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BMB Test 3 > B7.059 Stroke > Flashcards

B7.059 Stroke Flashcards

1
Q

incidence of stroke in the US

A 
1 mil new cases yearly
#3 cause of death
6 mil stroke survivors at high risk of recurrence
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2
Q

what is a stroke

A

sudden onset of focal brain deficits

usually from blockage or rupture of a cerebral blood vessel

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3
Q

3 common causes of ischemic stroke

A

atherosclerosis (large vessels)
cardiogenic
small vessel disease (lacunes)

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4
Q

types of strokes caused by atherosclerosis

A

artery to artery emboli

stenosis (less common)

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5
Q

primary cause of cardiogenic emboli

A

a-fib

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6
Q

small vessel disease processes

A

lipohyalinosis

microatheroma

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7
Q

toast classification of stroke causes

A 
85% infarction:
-20% cardiogenic
-25% atherosclerotic
-20% lacunes
-30% cryptogenic
-5% unusual
15% hemorrhage:
-intracerebral
-subarachnoid
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8
Q

mechanism of cardiogenic emboli

A

emboli from heart become lodged in cerebral blood vessels

typically red clot

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9
Q

diagnosis of cardiogenic stroke

A

identify source

  • continuous EKG (look for a-fib)
  • trans thoracic echo
  • trans esophageal echo
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10
Q

common sources of cardiogenic embolism

A 
nonvalvular a-fib- 45%
acute MI- 15%
prosthetic valves- 10%
rheumatic heart disease- 10%
ventricular aneurysm- 10%
uncommon source- 10%
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11
Q

treatment of cardiogenic ischemic strokes

A

aimed at prevention of future strokes

  • anticoagulation
  • watchman device
  • exception: endocarditis, treat underlying cause w antibiotics (infective) or immunosuppressive agents (marantic)
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12
Q

anticoagulation options for cardiogenic strokes

A 
warfarin (INR 2-3 for a-fib)
monoclonal Abs
-apixaban
-edoxaban
-dabigatran
-rivaroxaban
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13
Q

anticoagulation therapy in stroke prevention in a-fib

A

very effective

warfarin: 65% risk reduction
dabigatran: 75% risk reduction

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14
Q

why choose dabigatran over warfarin?

A

easier

decreased risk of intracranial hemorrhage

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15
Q

diagnosis of an atherosclerotic stroke

A

large vessel stroke plus:
1. evidence of atherosclerosis on imaging
OR
2. risk factors for atherosclerosis

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16
Q

imaging for atherosclerosis

A

carotid duplex
CT angio
MR angio
catheter angio

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17
Q

risk factors for atherosclerosis

A

in order of importance:

  1. age
  2. HTN
  3. smoking
  4. DM
  5. hyperlipidemia
18
Q

secondary prevention for atherosclerotic stroke

A

risk factor control
antithrombotic (usually antiplatelet)
carotid artery stenting or endarterectomy

19
Q

speak to risk factor control for prevention of atherosclerotic stroke

A

most important are HTN and smoking
improvement of DM control does not decrease stroke risk, but is worthwhile for other causes
hyperlipidemia control more important for coronary artery disease

20
Q

lipids and stroke prevention

A

hyperlipidemia not well established risk factor

stroke risk decreased in patients with diabetes, CHD, and PVD treated with statins

21
Q

effect of DM on stroke risk

A

increases stroke risk 2-4x
synergistic with other risk factors (HTN, hyperlipids)
tight glucose control doesn’t have proven benefit for stroke

22
Q

antithrombotic agents for atherosclerotic stroke

A
  1. aspirin
  2. clopidogrel
  3. dipyridamole
    - DO NOT use warfarin, similar effectiveness to aspirin with much higher bleeding risk
    - aspirin typically used
23
Q

does intracranial artery stenting work?

A

no, more damage than benefit

can dislodge additional emboli during procedure which can cause new strokes

24
Q

when should carotid endarterectomy. stenting be considered

A

symptomatic, high grade stenosis
risk of perioperative MI and stroke too high to justify surgery in most asymptomatic patients and patients with moderate stenosis

25
Q

mechanism of lacunar strokes

A

penetrating artery occlusion via lipohyalinosis or microatheroma

26
Q

lipohyalinosis

A

HTN and DM causes necrosis and hyalinization of small vessels that can lead to occlusion

27
Q

risk factors for small vessel disease

A 
age
HTN
DM
hyperlipidemia
smoking
28
Q

diagnosis of lacunar infarcts

A

clinical syndrome: will see subcortical signs without cortical findings
MRI confirmation (misses 25%)
risk factors: HTN, DM

29
Q

pure motor hemiparesis lacunar syndrome

A

localization to the posterior limb of the internal capsule, basilar pons

30
Q

ataxia-hemiparesis lacunar syndrome

A

localization to the internal capsule, basilar pons

31
Q

dysarthria-clumsy hand lacunar syndrome

A

localization to the anterior limb of the internal capsule, basilar pons

32
Q

pure sensory lacunar syndrome

A

localization to the thalamus

33
Q

prevention of recurrence of lacunar strokes

A

poorly studied
risk factor control: HTN. DM
antiplatelets assumed to be effective
NO operative intervention

34
Q

unusual causes of stroke

A 
arterial dissection (spontaneous, traumatic)
drugs of abuse (coke, meth)
35
Q

potential cryptogenic causes of stroke

A

hypercoagulable states
patent foramen ovale
monitor long term for a-fib

36
Q

why might patent foramen ovale cause stroke

A

fibrous adhesions fail to seal the atrial septum after birth (occurs in 25% of people)
persistence of a potential shunt between the R and L atria
paradoxical emboli

37
Q

acute treatment of ischemic stroke

A

IV alteplase (TPA)
catheter thrombectomy
must have excellent multidisciplinary system of care in place

38
Q

IV alteplase (TPA)

A

up to 4.5 hours after onset
effect for all ischemic stroke subtypes
intracerebral hemorrhage
NNT8

39
Q

catheter thrombectomy

A

up to 24 hr after onset
only effective in proximal large vessel occlusion
intracerebral hemorrhage
NNT 2

40
Q

2 types of spontaneous intracranial hemorrhage and their causes

A
  1. intracerebral
    - hypertensive
    - amyloid angiopathy
    - coagulopathy
  2. subarachnoid
    - ruptured berry aneurysm
    - thunderclap headache
41
Q

locations of intracerebral hemorrhage by subtype

A

hypertensive: subcortical
-thalamus
-cerebellum
-pons
-BG
amyloid angiopathy: lobar

42
Q

2 types of vascular dementia

A
  1. history of clinical strokes correlated with onset of cognitive deficits
  2. no history of clinical strokes by diffuse subcortical vascular disease on imaging
    * * both have a subcortical dementia pattern aka abnormal elementary neuro exam

BMB Test 3 (21 decks)

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