DSA 26 Cerebrovascular Disease

Question 1

stroke in MCA → lesion in motor cortex. presentation?

Answer 1

contralateral paralysis in upper limb and face

Question 2

stroke in MCA → lesion in sensory cortex. presentation?

Answer 2

contralateral loss of sensation in upper limb and face

Question 3

stroke in MCA → lesion in Wernicke’s area; Broca’s area. presentation?

Answer 3

aphasia if in dominant (usually left) hemisphere; hemineglect if lesion affects non dominant (usually right) side.

Question 4

stroke in ACA → lesion in motor cortex. presentation?

Answer 4

contralateral paralysis of lower limb

Question 5

stroke in ACA → lesion in sensory cortex. presentation?

Answer 5

contralateral loss of sensation in lower limb

Question 6

stroke in PCA → lesion in occipital cortex, visual cortex. presentation?

Answer 6

contralateral hemianopsia with macular sparing

Question 7

stroke in basilar artery → lesion in pons, medulla, lower midbrain, corticospinal and corticobulbar tracts, ocular CN nuclei, paramedian pontine reticular formation. presentation?

Answer 7

locked-in syndrome: preserved consciousness and blinking, quadriplegia, loss of voluntary facial/mouth/tongue movements

Question 8

identify: noises heard over vascular territories, usually over arteries

Answer 8

bruits

Question 9

where are carotid bruits heard best?

Answer 9

at bifurcation of carotid with sound transmitted to angle of mandible

Question 10

what is usually the initial brain imaging modality of choice when investigating patient with potential cerebrovascular disease?

Answer 10

CT scan

Question 11

identify: focal neurological deficit due to temporary reduction in blood flow to part of the brain, usually lasting minutes

Answer 11

transient ischemic attack

Question 12

during what time frame do TIAs ALWAYS resolve?

Answer 12

always resolve within 24 hours

Question 13

what is normal cerebral blood flow?

Answer 13

50cc per 100 gram per min

Question 14

what is the cerebral blood flow value defined as ischemia?

Answer 14

<25 cc per 100 gram per min

Question 15

during _______ (ischemia/infarction) neurons become dysfunctional but may recover if blood flow returns.

Answer 15

ischemia

Question 16

what is the cerebral blood flow value defined as infarction?

Answer 16

<13cc per 100 gram per min

Question 17

during _____ (ischemia/infarction) cell death in the brain typically occurs.

Answer 17

infarction

Question 18

true or false: asymptomatic carotid bruit is much riskier than TIA.

Answer 18

false, TIA is riskier

Question 19

what are individual stroke risk factors?

Answer 19

1.) prior stroke or TIA 2.) atrial fibrillation

Question 20

what is the most common stroke risk factor in the general population?

Answer 20

hypertension

Question 21

where does atherosclerosis tend to occur earliest?

Answer 21

locations of greatest vascular turbulence that is around the major bifurcations

Question 22

what is the equation for hemodynamics?

Answer 22

CPP = MAP - ICP

Question 23

patient presents with S/S of acute ischemic stroke or any acute focal neuro deficit, mild/moderate increase in BP. what do you do?

Answer 23

perform brain imaging before lowering the BP. if patient has an increased ICP, decreasing MAP might decrease CPP critically.

Question 24

patient presents with S/S of acute ischemic stroke or any acute focal neuro deficit, mild/moderate increase in BP. imaging doesn’t show evidence of something increasing ICP. now what?

Answer 24

if evidence of end organ damage, lower BP acutely. if not, lower BP gradually and carefully.

Question 25

central area of infarction surrounded by area of ischemia. what is the area of ischemia?

Answer 25

penumbra. usually seen in acute ischemic stroke

Question 26

what is the clinical significance of the penumbra?

Answer 26

brain within the penumbra might be salvageable. recovery of this area is primary reason people improve following strokes.

Question 27

as a physician, how should you manage the penumbra?

Answer 27

make every effort to maintain perfusion to this area of ischemia

Question 28

what is the indication for using tPA?

Answer 28

acute ischemic stroke

Question 29

what are tPA contraindications?

Answer 29

hemorrhage on CT seizure activity at onset recent intracranial hemorrhage, trauma, or surgery active bleeding or bleeding disorder coagulation abnormality uncontrolled HT at time of tx

Question 30

identify: small atherosclerotic ischemic stroke involving the small penetrating arteries of the brain resulting in little "lakes"

Answer 30

lacunar stroke

Question 31

where do lacunar strokes typically occur?

Answer 31

deep white matter

Question 32

patient suffers stroke. what leads you to suspect cardioembolic etiology?

Answer 32

younger patient (40s or 50s), no hypertension, no hyperlipidemia, non-smoker. possible cardiovascular risk factors

Question 33

\_\_\_\_\_\_\_ (thrombotic/embolic) ischemic infarct is unlikely to have reversal of occlusion.

Answer 33

thrombotic

Question 34

\_\_\_\_\_\_\_ (thrombotic/embolic) ischemic infarct has possibility of thrombolysis occurring and re-establish blood flow.

Answer 34

embolic

Question 35

what structure is frequently damaged when ischemic infarct occurs?

Answer 35

blood-brain barrier

Question 36

what happens if blood flow is re-established to area of brain with BBB damage?

Answer 36

hemorrhagic transformation

Question 37

true or false: hemorrhagic transformation virtually never occurs in cardioembolic infarct.

Answer 37

false, this is true for atherosclerotic infarct. occurs in approx. 10-15% of cardioembolic infarcts

Question 38

a patient experiences progressive deterioration with medical management of hemorrhagic stroke. next step?

Answer 38

surgical evacuation of hematoma after craniotomy may be life-saving

Question 39

what is the second most common cause of subarachnoid hemorrhage?

Answer 39

ruptured vascular malformation

Question 40

difference between primary and secondary prevention?

Answer 40

primary prevention involves patients who have NOT experienced an event due to risk factors.

Question 41

true or false: asymptomatic carotid bruit is a modifiable risk factor.

Answer 41

false, symptomatic carotid bruit is.

Question 42

\_\_\_\_\_\_\_ antibody is a modifiable risk factor.

Answer 42

anticardiolipin

Question 43

true or false: vasculitis is a modifiable risk factor.

Answer 43

true

Question 44

what risk factors might be added for women?

Answer 44

history of eclampsia migraine hormone replacement therapy

Question 45

rank the risk factors based on relative risk from greatest to least: hyperlipidemia, alcohol abuse, hypertension, smoking, diabetes

Answer 45

hypertension smoking diabetes alcohol abuse hyperlipidemia

Question 46

how do you treat a patient that has cardiac risk factors for stroke?

Answer 46

anticoagulation or vitamin K antagonist/antithrombotics \*\*unless contraindicated\*\*

Question 47

patient has previous TIA or mild stroke. no cardiac or surgical vascular risk factors. treatment?

Answer 47

antiplatelet agents: aspirin, clopidogrel, ticlopidine, dipyramidole

Question 48

describe the most ominous bruit and explain siginificance.

Answer 48

the most ominous bruit possible is a very high-pitched, barely heard bruit--this indicates a very severe stenosis

Question 49

describe symptoms of right carotid artery ischemia.

Answer 49

contralateral motor or sensory symptoms contralateral hemianopsia ipsilateral eye visual disturbance

Question 50

if patient CDUS suggests high grade stenosis of proximal internal carotid artery, what do you do next?

Answer 50

cerebral arteriogram. then if the cerebral arteriogram reveals some flow, perform carotid endarterectomy.

Question 51

what is the very first branch off the internal carotid artery in the head?

Answer 51

ophthalmic artery

Question 52

how can you distinguish internal carotid ischemia from MCA ischemia based on patient presentation?

Answer 52

ICA ischemia will present with ipsilateral monocular visual loss. MCA ischemia would present with contralateral hemianopsia.

Question 53

how do you treat a patient with atherosclerotic ischemic stroke?

Answer 53

modify all modifiable risk factors and initiate antiplatelet therapy

Question 54

when treating a patient, how do we distinguish a TIA from a stroke?

Answer 54

we dont. we treat the TIA as a stroke unless the patient is improving.

Question 55

what is the definition of uncontrolled hypertension in terms of tPA contraindications?

Answer 55

BP \> 180/110

Question 56

what is the significance of the ophthalmic artery branching off the internal carotid artery before the MCA?

Answer 56

cannot have an ophthalmic artery occlusion resulting from a MCA lesion

Question 57

what might result from an occlusion at the tip of the basilar artery? how would this affect the pupillary light reflex?

Answer 57

might cause cortical blindness due to infarction of both occipital lobes. pupillary light reflex would be normal--no component of this reflex is posterior to the Edinger-Westphal nucleus in the midbrain.

Question 58

how does cardioembolic stroke differ from atherosclerotic stroke?

Answer 58

blood flow may return to infarcted brain following cardioembolic stroke because we have our own endogenous thrombolytic system.

Question 59

ischemic stroke that enhances with contrast or has become secondarily hemorrhagic. suspect stroke is cardioembolic or atherosclerotic?

Answer 59

cardioembolic

Question 60

list 3 *non-vascular* causes of TIA.

Answer 60

1. ) partial seizure 2. ) migraine with aura 3. ) MS attack