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Clin Med - NEURO > Cerebrovascular disease and stroke > Flashcards

Cerebrovascular disease and stroke Flashcards

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1
Q

what is the definition of a stroke

A

a neurologic deficit attributed to an acute FOCAL injury of the CNS by a VASCULAR CAUSE, including cerebral infarction, intracerebral hemorrhage (ICH), and subarachoid hemorrhage (SAH)

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2
Q

what is a ischemic stroke

A

blood clot stops the flow of blood to an area of the brain

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3
Q

what is a hemorrhagic stroke

A

weakened/diseased blood vessel rupture - blood leaks into brain tissue

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4
Q

What are common stroke symptoms

A

sudden neurological deficit:
Vision, Speech,Sensory, Motor, Impaired coordination/balance
non-specific - AMS, confusion, dizziness, vertigo, headache, lightheadedness, memory impairment

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5
Q

what are vision changes in a stroke

A

diplopia, visual field cut

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6
Q

What are speech changes in a stoke

A

asphasia, dysarthria, dysphagia

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7
Q

what are sensory changes in a stroke

A

one-sided numbness/altered sensation

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8
Q

what are motor changes in a stroke

A

one-sided weakness

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9
Q

what are non-sepecific symptoms associated with stroke

A

AMS, Confusion, dizziness, vertigo, headache, lightheadedness, memory impairment

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10
Q

what are stroke risk factors

A

smoking, sedentary lifestyle and an unhealthy diet, air pollution, HTN, obesity, hyperglycemia, hyperlipidemia

sleep apnea, DVT/PFO, Atrial septal defect, Arterial dissection, hyper-coagulability, sicks cell, autoimmune disorders, contraceptives, pregnancy, PCOS, binge drinking, poor nutrition, cocaine and amphetamine use

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11
Q

what is the first branch of the internal carotid artery

A

Opathalmic artery

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12
Q

how do you differentiate between the internal and external carotid arteries

A

The external carotid has many branches and branches early and the internal carotid has less branches and delayed branching

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13
Q

what is the definition of ischemic stroke

A

an episode of neurological dysfunction caused by focal cerebral, spinal or retinal infraction.
Time based definition: >24 hours of neurological deficit
Radiographic definition: MRI needed

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14
Q

what are special cases of ischemic strokes

A

MRI-negative strokes: infarcts can be missed on MRI. stroke is ultimately a clinical diagnosis

Silent Strokes: imaging/pathological evidence of infarction without history of acute neurological dysfunction attributable to the lesion

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15
Q

What is the TOAST classification

A

classification of stroke by mechanism or cause:

Large-artery atherosclerosis (embolus/thrombosis)
Cardioembolism
small-vessel occlusion
Stroke of other determined etiology
stroke of undetermined etiology

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16
Q

what is cardioembolic

A

when a clot forms in heart and then travels to the brain (common in afib, cardiomyopathy and MRI)

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17
Q

what is a lacunar infarction

A

a small vessel stroke

infarction following atherothrombotic or lipohyalinotic occlusions

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18
Q

what is hypoperfusion

A

also known as borderzone stroke
decreased global blood flow (hypotension, heart failure, hypovolemia) can stress the most distal reaches in a vascular territory

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19
Q

what is a paradoxical embolism

A

a patent foramen ovale (PFO) acts as an open window to allow venous clots to bypass the lungs and enter the arterial pathway to the brain.

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20
Q

what needs to be identified in regards to paradoxical embolism

A

need to identify source of embolus, eg DVT to implicate it in stroke

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21
Q

what is stroke syndrome

A

pattern of deficits you will (may) see when a specific arterial territory in the brain is affected

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22
Q

what is aphagia

A

inability to effectively communicate

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23
Q

What are the classic lacunar syndromes

A

Pure motor hemiparesis
pure sensory stroke
sensorimotor
ataxic hemiparesis
dysarthria clumsy hand

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24
Q

how many neurons die per minute during a stroke

A

2 million per minute until reperfusion is achieved

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25
what is the ischemic core
brain tissue destined to die
26
what is penumbra
salvageable brain area (the shadow)
27
what is early thrombolytic/thrombectomy aimed at
rescuing tissue in the penumbra
28
what is key to establish during a stroke alert
Last Known Well Time (which is NOT the same as first seen abnormal)
29
what strokes are typically not eligible for thrombolytics or thrombectomy
"wake-up" strokes
30
what makes patients contraindicated for TPA treatment
hemorrhagic strokes
31
what is the initial stroke used to determine
hemorrhage vs not- hemorrhage to determine treatment (tPA or not)
32
what does the MRI assess for
necrotic brain tissue
33
what is the hyperacute phase of ischemic stroke treatment
tPA if within < 4.5 hours of symptom onset
34
what does tPA do
breaks down thrombus
35
what is the benefits of tPA
therapeutic benefit of tPA is greatest when given very early and declines throughout the first 4.5 hours after onset reduced mortality reduced symptomatic intracranial bleeding higher rates of independent ambulation at discharge higher rates of discharge to home
36
how many patients see improvement with tPA
1 out of every 3 patients
37
what is the risk of tPA
hemorrhage
38
what are the current inclusion criteria for tPA
diagnosis of ischemic stroke causing measurable neurologic deficit onset of symptoms < 3 hours before beginning treatment Aged greater than or equal to 18 years
39
what are the exclusion criteria for tPA treatment
history of head trauma/prior stroke in pervious 3 months aterial puncture at noncompressible intracranial tumor/mass elevated BP active internal bleeding blood glucose
40
what test is required prior to tPA treatment
CT and blood glucose stick
41
what are relative exclusion criteria for tPA treatment
minor/rapidly improving stroke symptoms pregnancy seizure at onset major surgery/trauma within past 14 days over the age of 80 severe strokes
42
what does LVO stand for
Large vessel occlusion
43
What has the greatest benefit of treatment for LVO
tPA and thrombectomy
44
what are key questions during stroke work up
where is the lesion? What is the mechanism (etiology)?
45
what are the key parts of stroke initial evaluation
History and physical exam quick, focused stroke scale CT (rule out bleed/structural abnormality) Labs MRI vessel imaging echocardiogram EKG special labs rhythm monitoring
46
what is the mainstay long-term treatment of stroke
antiplatelets (aspirin, clopidogrel, etc), high intensity statin
47
When is DAPT used
short term after severe intracranial stenosis or after high-risk TIA or minor stroke not helpful long term or if initiation is delayed >2wks
48
what is DAPT
dual-antiplatelet therapy
49
what is the efficacy of aspirin
best when given early, may reduce Severity of early recurrent stroke ~17% risk reduction over 3 years
50
what is the efficacy of Anticoagulation in Afib
warfarin ~66% effective in reducing stroke, possibly superior
51
what is the efficacy in high intensity statins
~20% risk reduction
52
what is the most important factor in treating a stroke
Risk factor management over 80% risk reduction
53
what are common post stroke complications
stroke deficits (vision, speech, sensorimotor, balance/gait) seizures, aspiration pneumonia, pressure ulcers, urinary retention/incontinence pain syndromes, cognitive impairment/dementia, falls/fractures, emotional/psychological impact, relationship/family stress anxiety/dression
54
what are the 10 warning signs of stroke
1. confusion 2. difficulty understanding 3. dizziness 4. loss of balance 5. numbness 6. severe headache 7. trouble speaking 8. trouble walking 9. vision changes 10. weakness
55
what does BEFAST stand for
Balance Eyes Face Arm Speech Time
56
how many strokes are recurrent
1 in 4 strokes are recurrent
57
how do you modify risk factors
control BP control cholesterol control your blood sugar discontinue smoking reduce/stop drinking alcohol exercise at least 30 minutes daily eat a heart-healthy diet
58
What is a TIA
transient ischemic attack - episode of temporary and focal neurological dysfunction of vascular origin, which are variable in duration, commonly lasting from 2-15 minutes. They leave no persistent neurological deficits
59
how do you differentiate between TIA and stroke
TIA has no evidence of infarct on brain imaging
60
what is the minimum treatment for TIA
anti-platelet agent plus statin plus control of blood pressure, blood sugar and other risk factors
61
what is the ABCD2 score used for
risk stratification for TIA Age Blood pressure Clinical features Duration of symptoms Diabetes
62
what is a hemmorrhagic stroke
caused by intraparenchymal hemorrhage: rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is NOT CASUED BY TRAUMA
63
what is the definition of silent cerebral hemorrhage
a focal collection of chronic blood products within the brain parenchyma, subarachnoid space, or ventricular system on neuroimaging or neuopathological examination that is not caused by trauma and without a history of acute neurological dysfunction attributable to the lesion
64
how is ICH categorized
medical emergency
65
what is the management of ICH
treat the cause rapid head CT (or MRI) to distinguish ischemic stroke from ICH, aneurysmal SAH give platelets if thrombocytopenic if on coumadin with elevated INR, reverse with vitamin K/K-centra acute BP lowering ICU monitoring
66
what is an asymptomatic aneurysm
unruptured - usually asymptomatic, unless they are large and causing symptoms from mass effect and compression on adjacent structures
67
what is the prognosis of a ruptured aneursym
fatality up to 60%
68
what is the pathophysiology of aneurysms
congenital/FH atherosclerosis HTN genetic abnormalities vasculopathies/inflammation arteriovenous malformations CT disorders infections sickle cell disease trauma neoplasms cigarette smoking illicit drug use alcohol
69
what are the primary cerebral aneurysms
Saccular, fusiform, mycotic and giant aneurysm
70
what is a saccular aneurysm
also known as berry aneurysm - bulges from one side of an artery, A neck leads to it.
71
what is a fusiform aneurysm
bulges from all sides of an artery - it rarely has a neck
72
what is a giant aneursym
can involve more than one artery. it is over 2.5 cm wide
73
what is a mycotic aneursym
caused by infected artery wall. this type is fairly rare.
74
what is the main cause of mycotic aneurysms
endocarditis
75
what are the most common locations of aneurysms
ACA, PCOM, branches of the MCA and top of the Basilar artery
76
what are the common signs and symptoms of aneurysms
incidental finding/asymptomatic minor aneurysmal hemorrhage with mild symptoms (fever, N/V, sweating, chills) catastrophic - aneurysmal subarachnoid hemorrhage (SAH) - "worst headache of my life", AMS, seizure, focal deficit due to mass effect or secondary ischemia
77
SAH is caused by what
rupture of the aneurysm - filled with blood causing sudden, intense headaches - sometimes described as "worst headache of one's life"
78
what is required if CT does not r/o SAH and there is a strong suspicion
do a lumbar puncture - xanthochromia (blood in the CSF) develops after 6 hours
79
What does the modified Fisher Scale have benefit for
determining vasospasm risk
80
what are complications of aneurysmal SAH
recurrent bleeding hyponatremia paroxysmal sympathetic hyperactivity seizure hydrocephalus vasospasm
81
what is the clinically applicable aneurysmal SAH scale
Hunt and Hess Scale - for prognosis
82
what are the surgical treatments for aneurysms
clipping and coiling coiling is used more frequently than clipping or ligation
83
what are medication treatments for aneurysmal SAH
Nimodipine (calcium channel blocker to reduce vasospasm) +/- antihypertensive osmotic agents if welling present antiepileptics pain/fever control stool softeners
84
Where is a subdural hemmorrhage
collection of blood in the subdural spaece - usually the result of head trauma
85
what is the presentation of subdural hemorrhage
shear damage to the bridging cortical veins as they cross the dura mild or indolent symptoms
86
how do you distingush a subarachnoid hemorrhage
cortical shaped arterial blood
87
how do you distinguish a subdural hemorrhage
crescent shaped, venous blood - located in the potential space between the dura and arachnoid matter
88
what is the presentation of extradual hemorrhage
blood collection between the skull and the dura - associated with head trauma/skull fracture
89
how do you distinguish a extradural hemorrhage
lens shaped (higher pressure) arterial blood does not cross sutures
90
what is GCA
giant cell arteritis inflammatory vasculitis
91
what is the serious complication of GCA
irreversible vision loss
92
what is GCA linked to
polymyalgia rheumatica
93
what is the SSX of GCA
sudden or insidious onset +/- prodrome anorexia, weight loss, fever, night sweats headache PMR pattern (shoulders, neck, hips/thighs) fatigue/malaise jaw claudication fever vision changes eye motion abnormalities
94
what are differential diagnosis for GCA
acute angle closure glaucoma herpes zoster iritis/uveitis tia/stroke migraine
95
how is GCA diagnosed/worked up
labs (CBC, ESR, CRP, LFTs) standard of care: emergent temporal artery biopsy non-invasive imaging (ultrasound, MRI/MRA)
96
what is the treatment of GCA
high dose steroids (at least prednisone 60mg) best within 24 hours duration of steroids can be up to 2 years can also use low-dose aspirin, proton pump inhibitor, bisphosphonates, calcium and vitamin D for bone protection)

Clin Med - NEURO (13 decks)

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