Lecture 16 and 17 -- CVD Flashcards

1
Q

what are two types of stroke

what is the only way to differentiate the two?

A

Hemorrhagic and Ischemic

Imaging

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2
Q

what are the two types of hemorrhagic stoke?

what imaging type is best for to see a hemorrhagic stroke

A

SAH

ICH

CT scan – quick and good for fluid

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3
Q

underlying causes of SAH

A

Berry Anuerysm – ballooning of an artery, weakening of the wall; typically in the branch points of Ant. Comm artery

Arterio-Venous Malformation – abnormally direct communication between arteries —> Veins without intervening capillary bed. Venous system exposed to high arterial pressures.

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4
Q

underyling causes of ICH?

A

HTN – long standing atheroscloerosis

Cerebral Amyloid Angiopathy – degenerative deposition of Amyloid in aterial walls of cortical vessels

Aneurysm, AVM

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5
Q

Treatment of hemorrhagic stroke?

A

Medical emergency; ICU; Neurosurgery consult

do not give TPA

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6
Q

Clinical defition of an ischemic stroke?

what imaging is used to view acute ischemic stroke?

A

Clinical manifestation of a CNS Infarcton
Sudden onset, focal deficits lasting > 24 hours
evidence of infarctioin on imaging

diffuse weighted MRI (this will not show up on CT)

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7
Q

brain’s compesnation mechanisms for reduced blood flow…

A

Vasodilation – increased transit time

Anaerobic metabolism – but when all energy resoruces depleted….

electrical failure — TIA, stroke

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8
Q

what is a TIA

how should it be managed clinically

A

TIA – transiet ischemia attach
transiet focal neurological deficits
No actual infarction
Technically TIA if symptoms last less than 24 hours (but in reality if symptoms last more than 2 hours, they are going to last more than 24 hours)

Warning sign for acute ischemic stroke; should not be ignored

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9
Q

ischemic penumbra vs ischemic core

A

penumbra: reversbile infarction

Core: irreversible

core grows with time
time = brain

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10
Q

rank the following in regards to sensitivity to ischemia from least to most:

oligodendrocytes, neurons, endothelium, astrocytes

A

Least: Endothelial cells

astro

Oligo

Neurons (hippo, purkinje cells, pyramidals of cortex, neostriatum)

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11
Q

what are 4 ways in which patients can deteroirate in the setting of ischemic stroke

A

Cytotoxic Edema –

Hemorrhagic Conversion

Herniations

Recurrent ischemic stroke –

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12
Q

Cytotoxic edema

pathophysiology –

how does this kill you?

how can this be alleviated?

A

Increased permeability of neuronal and glial cell membranes results in intracellular swelling

Kills you - – mass effect–> herniation

Alleviated – Hemicraniectomy

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13
Q

Review of imaging for storkes:
hemorrhagic?
acute ischemic?
cytotoxic edema?

A

CT

Diffusion weighted MRI

CT

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14
Q
Hemorrhagic COnversion -- 
what is it? 
difference between large and small strokes? 
how does it kill you?
alleviate this?
A

Friable endothelium; blood leaks out into parenchyma upon reperfusion

Large stroke – parenchyma is dead and therefore will not be symptomatic

Small stroke - parenchyma is viable; reperfusion will lead to further damage == symptoms

Kills you — herniation

alleviate this – hemicraniectomy

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15
Q

hemicraniectomy differences between and outcomes for lesions above the tentorium and below the tentorium

A

above the tentorium – slower deterioration; hemicraniectomy will save your life but you have had a massive stroke; therefore quality of life outcomes poor as patients have significant neuro deficits

below the tentorium (cerebellum) – can deteriorate very quickly without intervention; but following hemicraniectomy, outcomes are good becuase of redundant wiring of the cerebellum

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16
Q

Treatment for ishcemic stroke

A

TPA (alteplase)

Mechanical Clot Extraction Devices

17
Q

Know anterior vs posterior vascular lesions and manifestations; esp regarding vision

Example:
Isolated Homonymous hemianopia = ?

Unilateral monocular blindness = ?

A

Isolated Homonymous hemianopia = PCA

Unilateral monocular blindness = Ophthalamic artery

18
Q

Etiologies and subtypes of ischemic stroke ***

A

atherothrombotic cerebrovascular disease

Penetrating artery Disease – Small artery Disease – Lacunar Stroke

Cardiogenic Embolism

Other unusual Stroke

Idiopathic – 20 to 40%

19
Q

atherothrombotic cerebrovascular disease

what vessels?
how can this be visualzed?
pathogenesis

A

Arterial Stenosis in the Head or Neck (Large intra cranial arteries; Extra cranial – carotid arteries)

Artery to artery Emboli
Stenosis –> slowed blood –> thrombus –> Embolism

20
Q

treatment of atherothrombotic cerebrovascular disease -

A

l Carotid Endarterectomy –

Angioplasty Stenting –

21
Q

Penetrating artery Disease – Small artery Disease – Lacunar Stroke

what vessels?
pathology of these vessels –

A

Base of brain, lenticulostriates, cerebellum

Lipohyalnaosis – thickening of the vessel wall, but its weak

Antherosclerosis

22
Q

Manifestations of Penetrating artery Disease – Small artery Disease – Lacunar Stroke

A

Deep penetrating arteries — therefore don’t have cortical deficits

Lacunar clinical Syndromes — No Cortical Dysfunction:
Pure Motor Hemiparesis — no sensory findings, visual findings

Pure hemi-sensory loss — just sensation

23
Q

Cardiogenic Embolism

most commonly?
imaging?

A

AFIB
Mechanical heart valves, Acute MI, Abn heart valves, Endocarditis

acute infarcts on MRI that are on both hemipshers, anterior and posterior

24
Q

treatment and previton of Cardiogenic Embolism

A

Treatment – TPA

Prevention – Full does Anticoagulation
Wafarin (VKOR1)
Dabigitran (direct thrombin)
Rivorxaban/Apixaban (direct 10a)

25
Q

antiplatelet therapies

A

ASA
Plavix
Aggrenox – ASA/Extended release dipyridamole

26
Q

Non modfiable risk factors

A

Age — exponential increase; although any age can get a stroke
Gender – post menopausal women (lower estrogen)
Race – African Americans
Prior stroke –

TIA

27
Q

Modifiable risk factors

most easily modifiable?

A

Afib – Warfarin;
Stenosis of Internal carotid Artery – HTN – 30-40% reduction in stroke when HTN is controlled Tobacco Use – Framhingham HLD –atherothrombotic stroke; vascular disease elsewhere
DM

Most easily modifiable – HTN and Tobacco