3-Ischemia

Question 1

Define ischemic stroke

Answer 1

acute infarction ischemic injury to brain –> persistent focal neuro defect at 24 hrs

Question 2

Define TIA

Answer 2

ischemic neurological (focal brain or retinal ischemic) deficits completely resolve within 1 hr

Question 3

Large vessel ischemic stroke deficits correspond with

Answer 3

arterial region supplied by blocked artery

Question 4

middle cerebral artery stroke causes what?

Answer 4

hemiparesis
hemisensory loss
hemianopsia

ALL CONTRALATERAL TO SIDE OF OCCLUSION

aphasia (dominant)
neglect (non-dominant)

Question 5

small vessel strokes have what kind of deficits?

mechanism of why?

Answer 5

isolated on one side of body such as isolated motor or sensory loss

occlusion of small penetrating arteries that penetrate brain –> lacunar infarcts

Question 6

ruptured intracranial aneurysm

most common nontrauamatic cause of ___

Answer 6

subarachnoid hemorrhage

Question 7

ruptured intracranial aneurysm

presents with

Answer 7

1 o Cataclysmic onset, like a fire cracker

2 o Sudden onset neurological deficits

3 o Headache – “worst headache of my life”

4 o Nausea and vomiting

5 o Depressed level of consciousness

Question 8

intracerebral (intraparenchymal) hemorrhage
often due to?

commonly occur where?

progresses over how long

Answer 8

hypertension and age

basal ganglia
thalamus
pons
cerebellum

also can have lobar hemorrhage near cortex
progress over few hrs

Question 9

intracerebral (intraparenchymal) hemorrhage

presents with

Answer 9

1) begin with mild HA
2) some deficit/nausea
3) decr consciousness –> coma
4) hemiparesis –> hemiplegia

Question 10

subdural hemorrhage
usu due to?

bleed btwn what 2 layers

typically arterial or venous bleed

appearance n imaging

more common at what age?

Answer 10

due to trauma but not always

btwn dura and arachnoid

venous from tearing of bridging veins = low pressure, slow

crescent shape

elderly due to atrophy

Question 11

subdural hemorrhage

presents with

Answer 11

1) HA, n, v
2) decr eye, verbal, motor responses
3) confusion, LOC, localized weakness
4) speech/vision changes
5) seizures

Question 12

Epidural hemorrhage
usu due to?

bleed btwn what 2 layers

typically arterial or venous

appearance on imaging

Answer 12

trauma

btwn dura and skull

arterial (fractures –> tear middle meningeal) = high pressure

lens shaped

Question 13

Epidural hemorrhage

presents with

Answer 13

1) brief decr consciousness or LOC –> coma
2) then lucid interval –> LOC d/t incr ICP
3) N/V/HA
4) seizures

Question 14

Non-atherosclerotic causes of stroke in young patients
Vasculopathy mechanism
types

Answer 14

Non-inflamm, non-athero hyperplasia of arteries –> weakening

1) fibromuscular dysplasia
2) moyamoya
3) arterial dissection

Question 15

describe fibromuscular dysplasia
mechanism
assoc with

Answer 15

hypertrophy of arterial media –> segmental occlusion

assoc with saccular aneurysms and arterial dissection

Question 16

describe moyamoya
mechanism
assoc with

Answer 16

hyperplasia of arterial intima, usu proximal middle cerebral artery and distal internal carotid artery

assoc with saccular aneurysms and arterial dissection

Question 17

describe arterial dissection
mechanism
assoc with

blood dissect btwn what 2 layers

Answer 17

tear in endothelial lining of artery

assoc with CVD (FMD, marfans)

btwn endothelium and adventitia

Question 18

Non-atherosclerotic causes of stroke in young patients

hematological = hypercoaglulable states

Answer 18

1) deficiency in prot C, S, antithrombin
2) factor V leiden and prothrombin gene 20210 (decr anticoag products)
3) malignancies
4) sickle cell
5) hyperviscosity (incr prot, HCT, thrombocytopenia)
6) OCT esp smokers
7) antiphospholipid antibodies

Question 19

Non-atherosclerotic causes of stroke in young patients

inflamm

Answer 19

vasculitis secondary to CNS infections

Question 20

Non-atherosclerotic causes of stroke in young patients

migraines

Answer 20

via vasospasm or incr platelet aggreg

Question 21

Non-atherosclerotic causes of stroke in young patients

venous infarction

Answer 21

dehydration –> hypercoag state

Question 22

Non-atherosclerotic causes of stroke in young patients

vasospasm

Answer 22

1) sympathomimetic drugs
2) severe HTN
3) vessel irritation

Question 23

most strokes due to

Answer 23

atherosclerotic or thrombotic/embolic occlusion of vessels

Question 24

major risk factors for atheroscleortic strokes

Answer 24

1) age
2) HTN
3) lipid disorders
4) incr homocysteine
5) smoking
6) obesity
7) DM
8) physical inactivity
9) alcohol abuse
10) cocaine
11) congenital hearts 12) PFO/ASD/VSD
12) CHF, valvular, A-fib, myxoma

Question 25

how to prevent thrombus formation as way to decr stroke risk or after suffer thrombus ischemic stroke what is used primarily for small vessel infarcts and also large vessel occlusion or embolization

Answer 25

antiplatelet agents 1) aspirin 2) ticlodipine/clopidogrel/prasugrel 3) ASA/dipyridamole 4) ASA/clopidogrel anticoag used

Question 26

what is used for patients with afib or mech heart valve or short term thrombus in artery/dissection to decr risk of stroke

Answer 26

warfarin

Question 27

procedure to reduce risk in patients with stenosis

Answer 27

carotid endarectomy

Question 28

what happens in ED for ischemic strokes?

Answer 28

TPA maintain fluids maximize cardiac output maintain BP treat hypoglycemia

Question 29

what patients will benefit from tpa and which won't

Answer 29

benefit = thrombus/embolus not benefit = vasospastic, vasculopathic, inflamm

Question 30

basic principles of emergency treatment of ischemic stroke or hemorrhage

Answer 30

1) TPA 2) keep fluids up 3) maximize cardiac ouptut 4) resist temptation to lower BP

Question 31

how to treat diff factors of stroke • hypertension - • hyperlipidemia – • high homocysteine levels – * Smoking – * Obesity – * Physical inactivity – * Alcohol abuse

Answer 31

1) HTN = many drugs 2) hyperlipidemia = statins 3) high homocysteine = folate B6, B12 4) smoking = stop 5) obesity = dietary/lifestyle 6) physical inactivity = lifestyle mod 7) alcohol abuse = stop

Question 32

``` how to treat • Lumen stenosis – • Cardiac issues – • Atrial septal defects - • Atrial Myxomas – cardiac tumors can increase risk of embolus – ```

Answer 32

* Lumen stenosis – can be repaired surgically or via IV catheter * Cardiac issues – A-fib, CHF, valve disorders increase risk of embolus - treat with warfarin * Atrial septal defects – can be repaired or treated medically to prevent embolus * Atrial Myxomas – cardiac tumors can increase risk of embolus – remove

Question 33

do you take asa after a stroke

Answer 33

no because can't tell if ischemic or hemorrhagic stroke

Question 34

deep vs lobar intracerebral hemorrhage | locations

Answer 34

deep = basal ganglia, thalamus, pons, cerebellar lobar = frontal > parietal > occipital > temporal

Question 35

deep vs lobar intracerebral hemorrhage | major causes

Answer 35

``` deep = HTN, age lobar = amyloid angiopathy, age, dementia, coagulopathy (HTN 1/3) ```

Question 36

deep vs lobar intracerebral hemorrhage | outcomes

Answer 36

``` deep = poor lobar = well tolerated ```

Question 37

pontine intracerebral hemorrhage assoc with

Answer 37

locked in syndrome cortex is preserved so cognition but relay in pons destroyed —> quadriplegic and no facial but still have vertical eye reflex

Question 38

most common cause of subarachnoid hemorrrhage

Answer 38

trauma

Question 39

describe brain aneurysm difference btwn saccular and fusiform aneurysm

Answer 39

weak bulge in brain artery --> wall thinner and swells outward ``` saccular = branch points fusiform = less likely to rupture ```

Question 40

most common sites of brain aneurysm

Answer 40

ACom | PCom

Question 41

subarachnoid hemorrhage | symptoms

Answer 41

sudden severe HA sometimes focal deficit altered LOC --> arterial bleed = can dissect into brain tissue but usu no deficit

Question 42

risk factors for subarachnoid hemorrhage

Answer 42

``` smoking HTN --> risk for aneurysm formation women FHx aneurysm/SAH ADPKD Ehlers, danlos marfan fibromuscular dysplasia ```

Question 43

complications of SAH

Answer 43

1) rebleed 2) hydrocephalus 3) vasospasm 94-14 d) 4) cerebral salt wasting

Question 44

arteriovenous malformation define risk for what type hemorrhage presentation

Answer 44

1) abnormal connection btwn artery and vein w/o capill bed 2) IVH, SAH 3) hemorrhage, incidental, seizure

Question 45

risk factors for AVM

Answer 45

1) age 2) prior hem 3) deep 4) exclusive deep drainage 5) size doesn't predict

Question 46

causes of small vs large vessel stroke

Answer 46

``` small = lipohyalinosis large = embolic ```

Question 47

etiology of stroke pipes pump passengers

Answer 47

vessels heart platelets

Question 48

young stroke patient think of what?

Answer 48

dissection of artery --> occlusion or creating embolus to brain

Question 49

legs (numbness, weakness); no pain; sudden onset numbness and weakness (more in arms and face than legs usu symm); gaze preferences and aphasia vision loss and Wernicke’s aphasia high chance of causing coma

Answer 49

ACA MCA PCA basilar

Question 50

Gerstmann's syndrome features

Answer 50

acalculia left-right disorientation finger agnosia agraphia

Question 51

CT negative neuro deficits ``` sudden onset, slow improve sudden onset, rapid improve minute onset, rapid improve sudden onset, slow improve, LOC slow onset, ```

Answer 51

sudden onset, slow improve = stroke sudden onset, rapid improve = TIA minute onset, rapid improve = migraine sudden onset, slow improve, LOC = seizure slow onset = MS

Question 52

symptoms of small vessel strokes

Answer 52

hemiparesis | hemisensory loss

Question 53

subcortical or lacunar stroke symptoms

Answer 53

1) pure motor hemiparesis 2) hemi sensory loss 3) mixed motor sensory 4) clumsy hand dysarthria 5) ataxia hemiparesis (should not have but cerebellar fibers cross twice) face + arm + leg symm acute onset

Question 54

common features of vasculopathies

Answer 54

``` young age female lesion any portion of vessel pseudoaneurysm saccular aneurysm 10% familial ```

Question 55

symptoms started 1 hr ago

Answer 55

tpa used in acute stroke for 3-4.5 hrs intraarterial treatment IA = tPA or mech retrieval for PENUMBRA or Merci

Question 56

after given tPA NIHSS high what else to do

Answer 56

``` MERCI or penumbra or solitaire (stent retriever) ```