Stroke - Guest Lecture Flashcards
(96 cards)
1
Q
a brain attack in which there is damage resulting from an alteration in cerebral blood flow
A
stroke
2
Q
what are the 2 types of stroke and what are their %
A
- ischemic: loss of blood flow - 87%
- hemmorhagic: 10% intracerebral and 3% subarachnoid hemorrhages
3
Q
causes no permanent damage visible on MRI and whose sx resolve 100%
A
transient cerebral ischemia (TIA)
4
Q
relative lack of O2 in arterial blood generally leading to altered metabolism and if not reversed, leads to cell death
A
hypoxia
5
Q
complete deprivation of O2 supply
A
anoxia
6
Q
potentially reversible tissue dysfunction secondary to hypoxia (however it may also result from organic poison, severe hypoglycemia); is always pathological
A
ischemia
7
Q
tissues are lacking something
A
ischemia
8
Q
ischemia can result in necrosis in vulnerable brain regions (ie hippocampus) in as little as
A
2 minutes
9
Q
irreversible tissue death that is the result of ischemia
A
infarction
10
Q
brain tissue destined to die; all dead
A
ischaemic core
11
Q
salvageable brain area; not all is dead, can potentially save this area
A
penumbra
12
Q
what is the 5th leading cause of death in the US and is leading cause of long term disability
A
stroke
13
Q
how often does someone die of stroke in US, accounting for 1/20 deaths
A
4 minutes
14
Q
how many adults over 20 have had a stroke already and how much is this expected to increase by 2030
A
7.2 million
3.4 million
15
Q
how many stroke occur in the US per year and how many are new strokes
A
800,000
610,000
16
Q
how much do strokes cost the US/year
A
34 billion
17
Q
what percent of strokes occur in people under 50
A
10%
18
Q
build up of plaque in arteries
A
atherosclerosis (build up of fat, cholesterol)
19
Q
a blood clot that breaks off and travels
A
embolism
20
Q
what are sources of emboli
A
- carotid (artery to artery embolism)
- cardioembolic (atrial fib, vegetations, low EF/LV thrombus, paradoxical embolism (PFO), hypercoagutable state)
21
Q
most common cause of clots in the heart and causes a rhythm problem; most common irregular heart rhythm problem
A
artial fibulation
22
Q
clot build up in the heart; may be sterile thrombus or infectious
A
vegetations
23
Q
most common ischemic stroke
A
lacunar infarcts
24
Q
small infarcts that affect the deeper parts of the brain
A
lacunar infarcts
25
what structures do lacunar infarcts affect
basal ganglia, thalamus, white matter
26
what % of all strokes are lacunar
20%
27
occurs due to occlusion of deep penetrating branches of major cerebral arteries
lacunar infarcts
28
what are lacunar infarcts associated with
hypertension, DM
29
involves small arteries and arterioles
hypertensive small vessel disease
30
types/affected hypertensive small vessel disease
athersclerosis
arteriosclerosis
maroaneurysms
31
thickened eosinophilic walls (lipohyalinosis)
arteriosclerosis
32
order of sensitivity to hypoxic ischemic encephalopathy
cerebral cortex and striatum --> thalamus --> brainstem
33
what area will have decreased blood flow first in brain with clogged arteries
the area furthest away from clot
34
what type of metabolism is the brain
aerobic
35
the brain lacks significant energy reserves so it required a continuous supply of well ____ _blood
oxygenated
36
how much blood and O2 does the brain require and how much does the brain weigh
20% cardiac output
15% O2 consumption at rest
brain is 2% total body weight
37
what brain structures are vulnerable to damage based on their high energy demands and metabolism
- purkinje cells of cerebellum
- pyramidal cells of CA1 - sommer's sector of hippocampus
- middle layers of cerebral cortex - laminar necrosis (3 and 5)
- brain stem nuclei in infants
38
what area of the brain (gray or white) is at the highest level of hypoxia/metabolic poison
gray matter
39
inflammation of blood vessel walls; causes arteries to squeeze down
vasculitis
40
what are the 3 layers of an arterial wall
endothelial intima
smooth muscle media
connective tissue adventitia
41
cause of vasculitis
unknown, often not infectious
42
what is vasciulitis divided into
- large vessel (aorta and its main branches)
- medium vessel (muscular arteries)
- small vessel (arterioles, capillaries, venules)
43
74 y/o pt presents with history of HTN, smoking and diabetes. he presents with L arm and leg weakness. MRI shoes lacunar stroke, what is likely cause
- atheroembolic
- carioembolic
- septic emboli
- small vessel ischemia
small vessel ischemia
44
risk factors for intraparenchymal hemorrhage
- hypertensive hemorrhage
- vascular malformations
- amyloid angiopathy
- hemorrhagic transformation of infarcts
- hemorrhagic tumors
- anticoagulation
45
locations of intraparenchymcal hypertensive hemorrhage
basal ganglia
thalamus
pons
cerebellum
cerebral hemispheres (lobar)
46
tangle of abnormal arteries interposed between a feeding artery and draining veins
arteriovenous malformation (AVM)
47
arteries most to least at risk for AVM
MCA > ACA > PCA
48
cluster of cavernous vessels without intervening stroma; just veins are involved
cerebral cavernous malformation
49
epilepsy or recurrent HA common signs; annual risk of bleeding is 1%; familial forms are common in those of Mexican-american heritage; autosomal dominant (CCM1-3 genes in chromosome 3 and 7)
cerebral cavernous malformation
50
may produce lobar hemorrhage; most cases are due to deposition of beta-amyloid (associated with AD) in leptomeningeal and cortical small arteries; proteins causing bleeding in the brain
cerebral amyloid angiopathy
51
brain tumors that are prone to hemorrhage
- gliomas (GBM/oligo)
- metastatic: melanoma, renal cell carcinoma, thyroid carcinoma, choriocarcinoma, lung CA
52
3rd most common cerebrovascular lesion (after cerebral infarction and hypertensive hemorrhage); rupture of a berry aneurysm is the most common cause
non-traumatic subarachnoid hemorrhage (SAH)
53
is the most frequent intracranial arterial aneuryrsm
berry aneurysm (aka saccular or congenital anneurysm)
54
where to aneurysms tend to occur most often
at vessel branch points in circle of willis
55
individuals with two first degree relatives who have _______ should be screened with cerebral vascular imaging
intracranial aneurysms
56
list s/s of stroke
vertigo, fatigue/depressed level of consciousness, dysarthria, aphasia, dysphagia, apraxia, agnosia, gaze preference, ataxia, neglect, disconjugate gaze
57
room spinning
vertigo
58
slurred speech
dysarthria
59
trouble producing speech, cannot say what they want, frustrated
expressive aphasia (Broca's)
60
say words but don't make any sense, cannot follow commands
receptive aphasia (wernickes)
61
difficulty swallowing
dysphagia
62
cannot perform purposeful movements; inability to use voluntary use of strength
apraxia
63
difficulty recognizing things
agnosia
64
with gaze preference, do the eyes look toward or away from the side of the stroke
toward
65
loss of coordination but limbs are still strong
ataxia
66
unable to acknowledge one side of the body, pt doesn't realize they have a problem
anosognosia (neglect)
67
can acknowledge each side individually, but when on both sides simultaneously, they will not be able to see/feel impaired side
extinction (neglect)
68
how to test for disconjugate gaze and how to interpret
test by coverign one eye at a time for 30 seconds
- brain problem: blurry vision that goes away when pt covers 1 eye
- eye problem: blurry vision that stays blurry when cover 1 eye
69
for every _____ that the brain is starved for blood, 2 million neurons, 14 billion synapse and 12 kilometers of myelinated fibers are destroyed
1 minute
70
for every _____ in delay to reperfusion decreases the likelihood of a good outcome by 10%
30 minutes
71
what are the indications for reperfusion via systemic IV thrombolysis
- age >/= 18
- clinical diagnosis of ischemic stroke
- clearly defined set of sx with onset less than 4/5 hours prior to treatment
- CT scan shows no evidence of intracranial hemorrhage
72
a drug to restore blood flow; only for ischemic stroke
IV thrombolysis
73
on a perfusion scan, what does the purple and green coloring indicate
green = penumbrum (sick of dead brain)
purple = dead brain (core)
74
barriers to recovery following stroke
- post-stroke depression/anxiety
- pain (spasticity, shoulder subluxation, central post stroke pain, disuse and abnormal postures)
- falls
- fatigue
- changes in lifestyle
- recurrent stroke
75
non-modifiable risk factors of stroke
age
gender
race
eclampsia/pre-eclampsia
history of TIA/stroke
76
genetic risk factors for stroke
hypercoaguable state
fabry disease
sickle cell
T21
CADASIL
77
modifable risk factors for stroke
hypertension
dyslipidemia
diabetes
obesity
obstructive sleep apnea
tobacco use
A-fib
medication/iatrogenic
drug/alcohol abuse
vascular disease (CAD/PAD)
78
what is the most important modifiable risk factor for stroke
hypertension
79
what is the target BP reduction in hypertension
< 130/80
80
_____ with intensive lipid-lowering effects is recommended to reduce the risk of stroke and CV events among pts with ischemic stroke or TIA presumed to be of atherosclerotic origin; has good benefits but medication often leaves pt with severe muscle pain that is out of proportion
statin therapy
81
for patients with a prior history of stroke or TIA a goal of HgBA1c of ___ is resonable
7%
82
what percentage of patients with a stroke or TIA have sleep disordered breathing
50-75%
83
the risk for stroke in an asymptomatic carotid disease (CAD) is ______ as symptomatic CAD
not as high
84
pts with aysmptomatic carotid stenosis should be prescribed what
daily aspirin and statin
85
angioplasty and/or stenting is considered investigational and should only be considered when
failure of medical therapy
intracranial surgical interventions
86
- may consider CEA in asymptomatic pts with > 70% stenosis if the risk of perioperative MI/stroke/death is <3%; CAS may be considered in this setting but effectiveness compared to best medical management is not clear
- consider CEA or CAS in symptomatic pts with > 70% stensosis by non-invasive imaging or > 50% by cath based imaging
carotid revascularization
87
that is the optimal medical therapy for all pts with carotid A stenosis and a TIA/stroke
antiplatelet therapy
statin therapy
risk factor modifcation
88
risk factors specific to women
- pregnancy, preeclampsia, gestational diabetes, TOC use and hormone replacement
- migraine with aura, diabetes, A-fib, psychosocial stress
89
family risk factors
those with a parent who suffered a stroke under age 65 were at 3x higher risk for stroke
90
conditions associated with increased risk
sickle cell disease
T21
fabry disease
MELAS
CADASIL
intrinsic hypercoaguable state
autosomal dominant polycystic kidney disease
91
3 antiplatelet agents
aspirin
cilostazol
clopidogrel
92
for primary prevention in those with 10 years risk > 10%, may also be considered in those with CKD
- for patients with bio-prosthetic heart valve
initial agent for secondary prevention without extenuating circumstances (allergy, severe CKD, PUD)
aspirin
93
for primary prevention in those with peripheral arterial disease or in some cases with aspirin
cilostazol
94
may be considered for secondary prevention in pts who fail aspirin therapy; need to consider hypo/non-responders
clopidogrel
95
- nonvalvular A-fib with chads2vasc >/=2
- mitral valve stenosis and an embolic event or L artrial thrombus
- those with heart failure and ambolic event
- potentially those with hypercoaguable state
- evaluation for those with cryptogenic stroke and ESUS
anticoagulation
96
primary or secondary prevention in valvular A-fib and those with mechanical aortic or mitral valves
warfarin
