Vascular Neurology Flashcards by Christian Bernardo

4 classes of ischemic stroke

transient ischemic attack (TIA)
reversible ischemic neurologic deficit
evolving stroke
completed stroke

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TIA vs. stroke

main difference is in DURATION of symptoms
TIAs usually last a few minutes to less than 24 hours
blockage of blood flow does not last long enough to cause permanent infarction

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Why are TIA symptoms transient

reperfusion occurs (either due to collateral circulation or break up of embolus)

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Etiologies of TIA

embolic (most common)

but transient hypotension 2/2 carotid artery stenosis (>75% occlusion) can also cause

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TIA increases risk for…

STROKE in coming months

10% per year and 30% 5- year risk of stroke

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risk factors for ischemic stroke

2 MOST IMPORTANT = age and HTN

others - smoking, DM, hyperlipidemia, afib, CAD, fmaily hx of stroke, PREVIOUS STROKE/TIA, carotid bruits

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risk factors for stroke in younger patients

OCP use
hypercoagulable states (protein C/S def, APA syndrome, cocaine/amphetamines, polycythema vera, sickle cell

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transient, curtain like loss of sight in ipsilateral eye due to microemboli to the retina

amaurosis fugax (example of TIA)

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common sources of emboli that cause stroke

heart (mural thrombus from afib)
internal carotid artery
aorta
paradoxical stroke (ASD, patent foramen ovael, pulmonary AV fistula)

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thrombotic strokes occur due to atherosclerotic plaques in which arteries typically

large arteries of neck (carotid artery usu. at bifurcation of common carotid)
medium sized arteries of brain; i.e. middle cerebral artery MCA)

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where do you typically see lacunar strokes

in small vessels of brain

usually affects subcortical structures (basal ganglia, thalamus, itnernal capsule, brainstem)…NOT CORTEX

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how to evaluate for source of embolic stroke

echocardiogram
carotid doppler
ECG, holter monitoring

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predisposing factors for lacunar stroke

hx of HTN!

DM also important risk factor

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symptoms of vertebrobasilar arterial insufficiency

dizziniess, double vision, vertigo, numbness of ipsilateral face and contralateral limbs, dysarthria, hoarsness, dysphagia
caused by decreased perfusion in posterior fossa

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subclavian steal syndrome

stenosis of subclavian artery proximal to origin of vertebral artery - exercise of left arm causes reversal of blood flow down the ipsilateral artery to fill the subclavian artery distal to stenosis because it cannot supply adequate blood to left arm; leads to decreased cerebral blood flow “stolen” from basilar system

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BP in left arm is less than right arm; decreased pulses in left arm

subclavian steal

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treatment for subclavian steal syndrome

surgical bypass

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stroke with contralateral lower extremity and face

ACA

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stroke with aphasia, contralateral hemiparesis

middle cerebral artery

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dizziness, double vision, numbness of ipsilateral phase, contralaterla limbs, dysarthria, hoarseness, dysphagia, projectile vomiting, headahces, drop attacks

vertebrobasilar system

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pure sensory deficit

thalamus

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pure motor hemiparesis

internal capsule

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alexia without agraphia

left PCA

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patient presents to ED with stroke like symptoms…what to do and in what order

1) non contrast CT head
2) ECG, chest radiograph
3) CBC, plts
4) PT/INR
5) electrolytes
6) glucose
7) bilateral carotid ultra sound
8) echocardiogram

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how do ischemic strokes look on non contrast CT?

dark area

If you suspect stroke, but CT negative...what other test can you order?

MRI | more sensititive but no ideal in emergencies

What labs to order in YOUNG patient with stroke

high suspicion for vasculitis, hypercoagulable, or thrombophilia get: protein c, protein s, antiphospholipid antibodies, factor V leiden mutation, ANA/rheumatoid factor, ESR, VDRL/RPR, Lyme serology, TEE DON'T FORGET COCAINE NIGGA

definitive test for identifying stenosis of vessels of head and neck, and check for aneurysms

magnetic resonance angiogram (MRA) | evaluates carotids, vetebrobasilar circulation, circle of Willis, ACA, MCA, PCA

complications of stroke (3)

cerebral edema within 1-2 days -> mass effect seizure hemorrhage into infarction

When not to give TPA

- more than 3 hours have passed - uncontrolled HTN - bleeding disorder - patient is taking anticoagulants - hx or recent trauma or surgery these all increase risk for hemorrhagic transformation

If patient presents after 3 hours of stroke, what to give? | if patient can't take that, what else to give?

aspirin only! if not, clopidogrel if not, clopidogrel....ticlopidine

if patient is given TPA, what else can be given to reduce bleeding risk?

antihypertensives! do NOT give aspirin (this will make bleeding worse)

When to give warfarin/heparin for stroke

these haven't been proven effective in acute setting

antihypertensives are typically not given in stroke unless....

1) super high BP (>220/120) 2) patient is receiving tPA 3) acute MI< aortic dissection, severe heart failure, hypertensive encephalopathy

indications for carotid endarterectomy in preventing stroke in the setting of carotid artery atherosclerosis

1) symptomatic | 2) >70% occlusion

how to prevent carotid atherosclerotic strokes in NON-symptomatic patients

aspirin, BP control, control DM, smoking cessation, reduce obesity and hypercholesterolemia

how to prevent embolic strokes

aspirin, warfarin/NOACs if afib, reduction of atherosclerotic risk factors

how to prevent lacunar stroke

HTN control

causes of hemorrhagic stroke

1) HTN, particularly sudden increase 2) ischemic stroke converting to hemorrhagic stroke 3) amyloid angiopathy, iatrogenic (anticoag/antithromb use), brain tumors, AVMs)

locations of hemorrhagic stroke

basal ganglia (MOST COMMON) pons cerebellum

how to hemorrhagic strokes present

sudden focal neurologic deficit altered levels of consciousness, stupor/coma headache/dizziness/vomiting from increased ICP

in addition to noncon CT head, what panel to get in evaluating for hemorrhagic stroke

coag panel

complications hemorrhagic stroke

``` increased ICP rebleeding seizure hydrocephalus SIADH vasospasm ```

In ICH, what pupillary findings can be seen if pons, thalamus, and or putamen involved?

pons - pinpoint pupils thalamus - poorly reactive pupils putamen - dilated pupils

how to acutely manage hemorrhagic strokes

ICU admission ABCs NIGGA DAYUM BP control reduce ICP with mannitol/diuretics and hyperventilation

Dangers with aggressive BP control in hemorrhagic stroke

correcting too quickly can reduce CPP which will worsen neurologic deficit

Is surgery helpful for ICH?

not usually, treatment usually supportive for intraparenchymal bleeds DO IT FOR CEREBELLAR BLEEDS THOUGH, they can be life saving

subarachnoid hemorrhage (SAH) often occurs at junction of anterior communicating artery and...

ACA

SAH often occurs at bifurcation of....

MCA

SAH often occurs at junction of posterior communcating and....

internal carotid SAH's HAPPEN AT JUNCTIONS...see the pattern?

Where can you typically find berry/saccular aneurysms?

bifurcations

If you see a patient with polycystic kidney disease, you should check for...

BERRY ANEURYSMS

MCC SAH

berry aneurysm rupture can also be caused by trauma/AVMs

besides "worst headache of my life" how can SAH present?

``` sudden LOC vomiting meningismus (photophobia/nuchal rigidity/meningeal irritation) retinal hemorrhage death ```

First test for SAH....and if this is unrevealing, what to get?

non con CT | LP to look for blood in CSF/xanthochromia

once SAH is diagnosed, what test to get?

cerebral angiogram to detect bleeding source (and for surgical clipping)

If suspect SAH, CT negative, and there is papilledema, what test to get?

NOT LP!!! YOU CAN CAUSE HERNIATION | repeat CT first

contraindications for LP

``` herniation infection overlying puncture site bleeding disorder/coagulopathy brain abscess increased ICP (do imaging first) mass lesion (do imaging first) ```

treatment SAH

CONSULT NEURO

non surgical rx SAH

reduce rebleeding risk and cerebral vasospasm - bed rest - stool softeners to reduce straining - analgesia for headache - IV fliuds - gradual lowering of BP

what pharmacotherapy to prevent cerebral vasospasm

nifedipine

5 "deadly D's" of posterior circulation strokes?

``` Diplopia dizziness dysphagia dysarthria drop attacks + vertigo ``` can also cause homonymous hemianopsia

MCA strokes can cause CHANGes. | What CHANGes?

``` Contralateral paresis and sensory loss in face/arm Hemiparesis Aphasia (dominant) Neglect (non dominant) Gaze preference toward side of lesion ```

Vascular Neurology Flashcards

(63 cards)