Neurology

Vascular Emergencies

  1. Stroke
  2. Definition
  3. Stroke is defined as an acute focal neurological deficit due to interruption of blood flow through a cerebral vessel
  4. Brain attack
  5. Most disabling neurologic disorder
  6. Important Stroke Facts
  7. A stroke occurs every minute in the US
  8. Long hospital stay
  9. Leading casue of transfer to long term facility
  10. Cerebral vascular accident: 2 types
  11. Ischemic- Brain cell nutrients are blocked leading to cell deaths
  12. Embolic
  13. Thrombotic
  14. Hemorrhagic- blood is neurotoxic to surrounding cells leading to cell death
  15. Risk factors
  16. Cardiac disease/Hypertension
  17. Smoking
  18. Diabetes
  19. Obesity
  20. Oral contraceptives
  21. Sickle Cell Anemia
  22. Migraine
  23. Types of Ischemic Stroke:
  24. Ischemic penumbra in evolving stroke
  25. Transient Ischemic Attacks- Brain angina
  26. Large Vessel Thrombotic Stroke
  27. Small Vessel Lacunar Stroke
  28. Cardiogenic Embolic Stroke
  29. Penumbra
  30. Band of minimally perfused cells
  31. Blood flow to this “halo” is decreased
  32. Survival depends on timely return of circulation, toxic products released by the dying cells, the degree of cerebral edema, blood flow
  33. Transient Ischemic Accident
  34. Temporary disturbance in cerebral blood flow. Reverses prior to injury. Focal ischemic neurological deficit that lasts < 24 hours
  35. Etiology is atherosclerotic disease of cerebral vessels and emboli
  36. Often present with amaurosis fugax- clot from carotid to the retinal artery and temporary loss of vision
  37. Differential diagnosis to include: seizure, migraine, syncope
  1. Diagnostic studies
  2. Arteriogram
  3. Magnetic resonance angiography
  4. Cardiac workup/carotid Doppler
  5. Hematologic workup for coagulopathies, syphilis serology, CBC
  6. Echocardiogram
  1. Large Vessel Thrombotic Stroke
  2. Etiology is atherosclerotic plaques found at bifurcation of carotid artery or medium sized arteries
  3. Most commonly the middle cerebral artery
  4. Defects to the cortex
  5. Rapid onset- awake from sleep with symptoms
  6. Apraxia- can’t perform purposeful movements
  7. Small Vessel Lacunar Infarct
  8. Affects subcortical structures such as basal ganglia, thalamus, internal capsule, brain stem
  9. Stenosis of vessel lumen due to thickening of vessel wall
  10. Lacunes- infarct that has healed
  11. Does not affect cortex, affects brainstem- nausea and dizziness
  12. Risk factors: Include hypertension and diabetes
  13. Clinical manifestations include contralateral pure motor or pure sensory
  14. Diagnosis
  15. Clinical
  16. MRI
  17. Cardiogenic Embolic Stroke
  18. Etiology is thrombus from heart (rheumatic heart disease, atrial fibrillation, bacterial endocarditis)
  19. Most likely affecting the middle cerebral artery
  20. Can be caused by plaque in carotid arteries
  21. Clinical presentation
  22. Prevention includes treating heart disease including anticoagulation therapy
  23. Clinical presentation
  24. Thrombotic strokes- wake up during sleep
  25. Embolic strokes- suddenly during waking hours
  26. Hemorrhagic strokes- evolve over minutes
  27. History of TIA
  28. Involve weakness/numbness, dysarthria, gait disturbance
  29. Vision loss in one eye is a sign of TIA or impending stroke- amaurosis fugax
  30. Abrupt onset of neurologic problems and can have cardiac problems
  1. Cerebral Circulation
  2. Two internal carotids and two vertebral arteries
  3. Major branches of the Internal Carotid Artery
  4. Middle Cerebral Artery
  5. Anterior Cerebral Artery
  6. Homunculus
  1. MCA
  2. Contralateral hemiparesis, hemisensory deficit
  3. Homonymous hemianopsia opposite occluded artery
  4. Aphasia possible
  5. Confusion, apraxia, contralateral body neglect
  6. ACA
  7. Contralateral weakness
  8. Broca’s aphasia
  9. Incontinence
  10. Vertebral Arteries
  11. Merge at pons to form single basilar artery
  12. Posterior cerebral arteries (2)- supply occipital lobes and thalamus and upper midbrain
  13. Branches of the basilar and vertebral arteries arteries supply the medulla, pons, cerebellum, midbrain, and part of the diencephalons
  14. Respiratory problems, nausea, vomiting
  15. Posterior cerebral arteries supply remaining occipital and inferior regions of the temporal lobes and thalamus
  16. Vertebrobasilar Artery
  17. Involves cerebellum and brain stem- diplopia, vertigo, nausea, vomiting, dizziness
  18. Posterior cerebral artery
  19. Involves occipital lobe, portions of temporal lobe, thalamus
  20. Homonymous hemianopsia of contralateral visual field
  21. Vertical gaze, occulomotor nerve palsy
  22. Aphasia or alexia- can’t read
  23. Pupillary response intact
  24. Diagnosis
  25. CT scan
  26. Carotid Doppler and ultrasound
  27. Complete cardiological work-up including echocardiogram
  28. Labs to rule out other origins
  29. MRI for ischemic lesions and for follow-up
  30. Perfusion scans
  31. Arteriography
  32. Magnetic resonance angiography
  33. TIA
  34. Management
  35. Antiplatelet therapy
  36. Anticoagulant- for ischemic stroke due to cardiac embolus
  37. Endarterectomy
  1. Cerebrovascular accident
  2. Ischemic type management
  3. Anticoagulation with heparin
  4. Antiplatelet therapy
  5. Anticoagulation
  6. Window of opportunity with thrombolytics (tpa, tissue plasminogen activator)
  7. Lyses fibrin containing clots
  8. Who are the candidates for thrombolytics therapy?
  9. CT
  10. Three hour window for administration
  11. B/P <185/110
  12. No anticoagulants within 48 hours
  13. Platelet count >100,000
  14. No previous CVA or head trauma in preceding 3 months
  15. No major surgery in past 14 days
  16. No history of intracranial bleeds
  17. No rapid improvement
  18. No GI or GU hemorrhage within 21 days
  19. No seizure with onset of stroke
  20. Glucose >50, <200
  21. Complications
  22. Motor/Sensory deficits
  23. Language/speech deficits
  24. Speech
  25. Language
  26. Dysarthria- slurred speech
  27. Cognitive deficits
  28. Risk of contractures, need patient
  29. Dehabilitating
  30. Cerebral Aneurysm- hemorrhagic stroke
  31. Bulge in the muscular wall of an arterial vessel
  32. Causes bleeding into the subarachnoid space
  33. Risk factors include polycystic kidney disease, coarctation of aorta, arteriovenous malformations of the brain, hypertension, atherosclerosis
  34. Rupture leads to subarachnoid hemorrhage
  35. Non-ruptures
  36. Asymptomatic
  37. Large aneurysm
  38. Chronic headache
  39. Neurologic deficits
  40. Cerebral aneurysm ruptures
  41. Ruptured berry aneurysm account for 75% of non-traumatic subarachnoid hemorrhage
  42. Etiology includes aneurysm, trauma, erosion of the vessels by tumors, blood coagulation disorders
  43. Spontaneous hemorrhage of blood into brain tissue
  44. Risk groups age 50-60, hypertension
  45. Clinical presentation
  46. Sudden and severe generalized headache
  47. Collapse and loss of consciousness
  48. Vomiting
  49. Nuchal rigidity, photophobia
  50. Cranial nerve deficits
  51. Focal motor and sensory deficits
  52. Cerebral edema, increased ICP
  53. Hypertension
  54. Pituitary dysfunction
  55. Fever up to 102 F with confusion, stupor, and coma
  56. Diagnosis
  57. CT to identify aneurismal rupture
  58. CSF- elevated opening pressure containing bloody fluid
  59. Cerebral angiography- look for berry aneurysms
  60. Complications
  61. Vasospasm with cerebral ischemia
  62. Hydrocephalus
  63. Hypothalamic dysfunction
  64. Seizures
  65. Management
  66. Cerebral arteriography- within 24-72 hours
  67. Surgery
  68. Supportive treatment to prevent elevated arterial or intracranial pressures- if bursted
  69. Decrease or maintain cranial pressure
  70. Hypertension management
  71. Arteriovenous Malformation- no capillary bed
  72. 10% of subarachnoid hemorrhage
  73. Risk groups 20-40 years
  74. Congenitally abnormal arteries and veins
  75. Present with hemorrhagic stroke
  76. Veins exposed to high pressure of arteries
  77. Clinical presentation
  78. Subarachnoid hemorrhage
  79. Seizures
  80. Headache-throbbing
  81. Hemiparesis
  82. Speech deficits
  83. Learning disorders
  84. Diagnosis
  85. Cerebral angiography
  86. Management
  87. Surgical, endovascular occlusion