Cerebrovascular Dz

Question 1

2 types of stroke

Answer 1

Primary ischemic

Primary hemorrhagic

Question 2

Primary stroke

Answer 2

80% of strokes
Cerebral Embolism = 30%
Large artery thrombosis = 30%
Small artery thrombosis

Question 3

Primary hemorrhagic stroke

Answer 3

20% of strokes
Intracerebral hemorrhage (ICH) = 14%
Subarachnoid hemorrhage (SAH) = 6%

Question 4

Epidemiology of stroke

Answer 4

CVA affects 500K Americans each year
3rd leading cause of death in USA
Men > Women
Blacks > Whites
Incidence of stroke doubles for each decade beyond 55

Question 5

Risk Factors for stroke

Answer 5

Male 
Black
>55
Atrial Fibrillation
Hypertension ** 
Diabetes
Smoking
genetics

Question 6

Risk Factors of CVA in Younger Population

Answer 6

Mitral Valve Prolapse
Patent Foramen Ovale
Migrainous infarction
Hypercoaguable state
Illicit drug use

Question 7

Presentation of hemorrhagic stroke

Answer 7

Headache
Alteration in consciousness
Speech disturbance
Visual field deficits-homonymous deficit
Cognitive impairment

Question 8

Presentation of the Patient with CVA (Brainstem / Cerebellar Stroke)

Answer 8

Dysarthria 
Dysphagia
Ataxia
Diplopia
Vertigo 
Nausea
Nystagmus

Question 9

Strokes in a Middle Cerebral Artery territory have what symptoms?

Answer 9

In dominant hemisphere would include aphasia / dysphasia

Contralateral motor weakness (central facial + arm > leg)

Question 10

Posterior Cerebral Artery territory what symptoms

Answer 10

Contralateral homonymous hemianopsia

Speech unaffected – no weakness likely

Question 11

Vertebrobasilar artery territory have what symptoms?

Answer 11

Bilateral blindness

Lacunar (small vessel) stroke:
Paresis affecting face / arm / leg equally with no sensory loss

Question 12

internal capsule stroke has what presentation

Answer 12

pure motor stroke

Question 13

Berg Balance Scale

Answer 13

Good tool for determining pts who can safely ambulate vs require W/C
Scale is 0 – 56
0 – 20 high fall risk
21-40 medium fall risk
41 – 56 low fall risk

Question 14

Cerebral Arteriography is the gold standard for?

Answer 14

thrombosis, stenosis, arterial dissection, vascular anomalies such as aneurysms, AVM’s

Question 15

Contraindications for TPA

Answer 15

Hemorrhagic stroke
Large infarct 
>3 hrs since onset
Any question of coagulopathy
Recent major surgery
Prior stroke
Severe hypertension / severe metabolic disturbance

Question 16

11 Guidelines for the General Management of the Acute Stroke Patient

Answer 16

1. Stabilize vital signs
2. Protect Airway and prevent aspiration
3. Assess swallowing capacity
4. Early mobilization
5. Bowel program
6. Prevent pressure sores
7. Anti-embolus precautions
8. Rehab/therapy as indicated by deficit
9. Social service eval
10. Assess for post stroke depression
11. Long term mgmt of stroke risk factors.

Question 17

Most common locations for hypertensive ICH are

Answer 17

Basal ganglia
Thalamus
Cerebellum
Pons

Question 18

Intracerebral Hemorrhage management

Answer 18

Use of mannitol – potent osmotic diuretic that reduces cerebral edema
Evacuation of the hematoma may be indicated
Control BP aggressively
ICP can be lowered by intubating patient and placing on a vent

Question 19

Subarachnoid Hemorrhage

Answer 19

Bleeding into the subarachnoid space
Very common etiology of SAH is head trauma
Common with aneurysm or AVM rupture
Confirmed by LP – bloody CSF

Question 20

Symptoms of SAH

Answer 20

similar to meningitis due to meningeal irritation from blood – stiff neck (nuchal rigidity), photophobia, severe H/A, low grade fever

Question 21

Complications associated with aneurysms?

Answer 21

rebleed
hydrocephalus
cerebral edema
vasospasms

Question 22

What is embolic phenomena

Answer 22

similar to stroke except the embolus moves on before infarction can occur – so pts symptoms are of ischemia

Question 23

Difference between TIA and stroke

Answer 23

TIA resolves with NO deficit – CVA pt has neurological deficit
CT of TIA pt is negative for cerebral infarction
CT of Stroke pt is + for cerebral infarction
By old parlance of TIA – pt w/deficit after 24 hours had stroke

Question 24

Carotid TIA symptoms include? (5)

Answer 24

Amaurosis fugax
Aphasia
Hemiparesis
Hemisensory deficit
Homonymous hemianopsia

Question 25

Posterior circulation (Basilar artery) TIA symptoms include?

Answer 25

Ataxia
Bilateral visual loss
Quadriparesis
Perioral numbness
Vertigo / syncope / dysarthria / diplopia / nausea / dysphagia
Homonymous hemianopsia

Question 26

Treatment for TIA?

Answer 26

Anticoagulation
Look for possible cardiac source of emboli
Anticoagulation with Warfarin (Coumadin) aiming for INR of 2 – 3.
Coumadin does increase bleeding risk especially in elderly who are more prone to falls.

Question 27

How do you prevent stroke?

Answer 27

Recognize and counsel high risk pts
Reduce complications of cerebro- vascular disease w/early interventions
Reduce risk of diabetes
Smoking cessation, weight reduction, lower cholesterol, treat arrhythmias