Cerebrovascular Diseases

Front 1

Definition and causes of Cerebral Infarction- Carotid Circulation

Back 1

Thrombotic or embolic occlusion of a major vessel in the carotid circulation. Disorders predisposing to TIA and atheroscelrosis.

Front 2

Oclussion of what arteries is common in Cerebral Infarction - Carotid Circulation?

Back 2

• Opthalmic artery
• Anterior cerebral artery
• Anterior communicating artery
• Middle cerebral artery

Front 3

Oclussion of what arteries is common in Cerebral Infarction- Vertebrobasilar Circulation

Back 3

• Posterior cerebral artery
• Vertebral artery
• Posterior inferior cerebellar artery
• Basilar Artery

Front 4

Gold Standard for cerebral infarction?

Back 4

• CT scan of head
• Follow with diffusion-weighted MRI to define distribution and extent of infarction

Front 5

Tx of cerebral infarction?

Back 5

1) 1st line: Aspirin
2) IV thrombolytic therapy with recominant tissue plasminogen activator (rtPA) effective in reducing neurologic deficit when administered ASAP
3) Heparin

Front 6

Definition and causes of Cerebral Infarction- Carotid Circulation

Back 6

Thrombotic or embolic occlusion of a major vessel in the vertebrobasilar circulation. Disorders predisposing to TIA and atheroscelrosis.

Front 7

S/S of Cerebral (carotid) infarction?

Back 7

1) Anterior communication artery: weakness and cortical sensory loss in contralateral leg or arm.
2) Opthalmic artery: amaurosis fugax (sudden adn brief loss of vision)
3) Middle Communicating artery: contralateral LE hemiplegia and sensory loss & global aphasia

Front 8

Definition of Cerebral hemorrhage- Arteriovenous malformation?

Back 8

Congenital vascular malformations that result from a localized maldevelopment of part of the vascular plexus.

* Results in ruptured aneurysm in subarachnoid space if intravascular pressure increases high enough

Front 9

Clinical Presentation of arteriovenous malformation?

Back 9

1st sympt may be from stroke
confusion, tinnitus, gait, HA, seizures
Supratentorial lesions:
* HA (sometimes similar to migraine)
* Seizure
* Bruit over ipsilateral eye or mastoid region: (-) bruit does’t rule out AVM

Infratentorial:
* Usually clinically silent

Front 10

Two regions of arteriovenous malformation?

Back 10

Supratentorial: Most common
Usually ruptures before age 40

Infratentorial: brainstem

Front 11

Preferred imaging for AVM?

Back 11

* CT

* Angiography demonstrates vessels

Front 12

Tx of AVM?

Back 12

* Surgery if AVM has bled

* If not, prevent further progression of neurologic deficit

Front 13

Intracerebral hemorrhage - definition

Back 13

Subtype of intracranial hemorrhage that occurs within the brain tissue itself. Microaneurysms develop on perforating vessels in HTN pts

Front 14

Intracerebral hemorrhage - common sites/causes

Back 14

* MC in basal ganglia
* MC from trauma or ruptured aneurysm

Front 15

Three common risk factors of intracerebral hemorrhage?

Back 15

1) Hypertension (especially non-traumatic)
2) Bleeding disorders (sickle cell, cumaden, clotting disorders)
3) Amyloid angiopathy (in elderly)

Front 16

General Clinical Presentation of intracerebral hemorrhage?

Back 16

* Consciousness initially lost or impaired in about ½ of pts

* Vomiting/Headache

* Focal neuro symptoms by site

* Hemiplesia/hemiparesis or Hemisensory disturbance w/ deeply placed lesions

* meningeal irritation - nuchal rigidity

Front 17

Preferred imaging in intercerebral hemorrhage?

Back 17

* Non-contrast CT superior to MRI

* Angiography may be indicated to exclude aneurysm or AVM

Front 18

What is contraindicated in intercerebral hemorrhage?

Back 18

Lumbar puncture; may cause herniation

Front 19

Cerebral infarction (Anterior Communicating artery) - presentation

Back 19

* causes weakness and cortical sensory loss in the contralateral leg and sometimes mild weakness of the arm, especially proximally.

* Bilateral anterior cerebral infarction is especially likely to cause marked behavioral changes and memory disturbances.

Front 20

Cerebral infarction (middle cerebral artery) - presentation

Back 20

* contralateral hemiplegia, hemisensory loss

* homonymous hemianopia (ie, bilaterally symmetric loss of vision in half of the visual fields)

* eyes deviated to the side of the lesion.

Front 21

Cerebral infarction (posterior cerebral artery) - presentation

Back 21

may lead to a thalamic syndrome in which contralateral hemisensory disturbance occurs, followed by the development of spontaneous pain and hyperpathia.

Front 22

Cerebral Infarction - Tx

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* IV thrombolytic therapy with recominant tissue plasminogen activator (rtPA)
* Elevated intracranial pressure is managed by head elevation and osmotic agents such as mannitol.

Front 23

Cerebral Infarction - Tx * Caution w/ pts during the acute (<2wks)?

Back 23

* Attempts to lower the blood pressure of hypertensive pts of a stroke should generally be avoided

* loss of cerebral autoregulation, and lowering the blood pressure may compromise ischemic areas.

Front 24

Intracranial aneurysm - definition

Back 24

* Cerebrovascular disorder in which weakness of the walls of a cerebral artery casues ballooning

Front 25

MC location of an intracranial aneurysm?

Back 25

anterior circle of willis

Front 26

Saccular aneurysms, “berry type" - definition

Back 26

* tend to occur at arterial bifurcations, are frequently multiple (20% of cases), and are usually asymptomatic.

* associated with polycystic kidney disease and coarctation of the aorta.

Front 27

higher risk of subarachnoid hemorrhage is associated with?

Back 27

older age, female sex, “non-white” ethnicity, hypertension, tobacco smoking, high alcohol consumption

Front 28

S/S of aneurysms?

Back 28

* focal neurologic deficit by compressing adjacent structures. However, most are asymptomatic or produce only nonspecific symptoms until they rupture

* Could have sudden severe headache
* Nausea/Vomiting/Vision impairment/LOC

Front 29

Tx for aneurysm?

Back 29

* Prevent further bleeding by clipping aneurysm or coil embolization

* Ctrl HTN (do not lower diastolic below 100mmHg),

* Phenytoin (anti-siezure), Nimodipine (prevent vasospasm)

Front 30

MC cause of subarachnoid hemorrhage?

Back 30

Trauma.

Front 31

MC cause of non-traumatic subarachnoid hemorrhage?

Back 31

usually rupture of “berry” aneurysm or AVM

Front 32

Risk factors of subarachnoid hemorrhage?

Back 32

• Smoking
• Hypertension
• Hypercholesterolemia

Front 33

Presentation of a subarachnoid hemorrhage?

Back 33

* Sudden onset of the "worst HA of my life"
* Sever N/V leading too LOC
* Signs of meningeal irritation usually present, after a few hrs

Front 34

subarrachnoid hemorrhage HA is caused by?

Back 34

* Herald bleed or “warning leak” causing focal deficits my be present but not always. The “sentinel HA”

Front 35

Preferred imaging for a subarrachnoid hemorrhage?

Back 35

* CT (preferably w/ CT angiography) to confirm diagnosis <24 hrs

* >48hrs use MRI

* CT negative and suspicion high, perform lumbar puncture for RBC/high opening pressure

Front 36

Tx for a subarachnoid hemorrhage?

Back 36

* clipping aneurysm or coil embolization

* Ctrl HTN
* Phenytoin to ctrl seizure
* Manitol to reduce bleeding
* Nimopidine prevent vasospasm

Front 37

Lacunar Infarction - definition

Back 37

Small lesions that occur in distribution of short penetrating arterioles in the deeper parts of the brain

Front 38

Lacunar infarction - etiology

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• Affects the basal ganglia, pons, cerebellum, internal capsule
• Neurologic deficit may progress over 24-36 hrs before stabilizing

Front 39

4 characterics syndromes of lacunar infarctions?

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1. Pure sensory stroke (more common)
2. Pure motor hemiplegia- with internal capsule infarction
3. Ipsilateral ataxia w/ leg paresis
4. Dysarthria w/ clumsiness of hand

Front 40

Diagnostic findings for lacunar infarction?

Back 40

• CT as small, punched-out, hypodense areas
• Diffusion-weighted MRI sensitive to acute lesions

Front 41

Tx of lacunar infarction?

Back 41

* usually partial or complete resolution occurring over 4-6 weeks in many instances
* 1st line of tx: Aspirin and blood thinners (prines)
* Longterm- control risk factors (HTN, DM)

Front 42

Transient Ischemic Attack (TIA) - definition

Back 42

stroke-like symptoms that last less than 24 hrs, then symptoms resolve completely

Front 43

carotid circulation pts with a TIA may have?

Back 43

* Hand-arm weakness w/ sensory loss,
* Ipsilateral visual symptoms or aphasia
* Amaurosis fugax.
* possible bruit

Front 44

Vertebrovascular TIA pt's may present w/?

Back 44

* Diplopia * Ataxia * Vertigo * Dysarthria
* Cranial nerve palsies * LE weakness
* Perioral numbness * Drop attacks

Front 45

Tx for non-cardiogenic TIA?

Back 45

Prophylactic antiplatelet (aspirin, ticlopidine, etc.)

Front 46

Tx for Cardiogenic TIA?

Back 46

• Anticoagulation therapy
• Initially IV heparin for those admitted to hospital
• Warfarin for long-term tx

Front 47

Arteriovenous malformation - definition

Back 47

Congenital vascular malformations that result from a localized maldevelopment of part of the vascular plexus

Front 48

Arteriovenous malformation may lead to what more severe Dx?

Back 48

ruptured aneurysm in subarachnoid space if intravascular pressure increases high enough