Wake Cv Extracranial Cerebrovascular Disease

Front 1

What percentage of strokes are Hemorrhages?

Back 1

~20% of strokes

Aneurysms
Trauma
Anticoagulation related
Congenital anomalies

Front 2

What percentage of strokes are Ischemia?

Back 2

~80% of strokes

Front 3

What is the principal modifiable risk factor for stroke?

What are the other risk factors?

Back 3

HYPERTENSION

- increasing age
- cadriovascular disease (esp. atrial Fib)
- cigarette smoking
- carotid stenosis

Front 4

Stroke

Back 4

a focal neurological deficit related to neuronal cell death with signs and symptoms lasting greater than 24 hours

Front 5

Transient Ischemic Attack
(defintion and symtoms)

Back 5

a focal neurological deficit with signs and symptoms lasting less than 24 hours

- contralateral paresis
- contralateral numbness
- aphasia (if left hemispheric lesion)

Front 6

What areas of the brain does the anterior cerebral artery supply blood for?

Back 6

motor functions of arms and legs

Front 7

How does vascular disease cause stroke?

Back 7

- low flow/occlusion
- embolism (*** the vast majority)

Front 8

Ischemic Stroke Pathophysiology

Back 8

- Cadiac Source 20-40%
- Atherothrombotic 20-40%... i.e. carotid stenosis
- Lacumar infarcts 15-25%

Front 9

What are lacunar infarcts associated with?

Back 9

DM
HTN

Front 10

Major cause of preventable stroke

Back 10

- CAROTID DISEASE
- Vertebrobasilar disease (posterior circulation)
- Watershed/hypotension
- Idiopathic (in MCA or ACA)
- Iatrogenic

Front 11

What is the most common culprit in the production of stroks associated with atherosclerosis?

Back 11

Disease of the carotid bulb...rich source of emboli

Front 12

What are other causes, beside atherosclerosis, that cause carotid disease?

Back 12

Fibromuscular Dysplasia

Arteritis
- Takayasu’s
- Giant Cell Arteritis

Dissections

Radiation

Front 13

What are the risk factors associated with carotid disease and stroke?

Back 13

- ADVANCED AGE
- CIGARETTE SMOKING
- Hypertension
- CV disease
- Other PVD
- Hyperlipidemia

Front 14

What are symptoms for Carotid Stenosis

Back 14

- TIA

- Amaurosis fugax

- Completed Stroke

- Vertebrobasilar symptoms*

Front 15

Amaurosis fugax

Back 15

Temporary ipsilateral monocular visual loss due to embolization of retinal artery or branches

- ipsilateral carotid artery stenosis

- Visual field defect
- ‘Like a black shade’
- Not scotomas or ‘floaters’
- May see Hollenhorst plaques on fundoscopic exam

Front 16

Dx of Carotid Stenosis

Back 16

*** Carotid duplex
(Gold standard, Non-invasive, Safe)

CTA arteriography

MR Arteriography

Digital subtraction angiography

Front 17

If you have an asymptomatic carotid plaque, what is your stroke risk?

Back 17

(asymptomatic=carotid bruits detected)

5 year stroke risk ~11% with 60%+ stenosis

Front 18

If you have an symptomatic carotid plaque, what is your stroke risk?

Back 18

2 year stroke risk ~15-30% (50% or greater stenosis)

... may have the highest risk in days to weeks following the initial symptoms

Front 19

Secondary Prevention/ Medical Management

Carotid Stenosis

Back 19

Hypertension Management

Smoking Cessation

Lipid Management
- Statins

Diabetes Management

Antiplatelet agents
- Aspirin, Clopidogrel
- Dipyridamole, Ticlopidine

Front 20

Do you qualify for medical therapy and/or surgical therapy if you are:
symptomatic patients with <50% stenosis?

Back 20

medical therapy WITHOUT revascularization

Front 21

Do you qualify for medical therapy and/or surgical therapy if you are:
asymptomatic patients with <60% stenosis?

Back 21

medical therapy WITHOUT revascularization

Front 22

Do you qualify for medical therapy and/or surgical therapy if you are:
symptomatic patients with 50-99% carotid stenosis?

Back 22

carotid endartectomy PLUS medical therapy

Front 23

Do you qualify for medical therapy and/or surgical therapy if you are:
asymptomatic patient with 60-99% stenosis and low perioperative risk?

Back 23

carotid endartectomy PLUS medical therapy

Front 24

When is carotid stenting indicated?

Back 24

- high risk symptomatic patients with high grade lesions may be treated
- asymptomatic patients with critical (80% or greater) lesions and anatomic conditions precluding open endarterectomy

Front 25

Should carotid stents be placed in the elderly?

Back 25

No because a stent is a higher risk for stroke than the surgery

Front 26

Is carotid stenting a good procedure?

Back 26

Unproven Durability

Excellent stroke protection

? Higher perioperative stroke rates

Awaiting randomized data

Front 27

Is carotid endarterectomy a good procedure?

Back 27

Excellent Durability

Excellent stroke protection
(60-70% risk reduction of ipsilateral stroke within 5 years)

Safe

Front 28

Vertebrobasilar Stroke
Symptoms

Back 28

Dizziness
Vertigo
Diplopia
Blurred vision
Ataxia
Drop attacks
Bilateral sensory disturbances

- symptoms are much more frequently due to LOW FLOW then embolization

Front 29

What areas of the CNS are effects with Vertebrobasilar Stroke?

Back 29

cerebellum, pons, and medulla are affected

Front 30

Risk factors for Vertebrobasilar Stroke?

Back 30

Smoking

Advanced age

Other vascular disease

Cardiovascular disease

Front 31

What are the results of Vertebrobasilar Strokes?

Back 31

- severe disability

- high mortality

Front 32

Vertebrobasilar Stroke is usually associated with...
pathophysiology

Back 32

Flow limiting lesions- almost always MULTIPLE VESSELS (3+)
- Innominate artery
- Subclavian arteries
- Vertebral arteries (Retrograde flow)
- Carotid arteries

Front 33

What symptoms are much more common from decreased flow related phenomena?

Back 33

SYSTEMIC HYPOTENSION (main worry when there are multiple vessels with lesions... b/c you cannot compensate)

bradyarrhythmias
tachyarrhythmias
autonomic dysfunction
anatomic compression

Front 34

Lesions in which vessels put you at risk to emboli that cause Vertebrobasilar strokes?

Back 34

Innominate artery
Subclavian arteries
Vertebral arteries

Front 35

Presentation of other diseases that can be mistaken as Vertebrobasilar Strokes?

Back 35

Head turning
- Differential includes anatomic compression, middle ear

Rising from sitting or standing
- Differential includes postural hypotension, diabetic autonomic neuropathy

Usage of upper extremities

Front 36

Dx of Vertebrobasilar Disease

Back 36

Pulse examination
- Upper extremity blood pressures

Duplex assists in defining carotid issues
- Can assess flow in vertebrals
- TRANSCRANIAL DOPPLER to assess intracranial flow

Imaging
- CT arteriography
- MR arteriography
- Digital subtraction arteriography

Front 37

What are the inidications for treatment in cases of vertrbrobasilar ischemia?

Back 37

Known vertebrobasilar ischemia to increase blood flow to the basilar artery or prevent further embolization

Known extensive symptomatic extracranial occlusive disease with symptoms of global hypoperfusion

Front 38

Secondary Prevention/ Medical Management
in Vertebrobasilar Ischemia

Back 38

Hypertension Management

Smoking Cessation

Lipid Management
- Statins

Diabetes Management

Antiplatelet agents
- Aspirin, Clopidogrel
- Dipyridamole, Ticlopidine

Front 39

Is surgery indicated with known vertebrobasilar ischemia to increase blood flow to the basilar artery or prevent further embolization?

Back 39

Specific subclavian or vertebral artery must be treated
- Bypass
- Endarterectomy
- Angioplasty and stenting

Front 40

Is surgery indicated with known extensive symptomatic extracranial occlusive disease with symptoms of global hypoperfusion?

Back 40

hx of TIA in posterior circulation or symptoms of global hypoperfusion

- Often easier to treat anterior (carotid) disease first

- Can use transcranial doppler to assist in guiding vessel choice

Front 41

Giant Cell Arteritis

Back 41

- Also referred to as temporal arteritis
- Most common in older (7-8th decade) Caucasian women
Temporal headaches
Jaw claudication
Polymyalgia rheumatica
Amaurosis
Constitutional symptoms
Elevated sedimentation rate

Front 42

Giant Cell Arteritis
Diagnosis

Back 42

initially with elevated sedimentation rate

Definitive diagnosis with temporal artery biopsy

Front 43

Giant Cell Arteritis
Treatment

Back 43

Corticosteroids

Front 44

Carotid Artery Dissections

Back 44

Spontaneous
- Cocaine/methamphetamine use
- Associated Horner’s syndrome common
- Treatment- anticoagulation

Traumatic
- Compression-extension injury
- Occurs high in the neck (C2)
- Treatment- anticoagulation if possible

Can lead to pseudoaneurysms