10: Cerebrovascular disease Flashcards Preview

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Flashcards in 10: Cerebrovascular disease Deck (24):
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Transient Ischemic Attacks

Often resolve before the pt presents to a clinician
Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction

1

ACA- areas supply

-medial surface of the frontal lobe and parietal lobes
-anterior 4-5th of the corpus callosum
-anterior portions of the basal ganglia and internal capsule
-olfactory bulb and tract

2

ACA stroke- sx

Occlusion beyond anterior communicating artery (A2 segment) can produce sx
Contralateral motor and sensory loss mainly in the lower limbs
Gait apraxia (disorder of planning and initiating a skilled movement)
Abulia (delay in verbal and motor response)
Anosmia
Incontinence
Frontal cortical release reflexes: contralateral grasp reflex, sucking reflex
Gegenhalten (paratonic rigidity- toy snake)

3

MCA- areas supply

-Lateral aspects of frontal, temporal, parietal lobes
-Corona radiata
-Globus pallidus, caudate, putamen

4

MCA stroke- sx

Contralateral motor and sensory loss (esp upper limb and face)
Contralateral homonymous hemianopia
Eye deviation toward the side of lesion
involving Dominant hemisphere: global aphasia (Broca's: superior branch, Wernicke's: inferior branch)
involving non-Dominant hemisphere: anosognosia (neglect of contralateral limbs, dressing difficulty)

5

PCA- areas supply

-Occipital lobe
-Inferomedial temporal lobe
-Large portion of the thalamus
-Upper brainstem
-Midbrain

6

PCA stroke (P1: thalamus, sub-thalamus, midbrain)-sx

1: thalamic syndrome: contralateral hemisensory loss with severe burning sensation + chorea
2: Weber's syndrome*: ipsilateral CNIII paralysis + contralateral hemiplegia
3: Claude's syndrome*: ipsilateral CNIII palsy + contralateral ataxia

7

PCA stroke (P2)- sx

-Contralateral homonymous hemianopia with macular sparing
-Dyslexia (difficulty in reading), Dyscalculia, Visual agnosia (inability to recognize visual objects)
-Transient global amnesia
-Peduncular hallucinosis (bright color may be seen)

8

Anterior spinal artery occlusion- sx

Medial medullary syndrome or Dejerine syndrome
-Ipsilateral: CNXII- paralysis and atrophy of half tongue
-Contralateral: motor and sensory loss over half of the body

9

Lateral Medullary syndrome

occlusion of Posterior inferior cerebellar (PICA) or Medullary arteries
-Ipsilateral
1: numbness over face, dysphagia, hoarseness of voice, nystagmus, vertigo, nausea, vomiting (CN V, IX, X)
2: Vertigo, incoordination, dysarthria (cerebellar damage)
3: numbness of arm, body, leg (Gracile and Cuneate nucleus)
4: loss of taste sense (Nucleus/Tract solitarius)
-Contralateral: pain + thermal sensation deficit (spinothalamic tract)

10

Internal carotid artery stroke- sx

Features of MCA occlusion
Contralateral hemiparesis + hemisensory loss
Amaurosis Fugax (repeated transient monocular visual loss): warning sign of the lesion
Unilateral frontal headache
High pitch carotid bruit at the angle of the jaw

11

Complete Basilar artery occlusion- sx

Supplies pons and cerebellum
-Quadriplegia
-Multiple CN involvement (V, VI, VII, VIII)
-Cerebellar dysfunction: vertigo, dysarthria, incoordination

12

Small vessel (Lacunar) stroke- sx

1: Pure motor hemiperesis- posterior lobe of internal capsule (arm, leg, face**)
2: Pure sensory stroke- ventral posterolateral thalamus (VPL)
3: Pure motor hemiperesis with motor aphasia- genu and anterior limb of internal capsule + corona radiata
4: Ataxic hemiperesis- base of pons

13

Imaging

CT: Hemorrhage
MRI: Ischemia (within 45 mins of the onset)
Angiography: 'gold standard' for stroke*

14

Acute interventions in Stroke

*Thrombolysis using recombinant tissue plasminogen activator (r-TPA) for ischemic stroke: 0.9mg/kg (10% bolus and rest 90% in infusion 60mins)- (should start within 3hrs of onset)
Aspirin (within 48hrs-> reduced mortality)
Heparin (within 14days: risk of hemorrhagic stroke)
-stroke due to cerebral vasculitis: Steroids
-Mechanical thrombolysis: Concentric retriever (grasping device), Penumbra device (aspiration to remove clots)

15

Stroke- complication

Recurrence of stroke
Cerebral edema**-> high ICP + cerebral herniation
Hemorrhagic transformation**-> acute hydrocephalus or focal neurological deterioration
Seizures**

16

High ICP- tx

Head elevation
Mannitol and Frusemide
Hyperventilation

17

Control of risk factors of stroke

Sinus rhythm: antiplatelets (aspirin, clopidogrel)
A-fib: anticoagulants (warfarin)
>70% carotid artery stenosis: carotid end-arterectomy

18

Drugs causing intracranial hemorrhage

Cocaine, Amphetamine

19

Pontine hemorrhage- sx

Deep coma
Quadriperesis
Pinpoint pupils
Neck rigidity

20

Intraparenchymal bleeding- tx

Gradual decrease in BP: non vasodilating meds (Beta blocker, Ca channel blocker)
Only if ICP is very high**: Mannitol
Cerebellar hematoma >3cm: surgery

21

Common location of Berry's aneurysm

Terminal ICA
Bifurcation of MCA
Top of basilar artery

22

Delayed neurological complications in SAH

Re-rupture
Hydrocephalus
Vasospasm (4-14days after)
Hyponatremia (first 14days due to SIADH)

23

SAH- tx

Nimodipine** (reduce vasospasm)
Surgical ablation
Surgical clipping or coiling