Lecture 16 and 17 -- CVD Flashcards Preview

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Flashcards in Lecture 16 and 17 -- CVD Deck (27):
1

what are two types of stroke

what is the only way to differentiate the two?

Hemorrhagic and Ischemic

Imaging

2

what are the two types of hemorrhagic stoke?

what imaging type is best for to see a hemorrhagic stroke

SAH

ICH

CT scan -- quick and good for fluid

3

underlying causes of SAH

Berry Anuerysm -- ballooning of an artery, weakening of the wall; typically in the branch points of Ant. Comm artery

Arterio-Venous Malformation -- abnormally direct communication between arteries ---> Veins without intervening capillary bed. Venous system exposed to high arterial pressures.

4

underyling causes of ICH?

HTN -- long standing atheroscloerosis

Cerebral Amyloid Angiopathy -- degenerative deposition of Amyloid in aterial walls of cortical vessels

Aneurysm, AVM

5

Treatment of hemorrhagic stroke?

Medical emergency; ICU; Neurosurgery consult

do not give TPA

6

Clinical defition of an ischemic stroke?


what imaging is used to view acute ischemic stroke?

Clinical manifestation of a CNS Infarcton
Sudden onset, focal deficits lasting > 24 hours
evidence of infarctioin on imaging

diffuse weighted MRI (this will not show up on CT)

7

brain's compesnation mechanisms for reduced blood flow...

Vasodilation -- increased transit time

Anaerobic metabolism -- but when all energy resoruces depleted....

electrical failure --- TIA, stroke

8

what is a TIA
how should it be managed clinically

TIA -- transiet ischemia attach
transiet focal neurological deficits
No actual infarction
Technically TIA if symptoms last less than 24 hours (but in reality if symptoms last more than 2 hours, they are going to last more than 24 hours)

Warning sign for acute ischemic stroke; should not be ignored

9

ischemic penumbra vs ischemic core

penumbra: reversbile infarction

Core: irreversible

core grows with time
time = brain

10

rank the following in regards to sensitivity to ischemia from least to most:

oligodendrocytes, neurons, endothelium, astrocytes

Least: Endothelial cells

astro

Oligo

Neurons (hippo, purkinje cells, pyramidals of cortex, neostriatum)

11

what are 4 ways in which patients can deteroirate in the setting of ischemic stroke

Cytotoxic Edema --

Hemorrhagic Conversion

Herniations

Recurrent ischemic stroke --

12

Cytotoxic edema

pathophysiology --

how does this kill you?

how can this be alleviated?

Increased permeability of neuronal and glial cell membranes results in intracellular swelling

Kills you - -- mass effect--> herniation

Alleviated -- Hemicraniectomy

13

Review of imaging for storkes:
hemorrhagic?
acute ischemic?
cytotoxic edema?

CT

Diffusion weighted MRI

CT

14

Hemorrhagic COnversion --
what is it?
difference between large and small strokes?
how does it kill you?
alleviate this?

Friable endothelium; blood leaks out into parenchyma upon reperfusion

Large stroke -- parenchyma is dead and therefore will not be symptomatic

Small stroke - parenchyma is viable; reperfusion will lead to further damage == symptoms

Kills you --- herniation

alleviate this -- hemicraniectomy

15

hemicraniectomy differences between and outcomes for lesions above the tentorium and below the tentorium

above the tentorium -- slower deterioration; hemicraniectomy will save your life but you have had a massive stroke; therefore quality of life outcomes poor as patients have significant neuro deficits

below the tentorium (cerebellum) -- can deteriorate very quickly without intervention; but following hemicraniectomy, outcomes are good becuase of redundant wiring of the cerebellum

16

Treatment for ishcemic stroke

TPA (alteplase)


Mechanical Clot Extraction Devices

17

Know anterior vs posterior vascular lesions and manifestations; esp regarding vision

Example:
Isolated Homonymous hemianopia = ?

Unilateral monocular blindness = ?

***

Isolated Homonymous hemianopia = PCA


Unilateral monocular blindness = Ophthalamic artery

18

Etiologies and subtypes of ischemic stroke ***

atherothrombotic cerebrovascular disease

Penetrating artery Disease -- Small artery Disease -- Lacunar Stroke


Cardiogenic Embolism

Other unusual Stroke

Idiopathic -- 20 to 40%

19

atherothrombotic cerebrovascular disease

what vessels?
how can this be visualzed?
pathogenesis

Arterial Stenosis in the Head or Neck (Large intra cranial arteries; Extra cranial -- carotid arteries)

Artery to artery Emboli
Stenosis --> slowed blood --> thrombus --> Embolism

20

treatment of atherothrombotic cerebrovascular disease -

l Carotid Endarterectomy --

Angioplasty Stenting --

21

Penetrating artery Disease -- Small artery Disease -- Lacunar Stroke

what vessels?
pathology of these vessels --

Base of brain, lenticulostriates, cerebellum

Lipohyalnaosis -- thickening of the vessel wall, but its weak

Antherosclerosis

22

Manifestations of Penetrating artery Disease -- Small artery Disease -- Lacunar Stroke

Deep penetrating arteries --- therefore don't have cortical deficits


Lacunar clinical Syndromes --- No Cortical Dysfunction:
Pure Motor Hemiparesis --- no sensory findings, visual findings

Pure hemi-sensory loss --- just sensation

23

Cardiogenic Embolism

most commonly?
imaging?

AFIB
Mechanical heart valves, Acute MI, Abn heart valves, Endocarditis

acute infarcts on MRI that are on both hemipshers, anterior and posterior

24

treatment and previton of Cardiogenic Embolism

Treatment -- TPA

Prevention -- Full does Anticoagulation
Wafarin (VKOR1)
Dabigitran (direct thrombin)
Rivorxaban/Apixaban (direct 10a)

25

antiplatelet therapies

ASA
Plavix
Aggrenox -- ASA/Extended release dipyridamole

26

Non modfiable risk factors

Age --- exponential increase; although any age can get a stroke
Gender -- post menopausal women (lower estrogen)
Race -- African Americans
Prior stroke --

TIA

27

Modifiable risk factors

most easily modifiable?

Afib -- Warfarin;
Stenosis of Internal carotid Artery -- HTN -- 30-40% reduction in stroke when HTN is controlled Tobacco Use -- Framhingham HLD --atherothrombotic stroke; vascular disease elsewhere
DM

Most easily modifiable -- HTN and Tobacco