A17. Diagnostic procedures in cerebrovascular disorders Flashcards by M AAB

Cerebrovascular disorders epidemiology

are the third most common causes of death in the western world, after heart disease and cancer.

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Cerebrovascular disorders include

all disorders in which an area of the brain is temporarily or permanently affected by ischemia or hemorrhage , and
one or more of the cerebral blood vessels are involved in the pathological process

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Stroke types

Ischemic stroke (85%)
● Thrombotic (atherosclerotic)
● Embolic
● Haemodynamic
● Lacunar

Hemorrhagic stroke (15%)
● Subarachnoid (SAH)
● Intracerebral (ICH)

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which stroke is more common

85% of strokes are ischemic, and
only 15% are hemorrhagic

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List ischemic strokes

● Thrombotic (atherosclerotic)
● Embolic
● Haemodynamic
● Lacunar

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List Hemorrhagic strokes

● Subarachnoid (SAH)
● Intracerebral (ICH)

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Diagnostic procedures done in all patients suspected of cerebrovascular disorders

● Neuroimaging (CT or MRI)

● ECG (should not delay imaging or thrombolysis)

● Lab tests:
blood count,
INR,
serum electrolytes,
blood glucose,
CRP,
hepatic and renal functions

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Neuroimaging incase of suspected cerebrovascular disorders.

(CT or MRI

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Stroke protocol
what to do If suspected stroke patient

ABCDE (remember glucose - hypoglycemia can mimic acute stroke!)
Blood samples (urgent: Glucose, INR) and blood pressure is taken
GCS, NIHSS: neurological screening assessment
ECG (should not delay CT/MRI)
(Point 1-4 is usually performed simultaneously (nurses, doctors, neurologist work at same time)
CT or MRI (should be interpreted within 45 minutes)
Thrombolysis (rtPA) considered if within therapeutic window (e-learning: 6 hours, internet: 4,5
hours) and no contraindications

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why do we check glucose in suspected stroke patient

hypoglycemia can mimic acute stroke

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what do CT or MRI exclude

Primarily to exclude hemorrhage, but
also to visualize intracranial large vessel occlusion
and extent of irreversible damage

○ Hemorrhage: consult neurosurgeon
○ Ischemia: candidate for thrombolysis (exclude contraindications)

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what to do incase patient who has hemorrhage stroke

consult neurosurgeon

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what to do incase patient who has ischemic stroke

candidate for thrombolysis (exclude contraindications

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therapeutic window of stroke thrombolysis (rtPA)

e-learning: 6 hours, internet: 4,5
hours)

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rtPA stands for

Recombinant tissue plasminogen activators

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what is mandatory to image within the therapeutic time window

■ Brain parenchyma (non-contrast CT or MRI)

■ Extra- and intracranial vessels ( CT- or MR angiography)

● If CTA or MRA cannot be performed, Doppler US might be a solution in order to detect intracranial vessel occlusion

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brain parenchyma can be imaged by

■ Brain parenchyma
(non-contrast CT or MRI)

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Extra- and intracranial vessels can be imaged by

( CT- or MR angiography)

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what imaging can be used to detect intracranial vessel occlusion
If CTA or MRA cannot be performed

Doppler US might be a solution in order to detect intracranial vessel occlusion

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what to do If unsure about therapeutic window - e.g in wake-up-strokes

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■ DWI-FLAIR mismatch: if ischemia is seen on DWI, but not on FLAIR, it means that the stroke still is in the therapeutic window and can receive thrombolytic
therapy.
■ DWI-PWI mismatch: DWI shows infarct core, while PWI shows hypoperfused
tissue, and hence this mismatch shows the salvageable tissue (penumbra)

In DWI-FLAIR mismatch what does it mean if ischemia is seen on DWI, but NOT on FLAIR,

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it means that the stroke still is in the therapeutic window and can receive thrombolytic therapy.

Fluid attenuated inversion recovery

In DWI-PWI mismatch: what does it mean when DWI shows infarct core, while PWI shows hypoperfused
tissue

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hence this mismatch shows the salvageable tissue (penumbra)

what is mandatory before thrombolysis

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● Hypoglycemia (glucose): can mimic acute stroke
● Coagulopathies (INR): CI of thrombolysis (should be under 1,7 to perform)
● Blood pressure (BP): hypertension increase hemorrhagic risk of thrombolysis
○ Hemorrhagic stroke: should be under 140 mmHg
○ Ischemic stroke:
■ Hyperacute phase: treat only if above 220 mmHg
■ If thrombolysis performed: treat if above 185 mmHg

before thrombolysis in hemorrhagic stroke blood pressure should be

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under 140 mmHg

when do we treat hypertension in ischemic stroke

■ Hyperacute phase: treat only if above 220 mmHg ■ If thrombolysis performed: treat if above 185 mmHg

what should be done Urgently, but should not delay thrombolysis

● ECG ● Blood count with plt (severe thrombocytopenia/anemia are CI for thrombolysis) ● Electrolytes

Diagnostic considerations in cerebrovascular diseases

● Presence of clinical signs (WHO) ● Hemorrhagic vs. ischemic (CT, MRI) ● Pathomechanism (thrombotic, embolic, hemodynamic, small vessel disease) ● Duration of signs ● Brain region (hemisphere, cerebellum, brainstem; territorial-borderzone) ● Anterior-Posterior ● Supplying vessel (carotid artery, vertebrobasilar, lacunar, ACA, MCA, PCA) ● Prognostic by signs (Bamford – OCSP) ○ TACI, PACI, POCI, LACI ● Etiology - TOAST ○ Large vessel atherosclerosis ○ Small vessel occlusion (lacuna) ○ Cardioembolism ○ Other determined cause ○ Unknown cause

4 questions to think/ask about in cerebrovascular diseases

1. Is it a neurological disease? 2. If yes, where is the lesion? 3. What pathological conditions may cause a lesion at this site? 4. In this patient, which of these conditions are most likely to be present?

list examination done incase of suspected Hemorrhagic stroke

● CT and possibly CT angio ● CSF examination if strong suspicion, but normal CT ● TCD (transcranial doppler) can detect and monitor vasospasms in SAH ● Test for coagulopathies (must be corrected with antidotes) and blood pressure (must be kept under 140 mmHg)

TCD (transcranial doppler) what is it used for

can detect and monitor vasospasms in SAH

diagnostics In TIA patients or patients with fast recovery

● Diagnostic work-up, especially urgent vascular imaging ● Ultrasound ● CTA or MR

Etiology of ischemic strokes

* Cerebral embolism * Thrombus * Small vessel occlusion (lipohyalinosis) * Systemic hypoperfusion

etiology of intracerebral hemorhage

* Ruptured cerebral artery or microaneurysm * Trauma * Reperfusion injury after ischemic stroke

etiology of SAH

* Ruptured berry aneurysm * Arteriovenous malformation Trauma (see “Traumatic brain injury”)

Ischemic stroke risk factors

Age > 65 years Hypertension Atrial fibrillation Diabetes mellitus Carotid artery stenosis

Intracerebral hemorrhage risk factors

Age > 65 years Hypertension Vasculitis Malignancy Ischemic stroke

risk factors of Subarachnoid hemorrhage

Hypertension Tobacco use Family history

Ischemic stroke clinical features

Sudden onset of focal neurologic deficits Embolic stroke: possibly, spectacular shrinking deficit

Intracerebral hemorrhage clinical features

Headache, confusion, nausea Sudden onset of focal neurologic deficits

Subarachnoid hemorrhage clinical signs

Rapid onset of severe headache Meningeal signs Sudden onset of focal neurologic deficits

when is Lumbar puncture done and in which type of stroke

Subarachnoid hemorrhage If imaging is negative but suspicion for SAH remains high. CSF may show xanthochromia. (the yellow discoloration of cerebrospinal fluid (CSF) caused by hemoglobin catabolism)

treatment of ischemic stroke

* tPA (if within < 4.5 hours of onset of symptoms) * Intra-arterial thrombolysis * Thrombectomy * Aspirin or clopidogrel for secondary prevention

treatment of intracerebral hemorrhage

* Reversal of coagulopathy * Blood pressure management * Surgical intervention if there are signs of herniation or increased ICP

treatment of SAH

* Reversal of coagulopathy * Blood pressure management * Prevention of vasospasm * Surgical clipping * Endovascular coiling

when is Surgical intervention done in intracerebral hemorrhage

if there are signs of herniation or increased ICP

pathology of ischemic stroke

Pale infarct → liquefactive necrosis and glial scarring

pathology of hemorrhagic stroke

Hematoma surrounded by pale infarct and edema → hemosiderin-lined cavity with glial scarring

For both ischemic and hemorrhagic strokes: * most important **nonmodifiable risk factor** and * the most important **modifiable risk factor.**

nonmodifiable risk factor: **age** the most important modifiable risk factor: **arterial hypertension**

A17. Diagnostic procedures in cerebrovascular disorders Flashcards

(48 cards)