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Neurology > 420 Ischemic Stroke > Flashcards

420 Ischemic Stroke Flashcards

1
Q

decrease in the cerebral blood flow to zero causes death of brain tissue within how many minutes

A

4-10 mins

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2
Q

defined as the ischemic but reversibly dysfunctional tissue surrounding a core area of infarction

A

ischemic penumbra

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3
Q

goal of revascularization therapies

A

saving the ischemic penumbra

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4
Q

two distinct pathway of focal cerebral infarction

A

necrotic and apoptotic pathway

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5
Q

what is necrotic pathway

A

which cellular cytoskeletal breakdown is rapid due to principally to energy failure of the cell

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6
Q

what is apoptotic pathway

A

which cells become programmed to die

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7
Q

how does ischemic lead to necrosis

A

ischemia produces necrosis by starving neurons of glucose and oxygen which in turn results in failure of mitochondria to produce ATP

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8
Q

what is the first goal in the management of acute ischemic stroke

A

the first goal is to prevent or reverse pain injury; ABCs, treat hypoglycemia and hyperthermia

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9
Q

what is the main 6 treatment modality in the management of acute ischemic stroke

A

medical support, IV thrombolysis, endovascular revascularization, antithrombotic treatment, neuroprotection, stroke rehabilitation

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10
Q

conditions wherein blood pressure is lowered in cases of acute ischemic stroke

A

blood pressure should be reduced if exceed 220/120 mmHg if there is malignant hypertension or concomitant myocardial infarction; of if BP is more than 185/110 mmHg and thrombolytic therapy is anticipated

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11
Q

true or false. Fever is detrimental in acute ischemic stroke and should be treated with antipyretics and surface cooling

A

true.

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12
Q

what is the target serum glucose and how is hyperglycemia managed?

A

serum glucose should be monitored and kept below 10 mmol or 180 mg/dl and above 3.3 mmol or 60 mg/dl; elevated blood glucose is managed with insulin

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13
Q

When does cerebral edema peak in ischemic stroke?

A

edema peaks on the second and third day but can cause mass effect for about 10 days

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14
Q

True or false. The larger the infarct the greater the likelihood that clinically significant edema will develop

A

true.

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15
Q

predictor of deterioration requiring hemicraniectomy

A

size of the diffusion- weighted imaging volume of brain infarction during the acute stroke

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16
Q

vertigo, vomiting, neck or head pain should alert physician to what type of stroke

A

cerebellar stroke

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17
Q

recommended in patients with cerebellar stroke

A

suboccipital decompression is recommended in patients with cerebellar infarcts who demonstrate neurological deterioration and should be performed before significant brainstem compression occurs

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18
Q

how to give rtPA

A

0.9 mg/kg (max of 90 mg) to give 10% as bolus and the remaining as IV drip over 60 mins

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19
Q

what is the rtpa dose for Japanese and other Asian countries

A

0.6 mg/kg

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20
Q

True or false. Occlusions in such large vessels as the MCA, intracranial internal carotid artery, and the basilar artery may generally involve a large clot volume and often fail to open with IV rtPA alone

A

true.

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21
Q

what did the PROACT Trial II say

A

Trial found benefit in intraarterial prourokinase in acute MCA occlusions up to the sixth hour following onset of stroke

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22
Q

alternative or adjunctive treatment of acute stroke patient who are ineligible to have contraindication to rTPA

A

endovascular mechanical thrombectomy

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23
Q

true or false. Endovascular therapy improved clinical outcomes for internal carotid and MCA occlusions under 6 hours with or withou pre treatment with rTPA

A

True.

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24
Q

time of vessel opening associated with good prognosis

A

vessel opening 1 hour of arrival

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25
Q

time of vessel opening associated with poor prognosis

A

vessel opening 6 hours of arrival

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26
Q

when can revascularization beyond 6 hours be of benefit

A

extending time window beyond 6 hours appears to be effective if the patient has specific imaging findings demonstrating good vascular collaterals

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27
Q

is the only antiplatelet agent that has been proven to be effective for the acute management of ischemic stroke

A

aspirin

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28
Q

true or false.routine use of heparin or other anticoagulants for patients with atherothrombotic stroke is not warranted

A

True

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29
Q

concept of providing a treatment that prolongs the brain tolerance to ischemia

A

neuroprotection

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30
Q

two conditions which should be sought out in acute ischemic stroke as these two conditions have proven secondary prevention strategies

A

atrial fibrillation and carotid atherosclerosis

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31
Q

responsible for 20% of all ischemic stroke

A

cardioembolic

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32
Q

embolic from the heart often lodge in which vessels

A

emboli from the heart often loge in the intracranial internal carotid artery, the MCA, the posterior cerebral artery

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33
Q

most significant cause of cardioembolic stroke in most the world

A

nonrheumatic or nonvalvular atrial fibrillation

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34
Q

what is the presumed stroke mechanism in atrial fibrillation

A

thrombus formation in the fibrillating atrium or atrial appendage with subsequent embolization

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35
Q

additional risk factor for formation of atrial thrombi

A

left atrial enlargement

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36
Q

when does rheumatic heart disease cause stroke

A

when there is prominent mitral stenosis or atrial fibrillation

37
Q

true or false. Mitral valve prolapse is not a source of emboli unless the prolapse is severe

A

True

38
Q

which type of MI may be a source of emboli

A

transmural, involving the anteroapical ventricular wall

39
Q

what is a paradoxical emboli

A

occurs when a venous thrombus migrate to the arterial circulation via a patent foramen ovale or atrial septal defect

40
Q

diagnostic test that can show the conduit for paradoxical embolization

A

bubble contrast echocardiography

41
Q

how is bubble contrast echocardiography done

A

IV injection of agitated saline coupled with transthoracic or transesophageal echocardiography

42
Q

how is artery to artery embolic stroke produced

A

thrombus formation on atherosclerotic plaques may embolize to intracranial arteries producing an artery to artery embolic stroke

43
Q

in the carotid artery, where is the most common site of atherosclerosis

A

atherosclerosis within the carotid artery occurs most frequently within the common carotid bifurcation and proximal internal carotid artery

44
Q

produces stoke either by an embolic mechanism or by in-situ thrombosis of a diseased vessel. It is more common in patients of Asian and African- American descent

A

intracranial atherosclerosis

45
Q

common source of embolic stroke in young age 60 years old and below

A

dissection of the internal carotid or vertebral arteries or even vessels beyond the circle of Willis

46
Q

infarction following atherothrombotic or lipohyalonotic occlusion of a small artery in the brain

A

lacunar infarction or small vessel stroke

47
Q

what is small vessel stroke

A

denotes occlusion of such a small penetrating artery

48
Q

true or false. Small vessel stroke accounts for 50% of all strokes

A

false. Small vessel stroke accounts for about 20% of all strokes

49
Q

principal risk factors for small vessel stroke

A

hypertension and age

50
Q

Four most common small vessel stroke syndrome

A

pure motor hemiparesis; pure sensory stroke, ataxic hemiparesis, dysarthria and a clumsy hard

51
Q

less common cause of stroke. Primarily increase the risk of cortical vein or cerebral venous sinus thrombosis

A

hypercoagulable state disorders

52
Q

less common cause of stroke. Occurs as a complication of oral contraceptive use, pregnancy and the postpartum period, IBD

A

venous sinus thrombosis

53
Q

common sites of venous sinus thrombosis

A

lateral or sagittal sinus or of small cortical veins

54
Q

most common cause of stroke in children

A

sickle cell anemia (SS disease)

55
Q

less common cause of stroke. Affects the cervical arteries and occurs mainly in women. Carotid or vertical arteries show mulitple rings of segmental narrowing alternating with dilatation

A

fibromuscular dysplasia

56
Q

true or false. Vascular occlusion is usually incomplete in fibromuscular dysplasia

A

true.

57
Q

True or false. Renal artery involvement in fibromuscular dysplasia is common and may cause hypertension

A

true.

58
Q

less common cause of stroke. Temporal arteries undergo subacute granulomatous inflammation with giant cells

A

temporal arteritis

59
Q

True or false. Temporaly arteritis often cause stoke because it leads to internal carotid thrombosis.

A

False it rarely cause stroke because the internal carotid are not inflammed.

60
Q

idiopathic giant cell arteritis involving the great vessels arising from the aortic arch that may cause carotid or vertebral thrombosis

A

Takayas’s arteritis

61
Q

drugs that can leads to stroke

A

amphetamines and cocaine

62
Q

how does this drugs lead to stroke

A

acute hypertension or drug induced vasculopathy

63
Q

occlusive disease involving large intracranial arteries especially the distal internal carotid artery and the stem of the MCA and ACA. Vascular inflammation in absent. The lenticulostriate arteries develop a rick collateral circulation around the occlussive disease given an impression of puffed smoke on conventional x-ray angiography

A

Moyamoya disease

64
Q

occurs as a result of hyperperfusion state where blood pressure exceeds the upper limit of cerebral autoregulation resulting in cerebral edema

A

posterior reversible encephalopathy syndrome

65
Q

what is the MRI finding in PRES

A

edema present in the occipital lobes but can be generalized and do not respect any single vascular territory

66
Q

refers to multiple small vessel infarcts within the subcortical white matter

A

leukoaraiosis or periventricular white matter disease

67
Q

what is the typical MRI findings of periventtricular white matter disease

A

white matter injury surrounding the ventricles and within the corona radiata

68
Q

what is the pathophysiology of periventricular white matter disease

A

lipohyalinosis of small penetrating arteries within the white matter likely produced of chronic hypertension

69
Q

inherited disorder that presents as small vessel strokes, progressive dementia, and extensive symmetric white matter changes often including the anterior temporal lobes visualized by MRI

A

cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy (CADASIL)

70
Q

what is the genetic mutation in CADASIL

A

mutations in Notch-3

71
Q

episodes of stroke symptoms that last only briefly duration is less than 24 hours

A

transient ischemic attack (TIA)

72
Q

in patients with TIA, when does stoke most commonly occur

A

most stroke events occur in the first 2 days

73
Q

what does the POINT study say regarding management of TIA

A

aspirin plus clopidogrel is better than aspirin alone for 21 days in preventing stroke

74
Q

most significant risk factor for stroke

A

hypertension

75
Q

most effective strategy for primary and secondary stroke prevention

A

diabetes prevention

76
Q

irreversibly inhibits formation in platelets of thromboxane A2

A

aspirin

77
Q

block ADP receptors on platelets thus prevent the cascade resulting in the activation of glycoprotein IIb/IIIa receptor

A

clopidogrel and ticlopidine

78
Q

how was POINT trial done

A

Clopidogrel 300 mg then clopidogrel 75 mg OD plus aspirin 80 mg OD x 21 days

79
Q

what does the ARISTOTLE trial say

A

Apixaban 5 mg BID is non inferior to warfarin in stroke prevention

80
Q

what does the ROCKET-AF trial say

A

Rivaroxaban 20 mg OD is non inferior to warfarin in stroke prevention

81
Q

true or false. Intermittent atrial fibrillation carries the same risk of stroke as chronic atrial fibrillation

A

true.

82
Q

what did the WARRS trial show

A

there is no benefit of warfarin over aspirin for secondary stroke prevention

83
Q

what is the WASID trial show

A

no benefit of warfarin over aspirin in patients with symptomatic intracranial athersoclerosis

84
Q

what did the NASCET trial show

A

benefit of surgery in patients with carotid stenosis of more than 70%

85
Q

what do the ACAS and ACST recommend regarding carotid artery disease

A

asymptomatic carotid disease patients with more than 60% stenosis needs medical treatment with aspirin and carotid endarterectomy

86
Q

what is the natural history for stroke in patients with carotid artery disease

A

asymptomatic carotid stenosis have a 2% risk for stroke per year while symptomatic carotid stenosis have a 13% risk of stroke

87
Q

what did the SAPPHIRE trial show

A

stenting is at the very least comparable to endartectomy as treatment option for patient at high risk of surgery

88
Q

what the CREST trial show

A

carotid endarterectomy and stenting showed relative equivalence of risk between procedures

Neurology (14 decks)

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