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Neuro Module > Cerebral Vascular Disease > Flashcards

Cerebral Vascular Disease Flashcards

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1
Q

Definition of cerebral ischemia

A

inadequate blood or oxygen to brain

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2
Q

mild or acute ischemia

A

syncope

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3
Q

severe or long-standing ischemia

A

whole brain = hypoxic-ischemia encephalopathy

focal region = stroke

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4
Q

systemic causes of short-lived cerebral ischemia

A

hypotension, vasovagal reaction, arrhythmia, MI

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5
Q

PE of stroke/TIA work up

A

BP, RR, pulse
Fundoscopy
Listen for bruits, murmurs, abnormal rhythms
Careful neuro exam

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6
Q

Labs to work up stroke/TIA

A

CBC, ESR, CMP, Lipid profile, Clotting studies (PT/PTT), serologic test for syphilis

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7
Q

Imaging to eval for possible embolic cause of stroke

A

carotid U/S, ECG, Holter monitor, ECHO, TEE, angiogram

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8
Q

Why is getting a CT/MRI important in work up of stroke?

A

only way to differentiate ischemic and hemorrhagic stroke

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9
Q

Difference in causes of ischemic and hemorrhagic strokes?

A

ischemic - thrombosis or embolic blockage of blood flow to brain

hemorrhagic - bleeding inside or around brain tissue

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10
Q

Non-modifiable RF for stroke

A

age, male, African American, hypercoaguable state

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11
Q

Modifiable RF for stroke

A
  • stop smoking and drinking
  • control DM, HTN
  • treat hyperlipidemia, hyper coagulability, sleep apnea
  • convert A-fib to sinus rhythm
  • reduce obesity
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12
Q

How to decrease risk of A-fib?

A

anti-coags

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13
Q

How are mitral valve defects and A fib ruled out as causes of stroke?

A

TEE r/o mitral defect

ECHO r/o A-fib

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14
Q

What are two types of stroke and which is more likely?

A

Ischemic (85%)

Hemorrhage (15%)

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15
Q

What is most likely cause of hemorrhagic stoke?

A

HTN

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16
Q

In a stroke, if blood quickly restored then it is a ______. But if prolonged ischemia _______.

A

TIA

tissue necrosis -> hemorrhagic stroke

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17
Q

RF specific to ischemic stroke

A

atherosclerosis, AGE, fhx, HTN, DM, tobacco, high lipids, A-fib, recent MI, valvular disease, patent foramen ovale, hypercoaguable states, systemic vascular disease, HIV/AIDS

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18
Q

What are some hypercoaguable states?

A

cancer, thrombocytosis, factor V Leiden, oral contraceptives

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19
Q

When is tPA not appropriate for stroke treatment?

A 
hemorrhagic strokes (or other bleeds)
acute stroke tx
after 4.5 hours of sx onset
thrombolysis (on blood thinner)
uncontrolled HTN
pregnancy
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20
Q

How/when does tPA work?

A

= tissue plasminogen activator

breaks up clots; used in immediate treatment of stroke (within 4.5 hrs) or MI (within 12 hrs)

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21
Q

What tx is used for acute stroke symptoms and prevention?

A

anti-platelet tx: Aspirin/Clopidogrel

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22
Q

Medical management to reduce complications and prevent secondary stroke?

A
  • reduce RFs
  • take Aspirin
  • Save ischemic penumbra region
  • Rehab: PT/OT, speech pathologist, respiratory therapist, social worker, psychologist
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23
Q

What is major risk of having TIA?

A

15% risk of full stroke after TIA, esp first 2 days

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24
Q

amaurosis fagux

A

TIA with transient monocular blindness from emboli to central retinal artery of one eye (branch of internal carotid artery); high correlation with ipsilateral carotid stenosis

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25
How is TIA defined?
stroke that resolves within 24 hours; usually less than 1 hr
26
Major causes of TIA
- stenosis of major artery (carotid, vertebral) - embolic phenomena (A-fib) - thrombosis of smaller BV in brain
27
What is an important part of PE for TIA?
Listen to carotid arteries
28
What drug can reduce ICP?
Mannitol
29
TIA treatement
Urgent eval and tx! Aspirin Avoid tPA Hospitalization for acute workup and availability of tPA if stroke occurs
30
________ are 20% of ischemic strokes.
small vessel strokes (Lacunar stroke)
31
5 classic signs of lacunar stroke?
1) Pure motor hemiparesis (hyperreflexia, +Babinski) 2) Pure sensory stroke (unilateral sensory loss) 3) Ataxia hemiparesis (pyramid signs, cerebellar ataxia) 4) Dysarthria & clumsy hand (unilat facial weakness, dysarthric speech, tongue deviation) 5) Mixed sensorimotor stroke (pyramid signs, sensory loss)
32
Where do small vessel strokes occur?
brainstem, thalamus, pons
33
What are the effects of a middle cerebral artery stroke?
- contralateral hemiplegia (motor) - contralateral hemianesthesia (sensory) - ipsilateral gaze preference - dysarthria due to facial weakness - aphasia if L side
34
What are the effects of a posterior cerebral artery stroke?
3rd nerve palsy (eye down & out, dilated pupil) Ataxia Cortical blindness Hemianopia
35
What part of brain is affected by posterior cerebral artery stroke?
midbrain, subthalamic, thalamic, cerebellum
36
Signs/sx of hemmorhagic stroke
ELEVATED ICP -> HA, altered mentation, confusion, coma, vomiting (no nausea), seizures, papilledema, Cushing's triad, irregular respirations, arrhythmias
37
Cushing's triad
high BP, low pulse, widening pulse pressure
38
Where is intraparenchymal bleeding?
bleeding into substance of brain
39
Where is subarachnoid bleeding?
bleeding between arachnoid and pia mater
40
RFs and causes of intraparenchymal bleeding?
RFs: age, heavy alcohol, anticoags, cocaine, Asians/African Americans Causes: HTN, trauma, cerebral amyloid angiopathy
41
Causes of subarachnoid bleeding?
- aneurism (spontaneous rupture of artery) | - occasionally trauma
42
Most common site for intraparenchymal hemorrhage
basal ganglia
43
signs/sx of basal ganglia hemorrhage
CONTRALATERAL HEMIPARESIS ``` mild = face sag, slurred speech, extremity weakness progression = flaccid paralysis, upper brainstem compression (coma, irreg breathing, dilated ipsilateral pupil) ```
44
signs/sx of thalamus hemorrhage
Contralateral hemiparesis/hemiparesis Sensory defect involving all modalities Aphasia Anisocoria (different sized pupils) w/o light reflex
45
signs/sx of cerebellar hemorrhage
Occipital headache Repeated vomiting Gait ataxia Dizziness/vertigo progression = stuporous, coma, brainstem compression
46
signs/sx of pontine hemorrhage
Deep coma w/ quadriplegia over minutes Decerebrate rigidity Pinpoint pupils which react to light Doll eye phenomena
47
occipital lobe hemorrhage ->
hemianopia
48
L temporal lobe hemorrhage ->
aphasia, delirium
49
parietal lobe hemorrhage ->
hemisensory loss
50
frontal lobe hemorrhage ->
arm weakness
51
Effects of thalamus/midbrain compression
stupor, coma, herniation
52
saccular aneurism aka _______.
"Berry" aneurism
53
Chief complaint of saccular aneurism
abrupt onset of "worst headache of my life" = thunderclap HA
54
Common location of saccular aneurisms
Circle of Willis
55
RFs of saccular aneurism
congenital arterial wall weakness | Polycystic kidneys
56
What is major cause of delayed death and morbidity in saccular aneurism?
cerebral vasospasm 4-14 days following initial bleed * 50-70% mortality, 70% morbidity
57
Hallmark diagnostic finding of saccular aneurism?
Blood in CSF upon lumbar puncture
58
Definitive dx of saccular aneurism
angiography (only if patient stable)
59
What imaging is done for all suspected hemorrhagic strokes?
Head CT - better at viewing bleeding than MRI
60
saccular aneurism management
1. AIRWAY 2. Control BP (150 systolic) Bed rest, head elevation, mild sedation, analgesia, stool softener Surgery: surgical clipping or endovascular coil
61
Of those who survive initial bleed of saccular aneurism, _____ rebleed in 1 month.
30%
62
Which brain bleeds involve venous blood?
subdural hematomas
63
RF of subdural hemorrhage
alcohol, anti-coags, elderly
64
Causes of acute subdural bleed
``` Contusion Shearing injury (e.g. shaken baby syndrome) ``` BUT trauma not always required if +RFs
65
Signs of acute subdural hematoma
Rapid ICP increase Unilateral headache with enlarged pupil on ipsilateral side ("blown pupil") Drowsy/comatose
66
CT scan results of subdural hematoma
hematoma that layers out in crescent shape
67
Acute vs Chronic Subdural Hematoma treatment
Acute: immediate Burr hole drainage or craniotomy Chronic: "watchful waiting" (hematoma may reabsorb on its own) or surgical evacuation
68
Pathophysiology of chronic subdural hematoma development
brain ages and atrophies -> small bridging veins stretch -> increased tear risk chronic/older collection of blood between dura and brain
69
Signs of chronic hematoma
headache, slowed thinking, drowsiness, personality changes, depression, dementia, seizures, motor/sensory deficits
70
How long for chronic hematoma to develop?
variable; days to weeks to months
71
Layers from skull to brain
skull, epidural space, dura mater, subdural space, arachnoid membrane, subarachnoid space, pia mater, brain
72
Why is dramatically high BP a sign of saccular hemorrhage?
body's attempt to profuse brain
73
Causes of epidural bleeds
TRAUMA - laceration of middle meningeal artery with overlying skull fracture
74
Compare epidural and acute subdural bleeding
- Epidural more rapid in development Epidural rounded blood layer, whereas acute subdural blood crescent shaped - Same treatment (Burr hole, rapid evacuation) and presentation (comatose, dilated pupils, headache)
75
Why is epidural hematoma more rounded on CT?
hematoma can't expand past skull sutures
76
Symptoms of AV Malformation
asx until it bleeds | +/- headache, seizures, pulsating noise in head
77
Where is bleeding of AV Malformation
surface or deep within brain tissue = intraperenchymal
78
Best imaging for AV Malformation
MRI > CT better to see tissue of vessels
79
Gold standard of AV Malformation dx
angiography
80
Treatment of AV Malformation
Surgical tx if accessible Embolization Stereotactic radiation (slow sclerosis of vessels over 2-3 yrs)
81
What age is AV Malformation most common?
10-30 yo

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