Cerebrovascular Disease

Question 1

Vascular territories:

Anterior cerebral artery issues affect what?

Answer 1

Deficits: Upper motor neuron-type weakness & cortical-type sensory loss; contralateral hemiplegia initially

• Contralateral leg (more common than arm or face)
• “Alien hand” syndrome: Semiautomatic movements of the contralateral arm not under voluntary control

Question 2

Vascular territories:

Posterior cerebral artery issues affect what?

Answer 2

Contralateral homonymous hemianopia

Question 3

Vascular territories:

Middle cerebral artery issues affect what?

Answer 3

This is most commonly the site of issue

Deficits: Aphasia, hemineglect (lack of awareness to half of body), hemianopia, face-arm or face-arm-leg sensorimotor loss

• Gaze preference toward side of lesion
• Lacunes: Small, deep infarcts involving penetrating branches of MCA or other vessels

Question 4

What are the 3 categories of cerebrovascular diseases?

Answer 4

• Thrombosis
• Embolism
• Hemorrhage

Question 5

What is the difference between a transient ischemic attack and a stroke?

Answer 5

Both: Clinical designation
TIA: Symptoms disappear within 24h
Stroke: Acute onset and persist beyond 24h

Infarction is the resultant lesion on the brain parenchyma

Question 6

What are the 4 most common cerebrovascular disorders?

Answer 6

• Global ischemia (Blood pressure issues, strangulation, carbon monoxide, etc)
• Embolism
• Hypertensive intraparenchymal hemorrhage
• Ruptures aneurysm

Question 7

What are watershed infarcts?

Answer 7

Region between two vessels that is most susceptible to ischemia & infarction
- Damage to this region produces a sickle-shaped band of necrosis over the cerebral convexity a few centimeters lateral to the interhemispheric fissure

Can have secondary hemorrhagic transformation

Question 8

What symptoms happen with infarct to the ACA-MCA watershed area?

Answer 8

Occlusion of the internal carotid artery, hypotension in pt w carotid stenosis

• Proximal arm & leg weakness
• Transcortical aphasia: (language issues)

Question 9

What symptoms happen with infarct to the PCA-MCA watershed area?

Answer 9

Higher-order visual processing

Question 10

Assortment of info about carotid stenosis

Where do thrombi formed here go if they embolize?

Answer 10

• Atherosclerosis commonly leads to stenosis of internal carotid artery just beyond bifurcation
• Carotid bruit continues into diastole
• Thrombi formed here can embolize distally, esp to MCA, ACA, and ophthalmic artery

Question 11

What are symptoms of carotid stenosis?

What can be done about stenosis?

Answer 11

Contralateral face-arm of face-arm-leg weakness, contralateral sensory changes, contralateral visual field defects, aphasia or neglect

Angioplasty or stenting or endarterectomy

Question 12

Where are 3 primary sites of thrombosis?

Answer 12

• Carotid bifurcation
• Origin of MCA
• Either end of basilar artery

Often d/t atherosclerosis

Question 13

What are 6 common sources of emboli in cardioembolic infarcts?

Answer 13

• Atrial fibrillation (Left atrial appendage)
• Myocardial infarction (Hypokinetic or akinetic areas)
• Valvular disease
• Artery-to-artery emboli (Emboli from stenosed internal carotid artery, vertebral stenosis)
• Dissection: Carotid or vertebral (atherosclerosis of aortic arch)
• PFO (bypasses lungs and goes straight to brain; paradoxical embolus)

Question 14

What are 4 sources of emboli that are not blood clots?

Answer 14

• Air emboli
• Septic emboli
• Fat or cholesterol emboli
• Marantic emboli (non-bacterial) from hypercoagulable states like advanced malignancy, amniotic fluid emboli, etc

Question 15

What artery is most often affect by embolic infarction?

Answer 15

MCA

- Emboli lodge where blood vessel branch or pre-existing areas of luminal stenosis

Question 16

What are shower emboli?

Answer 16

Fat after a long bone fracture

Question 17

Name 7 hypercoagulable states

Answer 17

• Heritable coag factor disorders
• Dehydration
• Adenocarcinoma/malignancies
• Surgery, trauma, childbirth
• DIC
• Hematologic disorders
• Vasculitis

Question 18

What are symptoms of TIAs?

Answer 18

Positive or negative (doing something you don’t want or not doing something you do want) in motor, somatosensory, visual, auditory, olfactory, kinesthetic, emotional, cognitive

Question 19

Common causes of TIA

Answer 19

Previous TIA, migraines, seizures, non-neurologic conditions like arrhythmias or hypoglycemia

Question 20

What do TIAs indicate?

Answer 20

• Warning sign for potentially larger ischemic injury to the brain
• Neurological emergency even when symptoms cease

Question 21

What are the 2 different types of stroke? Are they associated with emboli or thrombi?

Answer 21

Hemorrhagic (red)

• Emboli associated
• Hemorrhage secondary to reperfusion of damages vessels

Ischemic (pale)

• Thrombus associated
• Can have secondary hemorrhage

Question 22

Hypertensive cerebrovascular disease:

Lacunar infarcts. What are they, what do they commonly affect?

Answer 22

Deep penetrating arteries & arterioles develop arteriolar sclerosis

• Lenticulostriate arteries
• Commonly affect basal ganglia

Question 23

Hypertensive cerebrovascular disease:

What are slit hemorrhages?

Answer 23

Small caliber penetrating vessels

Question 24

Hypertensive cerebrovascular disease:

What is hypertensive encephalopathy, what is a common RF for it?

What is vascular multi-infarct dementia?

What is Binswanger disease?

What are Charcot-Bouchard microaneurysms?

Answer 24

Malignant HTN; HTN is a risk factor most commonly a/w deep brain parenchymal hemorrhages

Vascular multi-infarct dementia: Dementia, gait abnormalities, pseudobulbar signs

Binswanger disease: Large area of subcortical white matter w myelin and axon loss

Charcot-Bouchard microaneurysms: A/w chronic HTN; minute aneurysms in the basal ganglia (less than 300 micrometers)

Question 25

Hypertensive cerebrovascular disease: What is cerebral amyloid angiopathy? What is CADASIL? What age does it present? What gene is a/w it? What happens to vessels and what stain does it use?

Answer 25

CAA: Lobar hemorrhage; same A beta amyloid deposited in the walls of vessels (same as in Alzheimer's ) producing microbleeds CADASIL: Cerebral autosomal dominant arteriopathy w subcortical infarcts and leukoencephalopathy - Recurrent strokes and dementia - First detectable ~35yo - NOTCH 3 gene - Thickening of media and adventitia, loss of smooth muscle cells, basophilic PAS+ deposits

Question 26

What is an aneurysm? Where are they most frequently located? What increases incidence of aneurysm?

Answer 26

Localized abn dilation of blood vessel or the heart Most frequently seen in anterior circulation (Circle of Willis, basilar SAH) - Most frequent cause of clinically significant SAH is rupture of saccular (berry) aneurysm Inc incidence if first-degree relative affected, adult (AD) polycystic kidney disease, Ehlers-Danlos, Marfans, and neurofibromatosis type 1 (NF1)

Question 27

A few things to note about aneurysms

Answer 27

- Rupture more common in fifth decade of life and more frequent in females - Repeat bleeding common - First few days after SAH, inc risk of addt'l ischemic injurt from vasospasm

Question 28

What are the 4 groups of vascular formations? Which is most common?

Answer 28

- AV malformations (most common) - Cavernous malformations/hemangiomas - Capillary telangiectasias - Venous angiomas

Question 29

Sx of AV malformations and Cavernous?

Answer 29

Hemorrhage & neurological sx

Question 30

What are cavernous malformations and where/what do they affect? What can be seen in surrounding area?

Answer 30

Distended, loosely organized vascular channels arranged back-to-back with no intervening brain parenchyma - Cerebellum, pons, subcortical regions - No AV shunting - Foci of old hemorrhage, infarction, calcifications seen in surrounding area

Question 31

What are AV malformations? Where are they most common? What gene mutation are they a/w?

Answer 31

Tangle of vascular channels w prominent pulsatile AV shunting and high blood flow - Often in subarachnoid space, may extend into brain parenchyma - Seen as arteries to veins without intervening capillaries Often a/w KRAS oncogene, some RAS signaling

Question 32

What causes vascular dementia? What is seen with this in the brain? Binswanger disease?

Answer 32

Can be caused by cerebral atherosclerosis (from chronic HTN) or vessel thrombosis/embolus Multiple bilateral grey matter (cortex, thalamus, BG) and white matter infarcts Binswanger is subcortical white matter dementia (loss of white matter, myelin, axons)

Question 33

What are symptoms of vascular dementia?

Answer 33

Sx: Dementia, gait abnormalities, pseudobulbar signs (frequent, involuntary and uncontrollable outbursts of crying or laughing that are exaggerated d/t upper motor neuron lesions of CNIX)