Cerebrovascular DiseaseCerebrovascular Disease2/22/06

Basic Science

Which of the following contributes Which of the following contributes to ischemic strokes:to ischemic strokes:

1) Embolization of atherosclerotic and thrombotic material

2) Thrombotic occlusion

3) Hypoperfusion

4) All of the above

Which of the following contributes Which of the following contributes to ischemic strokes: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

A 66-year-old woman has the sudden loss of movement on part of the left side of 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 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. cerebral angiogram reveals occlusion of a branch of her middle cerebral artery.

Laboratory findings include a hemoglobin A1C of 9%. Which of the following Laboratory findings include a hemoglobin A1C of 9%. Which of the following components of blood lipids is most important in contributing to her disease? 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

AnswerAnswer

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.

Which of the following are true of Which of the following are true of TIAs?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)

Which of the following are true of Which of the following are true of TIAs?TIAs?

1 is True

Which of the following are Which of the following are characteristic of vertebrobasilar characteristic of vertebrobasilar

system TIA’s?system TIA’s?1) Motor dysfunction ( weakness, paralysis

and clumsiness)

2) Loss of vision in one or both homonymous visual fields

3) Vertigo, loss of balance, disequilibrium

4) Amaurosis fugax

Which of the following are Which of the following are characteristic of vertebrobasilar characteristic of vertebrobasilar

system TIA’s?system TIA’s?1-3 are true. Amaurosis fugax is

characteristic of carotid artery disease.

Amaurosis fugax:Amaurosis fugax:

1) Usually involves both eyes

2) Effects are permanent

3) Symptoms are described as loss of lateral visual fields

4) Results from embolization to corresponding retinal artery

5) Associated with Macular sparing

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

1) MRA

2) CT angio

3) Arteriography

4) Carotid Duplex

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

Carotid Duplex

Describe the Two diagnostic Describe the Two diagnostic modalities of carotid duplex modalities of carotid duplex

scanning:scanning:

Current indications for Carotid Current indications for Carotid Endarterectomy include:Endarterectomy include:

1) Carotid stenosis of 50% or greater with ipsilateral TIA’s

2) Amaurosis fugax

3) Large stroke

4) Recurrent, symptomatic carotid stenosis

Current indications for Carotid Current indications for Carotid Endarterectomy include:Endarterectomy include:

1,2 and 4

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

1) 50%2) <5%3) 10-30%4) >80%

Risk of stroke after TIARisk of stroke after TIA

Answer 10-30% in first yearAt 5years 30-50%

Neurologic deficits beginning Neurologic deficits beginning after 12 hours post-op can be after 12 hours post-op can be

due to?due to?1) Thromboembolism from the

endarterectomy site2) Post-op Hypoperfusion Syndrome3) Intracerebral Hematoma4) Intimal Flap

Neurological deficits after Neurological deficits after CEA?CEA?

Answer all of the above

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

1)Recurrent Laryngeal> Hypoglossal>Marginal Mandibular Nerve>Superior Laryngeal>Spinal Accesory

2)Hypoglossal>Recurrent Laryngeal>Superior Laryngeal>Marginal Mandibular>Spinal Accesory

3)Superior Laryngeal>Recurrent Laryngeal>Spinal Accesory>Marginal Mandibular>Hypoglossal

4)Marginal Mandibular>Spinal Accessory>Hypoglossal>Superior Laryngeal

Nerve Damage?Nerve Damage?

Answer: Recurrent>Hypoglossal>Marginal Mandibular>Sup. Laryngeal>Spinal Accessory

Regarding non-neurological complications Regarding non-neurological complications after CEA, Hypotension and bradycardia after CEA, Hypotension and bradycardia

are usually the result of?are usually the result of?1) Interruption of the Carotid Sinus Nerve2) Hypovolemia3) Increased baroreceptor activity during

dissection or 4) Stimulation of the sinus nerve following

removal of a rigid atheromatous plaque

What is the most common non-stroke What is the most common non-stroke related cause of morbidity and related cause of morbidity and

mortality immediately and long term mortality immediately and long term after CEA?after CEA?

1) Myocardial Infarction2) PVD3) ESRD4) Hypertension

Hypotension and Bradycardia Hypotension and Bradycardia after CEA?after CEA?

Secondary to 3,4, Baroreflex stimulation or stimulation of the sinus nerve.

Interruption of the sinus nerve results in Hypertension