing aortic dissection?
CT angiogram aorta
169
How high is the mortality for aortic dissection?
About 50% pre hospital
170
What does treatment of aortic dissection depend on?
Whether the dissection is type A or type B
171
Both Type A and Type B aortic dissection involve blood pressure control with beta blockers, calcium channel blockers, IV nitrate etc.
But additional surgery is different how?
Type A = emergency surgery
Type b = per ur Amelia (Endo vascular) intervention
172
Would you ever use IV nitrate for treatment of aortic dissection?
Yah
173
Syphyllis predisposes patients to what
Thoracic aortic disease such as stenosis, aneurysm, thrombosis
174
What’s takayusu arteritis
Granulomatous vasculitis
Can result in stenosis, aneurysm
Also thrombosis
Just weird stuff basically
175
Because takayusu arteritis is basically inflammation, what does it involve treatment-wise
Steroids and immunosuppressive therapy
176
What’s syphilis
As STD (that has cardiac manifestations)
177
What will treatment of antibiotics prevent in syphilis
Late stage complications
178
2 examples of cardiac manifestations of syphilis??????????
Syphilitic aortitis - aneurysm
Aortic regurgitation
179
3 examples of congenital aortic aneurysm?????????????????????????
Bicuspid aortic valve
Coarctation
Marfans syndrome
180
Why in bicuspid aortic valve,(congenital) are you prone to aneurysm and dissection
Reduced tensile strength bro
You can develop stenosis or regurgitation
MONITOR THE SITUATION BRO
181
Coarctation is aortic narrowing WHERE
Close to where the the ductus arteriosus (pre birth) inserts/ where the ligamentum arteriosum is now
182
What was the ductus arteriosus
It went between the primary artery and the aorta
183
There are three types of coarctation, what are they and which one is worst
Pre-ductal
Ductal
Post-ductal
Pre ductal is worse OBVS YOU NINCOMPOOP
184
Why cold legs in coarctation?
Reduced blood supply and reduced blood pressure in the legs
Therefore also poor leg pulses
185
What’s the radial radial delay thingy with coarctation
Well bro
If before left subclavian artery = radial-radial delay, and RIGHT radial-femoral delay
But if after left subclavian artery = no radial-radial delay, and a right and left radio-femoral delay
186
For coarctation, difference in radial radial thingy for before and after left subclavian artery????
If before left subclavian artery = radial-radial delay, and RIGHT radial-femoral delay
But if after left subclavian artery = no radial-radial delay, and a right and left radio-femoral delay
187
Presentation of coarctation??? Severe vs less severe please
If severe, in infancy, = heart failure and failure to thrive
If less severe, = can present later in life with hypertension
188
Diagnosis of coarctation with what imaging
CT
MRI
189
What could you see on X-ray for coarctation?
Notching of the ribs
190
What’s ‘notching of the ribs’
Image looks like that due to enlargement of intercostal arteries
191
Marfans is caused by a mutation in which gene
Fibrillin 1
192
What is Marfans
A connective tissues disease
Multi-system
193
2 cardiac manifestations of Marfans???????
Aortic/mitral valve prolapse leading to regurgitation
Aortic aneurysm and dissection
194
Connection between Marfans pregnancy and cardiac stuff
Pregnant marfaners = risk for aortic thoracic aneurysm and dissection is increased
195
The most commonly affected area for aneurysm?
Ascending aorta
196
The first time a Patient May become aware of an aneurysm is when
When it ruptures
Causing life threatening bleeding into mediastinum cavity
Very high mortality
197
When do false aneurysms typically occur
After trauma, such as a road traffic accident or after surgery
198
Which gender more commonly affected for aneurysms
Male
199
Is Marfans a risk factor for aneurysms
Yah
200
Why symptoms in aneurysms?
Due to taking up space in mediastibum
201
Presentation symptom of aneurysm relating to chest
Pain
202
Presentation symptom of aneurysm relating to trachea or left bronchus compression
Cough sob and Stridor
203
Presentation symptom of aneurysm relating to phrenic nerve compression
Hiccups
204
Presentation symptom of aneurysm relating to compression of oesophagus
Dysphagia (can’t swallow)
205
Presentation symptom of aneurysm relating to compression of recurrent laryngeal nerve
Hoarse voice
206
2 main investigations for aneurysm diagnosis?
Echocardiogram
CT or MRI angiogram
207
Management for aortic aneurysm
Stop smoking
Healthy diet and exercise
Optimising management of hypertension, diabetes. And hyperlipidaemia
208
3 modifying management options of aneurysms
Surveillance with regular imaging
TEVAR: thoracic endovascular aortic repair (with catheter inserted via femoral artery, for stent graft)
Open surgery: to remove section of the aorta with the defect in the wall and replace it with a synthetic graft
209
3 complications of aortic aneurysm
Aortic dissection
Ruptured aneurysm
Aortic regurgitation
210
If a ruptured aneurysm bleeds into the oesophagus, what happens
Haematesis (vomit blood)
211
Ruptured aortic aneurysm bleeding into airways could lead to what
Haemoptysis
212
Ruptured aneurysm which bleeding into the pericardial cavity = what
Cardiac tamponade (compression the the heart)
213
Ruptured thoracic aneurysm often leads to what (as well as death) (3)
Severe chest pain or back pain
Haemodynamic instability (hypertension and tachycardia)
Collapse therefore
214
Emergency open surgery is required for ruptured aortic aneurysm, explain
Replacement of affected section of the aorta with a synthetic graft
215
What’s cardiac tamponade
Where the pericardial effusion is large enough to raise the intrapericardial pressure, squeeze heart
216
Cardiac tamponade affects diastole and systole how
Reduced heart filling during diastole
Decreasing cardiac output during systole
217
What’s pericarditis
Inflammation of the pericardium
218
Cause of pericarditis
Idiopathic
Or
Viral
219
What’s pericarditis treated with
NSAIDS
220
How does pericarditis present
With chest pain and fever
221
Could the Epstein Barr virus (like HIV, TB) cause pericarditis?
Yah
222
Autoimmune conditions such as lupus and arthritis can causes pericarditis
Yah
223
Open heart surgery and trauma could cause pericarditis
Yah
