Ischemic Stroke Flashcards
(39 cards)
Ischemic Stroke Definition
Fixed focal neurological deficit attributable to arterial or venous territory, with evidence of acute infarction.
So what’s a TIA
a brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction
Large vessel s/s
ACA: legs
MCA: “Classic” one sided weakness/numbness
PCA: vision
Basilar: quickly leads to coma and death
tPA! (aka alteplase)
Used in the acute stroke setting up to 3 or 4.5 Hours
SHOULD HAVE NORMAL CT SCAN, Abnormal perfusion scan
Catheter Options
MERCI/ PENUMBRA (vacuum)
Stent retriever + vacuum (faster)
Clopidogrel
Antiplatelet agents that work by a different mechanism than ASA
Effectiveness and tolerability about the same as ASA
Stronger may be good for heart, bad for Brain and GI
Way more expensive (x100)
ASA Therapy and Stroke
Effective in secondary prevention of stroke and TIA
Heart and peripheral vascular disease benefits
Well understood / known safety profile
Cheaper than dirt
Underused
metabolic, lifestyle, and structural risk factors for stroke.
HTN** Lipid disorders Homocysteine elevation Smoking Obesity Physical inactivity Diabetes Alcohol
non-atherosclerotic causes of stroke in a young patient
General
Vasculpothy Hematologic Inflammatory Venous infarction Vasospasms
non-atherosclerotic causes of stroke in a young patient
Vasculpothy
fibromuscular dystrophy, Moya- Moya, arterial dissection
non-atherosclerotic causes of stroke in a young patient
Hematologic-
Hematologic- familial deficiency, malignancies, sickle cell, hyperviscoity, birth control, antiphospholipid antibodies
non-atherosclerotic causes of stroke in a young patient
Inflammatory-
Inflammatory- vasculitis, migraine
fibromuscular dystrophy
F, 30 yo
media layer hypertrophy
dilate arteries to avoid stenosis
acs. w/ intracranial saccular aneurysm
Moya-Moya
F, 30-40 (asian/ african)
Middle cerebral artery occlusion
Intimal hyperplasia
acs. w/ intracranial saccular aneurysm & disection
Spontaneous dissection
FMD, marfran, coarc, intracranial ansm. Stroke risk
Familial Deficiency
Protein C, Protein S, or Antithrombin, or the presence of Factor V Leiden, or Prothrombin Gene
. Treatment for symptomatic individuals is often with anticoagulation.
Malignancies
can cause a poorly understood hypercoagulable state too. No specific testing is done when this is suspected beyond the search for the malignancy. As above, the peripheral venous events are much more common than any arterial event.
Sickle Cell Anemia:
SSA responds to transfusion. The Sickle Cell Trait cells can on occasion ‘sickle’ with dehydration or altitude, but this doesn’t seem to impart any additional risk of stroke or CNS hemorrhage.
Hyperviscosity States:
Protein, elevated hematocrit (60%), thrombocytosis (1,000,000), etc. can generate slowness of flow beyond the pump & pipes ability to compensate.
Oral contractive
implicated as a cause of stroke or venous thrombosis. This is a concern in patients who smoke, have other risks, or have subtle increases in blood pressure from OCP use.
. Hormone Replacement Therapy can either increase, or decrease your risk depending on the study.
Anecdotally, Neurologists note the triad of Migraine/Smokers/OCP increase risk by 25 times. Bonus if you add Cocaine or Meth, eh?
Antiphospholipid antibodies
cause a triad of spontaneous miscarriage, thrombocytopenia, and recurrent large vessel thrombosis, arterial or venous. attack of the phospholipid membranes in the platelet, and endothelium.
Rx is directed at the individual problem, and can involve no treatment, any antithrombotics, or even anticoagulation with warfarin.
Vasculitis
can affect the cns in many ways. T
Vasculitis has traditionally been considered a manifestation of immunological disorders, but over time, infectious causes are emerging. Varicella-Zoster Virus is increasingly being found in CNS vasculitis.
Venous Infarction
The most common cause is major head trauma. Most non-traumatic venous infarction occurs from dehydration, CNS infections, and hypercoagulable states (transient or genetic). Post-partum Sagittal Sinus Thrombosis around days 3-5 is a popular board question
Vasospasm
still being better defined to distinguish them from more typical inflammatory causes, but certainly sympathometic drugs, severe hypertension, primary vessel irritation (intrathecal drug, catheter contrast, SAH blood) trigger vasospasm that can cause permanent injury.
