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54 Cards in this Set

  • Front
  • Back
What non-modifiable risk factors have been associated with stroke?
Advancing age (independent factor)
Hypertension (#1 based on prevalance)
Hx of TIA
Atrial fibrillation associated with valvular dz increase risk the most, non-valvular afib less so
What is the most common cause of ischemic stroke?
Cardiogenic embolism
small penetrating arterial dz (lacunar infarct), large artery dz and cryptogenic stroke
What is the yearly mortality associated with all strokes?
Discuss the 30-day mortality rate of thrombotic and embolic stroke.
Embolic rate is higher then thrombotic due to the propensity to have further emboli in the brain.
What is the major underlying pathology associated with extracrainal/larger arteries in the brain?
deposition of lipid in the subendothelium (arterio/atherosclerosis) leading to ectasia and stenosis of arteries
What is ectasia?
vascular enlargement
What is a lacune?
small subcortical infarction associated with lipohyalinosis (lipid dep), disruption of arterial wall and fibrinoid necrosis of penetrating arteries. Most frequently occuring and most benign brain infarction.
What is the appearance of ischemic infarcts on CT?
Low density (hyodense)
What are early signs of infarction frequently noted on CT?
effacement of cortical sulci, or loss of cortical ribbon (area between frontal/temporal lobes) definition
How do infarcts appear on MRI?
T1? T2?
MRI infarcts appear as low signal or dark (hypointense)
on T1 weighted images. On T2 weighted images appear bright (high signal). On DWI very bright
What is ischemic penumbra?
Salvageable hypoperfused areas of the brain circrumscribing the necrotic area....detected with perfusion weighted imaging
What clincal syndromes are associated with occlusion of the middle cerebral artery?
1. hemiparesis
2. hemisensory loss
3. language deficit (w/left hemisphere involvement)
4. spatial/visual neglect
(w. right hemishpere involvement)
What clincal syndromes are associated with occlusion of the anterior cerebral artery?
weakness involving contralateral leg (least frequent)
What clincal syndromes are associated with occlusion of the posterior cerebral artery?
contralateral hemianopsia (visual field loss)
What clincal syndromes are associated with occlusion of the verterbral-basilar arteries?
vertigo, dysarthria, diplopia, ataxia, hemiparesis, hemisensory changes
Discuss syndromes associated with lacunar infarct?
1. pure motor hemiparesis
2. pure sensory loss
3. ataxic-hemiparesis
4. dysarthria-clumsy hand syndome
lacunar infarcts are due to occlusion of small subcortical penetrating arteries.
What symptoms are associated with multifocal and bilateral lacunes?
1.multi-infarct dementia
2. gait disorders
3 dysarthria
* This triad is called the lacunar state
What is the treatment/ work-up for ischemic stroke?
1. MRI, MRA, DWI, carotid dopplers
2. Echocardiogram (to rule out cardiac source) *look for PFO in young- a common cause of stroke from paradoxical embolus
3. Treatment of risk factors
4. *IV heparing anitcoagulation.
Define crescendo TIAs.
multiple Transient ischemic attackes occuring in a short period of time.
What is the benefit of IA rtPA versus IV tPA?
Intraarterial extends the window in which tPA can be administered to 6 hours for anterior circulation and 12 hourst for posterior circ.(brainstem)
What is the MERCI device?
A clot retrieval device that can be used withing 8 hours of the onset of ischemic stroke.
What patients should be considered for CEA (Carotid Endarterectomy)?
Patients with non-disabling infarcts that have symptomatic (stroke or TIA) internal carotid artery stenosis of > 70%, non-symptomatic the cutoff is 60% occlusion
Define "malignant" MCA Infarction? What is the treatment?
Hemispheric MCA infarct with significant edema. Tx: Hemicraniectomy with duroplasty or dehydrating osmotic agents (mannitol)
T/F CEA immediately following acute stroke is contraindicated?
T. Surgical cannulation of a thrombosed ICA following a cerebral infarction could lead to hemorrhagic conversion of bland infarct with resultant mass effect.
T/F carotid bruit is not neccessarily essential for Dx of carotid stenosis.
Presence of carotid bruit may indicated stenosis, but absence can indicate patency or highly stenosed vessel permitting very little flow.
How does one effictively prophylax against thrombotic stroke?
Antiplatelet agents
1. aspirin
2. Clopidogril (Plavix)
3. Aggrenox (combo of dipyrimadole and aspirin)
From where do brain emboli arise?
Cardiac sources (a-fib, mural thrombi, infective endocarditis)
Non-cardiac sources (artery-artery embolus from any atherosclerotic source)
Annuerysms...cardiac dissection
Where are most brain emboli localized?
Middle cerebral artery (MCA) affecting primarily cortical areas
Discuss the pathophysiology of hemmorrhagic conversion of ischemic stroke.
Emboli may break up after a brain infarction permitting reperfusion and hemmorrahgic infarction (hemorrhage will be high density white on CT scan)
What is the treatment for embolic infarction? What about embolic infarction secondary to carotid dissection.
Anticoagulation with IV heparin followed by warfarin for Embolic Stroke. Carotid dissection pts are anticoagulated for 6mos and converted to an aspirin/day.
What are the two causal pathologies associated with primary intracerebral hemorrhage?
Hypertension and cerebral amyloid angiopathy (CAA).
*CAA is frequently associated with lobar hemorrhage.
What are the four most common sites affected by hypertensive Intracerebral hemorrhage?
Basal ganglia (putamen)
What three factors determine the outcome of intracerbral hemmorhage?
1. Size of hemmorhage (>60cc has a 70-80% mortality)
2. Location (deeper lesions are worse)
3. Initial clinical presentation
How is ICH treated?
maintainenance of blood systolic pressure between (150-160mHg)
For what types of hemorrhages is surgical evacuation indicated?
Lobar or superficial, Surgical evacuation will reduce the mass effect
True/False. Surgical evacuation is indicated for deep hemorrhages in the left hemisphere?
False. Surgical evacuation in the dominant hemisphere may lead to speech difficulties. It is seldomly efficacous in deep hemorrhages.
Discuss the pathophysiology of subarachnoid hemorrhage (SAH)?
Saccular annuerysm ("berry")...occuring most often in women ages 40-60.
Less commonly (AVM) arteriovenous malformations as they bleed intraparenchymally young patients (not into the Sub arachnoid space). Typically present as the "worst headache of my life"
What are the three most common sites for saccular annuerysms?
1. Junction of ICA and 1.Posterio communicating arteries
2.ACoM a
4.PICA (posterior internal carotid)
What is xanthochromia?
yellow-tinged appearanec of CSF due to breakdown of blood products...usually seen in SAH
T/F. A normal CT scan rules out Subarachnoid hemmorrhage.
False. LP should be performed as xanthochromia is typically present 6 hours after SAH.
What are secondary complications of SAH?
1. Rebleeding (clipping or coil embolization reduces risk)
2. Vasospasm or (DCI) delayed cerebral ischemia- due to irritation of vasculature by metabolic products of blood
What is the treatment for SAH?
Nimodipine (oral Ca channel blocker)...prophylaxis for vasospasm.
For what pathology is treatmemnt "triple-H" indicated?
Vasopasm. 3H (hypertension, hemodilution and hypervolemia) instituted to restore or aid perfusion
What vasculopathies are frequently associated with brain infarctions and TIA's?
dysimmune vasculopathies such as SLE, thrombotic thrombocytopenic purpura and antiphospholipid antibody syndrome.
What symptoms are frequently associated with TIA's?
Transient aphasia, dysarthria, numbness/weakness on one side of the body, loss of vision in one or both eyes
diploplia, vertigo
Define aphasia.
language difficulty
Define dysarthria.
slurred speech
Define amaurosis fugax & hemianopsia.
loss of vision in one or both eyes respectively.
True/False. Loss of consciousness are frequently associated with TIA's.
False. Loss of consciousness is rare with TIA's
True/False. Cardiac Emboli are rarely causal for TIA's.
Why is TIA considered a medical emergency?
5% of patients have a stroke within 2days of TIA onset. 10% have strokes within 90days after onset.
How is TIA treated?
Dependent upon etiology...if carotid artery stenosis (70%) CEA is recomended. Otherwise anticoagulation with warfarin or antiplatelet therapy (aspirin, clopidogrel or aggrenox) reduce recurrence of TIA or stroke.
True/False. Low dose of alcohol is neuroprotective against stroke.
True/False. If you have a stroke your risk of dying will be from a subsequent stroke.