Cerebrovascular Disease

1
Cerebrovascular Disease

• 2/22/06
• Basic Science

2
Which of the following contributes to ischemic
strokes

• 1) Embolization of atherosclerotic and
  thrombotic material
• 2) Thrombotic occlusion
• 3) Hypoperfusion
• 4) All of the above

3
Which of the following contributes to ischemic
strokes

• 4) Atherosclerosis of arteries supplying the
  brain is a leading cause of ischemic strokes.
  Large-artery atherosclerosis, most often
  involving the carotid bifurcations, causes stroke
  by three principle mechanisms embolization of
  atherosclerotic and thrombotic material,
  thrombotic occlusion, and hypoperfusion from
  advanced hemodynamically significant stenoses

4
A 66-year-old woman has the sudden loss of
movement on part of the left side of her body.
She has smoked a pack of cigarettes a day for the
past 45 years. A cerebral angiogram reveals
occlusion of a branch of her middle cerebral
artery. Laboratory findings include a hemoglobin
A1C of 9. Which of the following components of
blood lipids is most important in contributing to
her disease?

• 1) Chylomicrons
• 2) Lipoprotein lipase
• 3) Oxidized LDL
• 4) VLDL
• 5) HDL cholesterol

5
Answer

• 3 is CORRECT. She has had a 'stroke' which is
  most often a consequence of cerebral
  atherosclerosis or embolic disease from the heart
  as a consequence of ischemic heart disease from
  atherosclerosis. LDL brings cholesterol to
  arterial walls, and when increased LDL is present
  or when there is hypertension, smoking, and
  diabetes, there is more degradation of LDL to
  oxidized LDL which is taken up into arterial
  walls via scavenger receptors in macrophages to
  help form atheromas.

6
Which of the following are true of TIAs?

• 1) Episodes typically last 2-15 Minutes
• 2) Episodes can last up to 48 Hours
• 3) Episodes are likely to leave persistent
  deficit
• 4) Have similar manifestations regardless of
  Vascular System affected (eg. LCA vs RCA vs
  Vertebrobasilar Artery)

7
Which of the following are true of TIAs?

• 1 is True

8
Which of the following are characteristic of
vertebrobasilar system TIAs?

• Motor dysfunction ( weakness, paralysis and
  clumsiness)
• Loss of vision in one or both homonymous visual
  fields
• Vertigo, loss of balance, disequilibrium
• Amaurosis fugax

9
Which of the following are characteristic of
vertebrobasilar system TIAs?

• 1-3 are true. Amaurosis fugax is characteristic
  of carotid artery disease.

10
Amaurosis fugax

• Usually involves both eyes
• Effects are permanent
• Symptoms are described as loss of lateral visual
  fields
• Results from embolization to corresponding
  retinal artery
• Associated with Macular sparing

11
What is the single best initial test to evaluate
Carotid occlusive disease?

• MRA
• CT angio
• Arteriography
• Carotid Duplex

12
What is the single best initial test to evaluate
Carotid occlusive disease?

• Carotid Duplex

13
Describe the Two diagnostic modalities of carotid
duplex scanning
14
Current indications for Carotid Endarterectomy
include

• Carotid stenosis of 50 or greater with
  ipsilateral TIAs
• Amaurosis fugax
• Large stroke
• Recurrent, symptomatic carotid stenosis

15
Current indications for Carotid Endarterectomy
include

• 1,2 and 4

16
What is the risk of stroke in the first three
years after TIA?

• 1) 50
• 2) lt5
• 3) 10-30
• 4) gt80

17
Risk of stroke after TIA

• Answer 10-30 in first year
• At 5years 30-50

18
Neurologic deficits beginning after 12 hours
post-op can be due to?

• 1) Thromboembolism from the endarterectomy site
• 2) Post-op Hypoperfusion Syndrome
• 3) Intracerebral Hematoma
• 4) Intimal Flap

19
Neurological deficits after CEA?

• Answer all of the above

20
During CEAs nerve injury occurs most frequently
in which order?

• 1)Recurrent Laryngealgt HypoglossalgtMarginal
  Mandibular NervegtSuperior LaryngealgtSpinal
  Accesory
• 2)HypoglossalgtRecurrent LaryngealgtSuperior
  LaryngealgtMarginal MandibulargtSpinal Accesory
• 3)Superior LaryngealgtRecurrent LaryngealgtSpinal
  AccesorygtMarginal MandibulargtHypoglossal
• 4)Marginal MandibulargtSpinal AccessorygtHypoglossal
  gtSuperior Laryngeal

21
Nerve Damage?

• Answer RecurrentgtHypoglossalgtMarginal
  MandibulargtSup. LaryngealgtSpinal Accessory

22
Regarding non-neurological complications after
CEA, Hypotension and bradycardia are usually the
result of?

• 1) Interruption of the Carotid Sinus Nerve
• 2) Hypovolemia
• 3) Increased baroreceptor activity during
  dissection or
• 4) Stimulation of the sinus nerve following
  removal of a rigid atheromatous plaque

23
What is the most common non-stroke related cause
of morbidity and mortality immediately and long
term after CEA?

• 1) Myocardial Infarction
• 2) PVD
• 3) ESRD
• 4) Hypertension

24
Hypotension and Bradycardia after CEA?

• Secondary to 3,4, Baroreflex stimulation or
  stimulation of the sinus nerve.
• Interruption of the sinus nerve results in
  Hypertension