Transcript Slide 1

Cerebrovascular Disease
2/22/06
Basic Science
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
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
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)
2)
3)
4)
5)
Chylomicrons
Lipoprotein lipase
Oxidized LDL
VLDL
HDL cholesterol
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.
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)
Which of the following are true of
TIAs?

1 is True
Which of the following are
characteristic of vertebrobasilar
system TIA’s?
1)
2)
3)
4)
Motor dysfunction ( weakness, paralysis
and clumsiness)
Loss of vision in one or both
homonymous visual fields
Vertigo, loss of balance, disequilibrium
Amaurosis fugax
Which of the following are
characteristic of vertebrobasilar
system TIA’s?

1-3 are true. Amaurosis fugax is
characteristic of carotid artery disease.
Amaurosis fugax:
1)
2)
3)
4)
5)
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
What is the single best initial test to
evaluate Carotid occlusive disease?
1)
2)
3)
4)
MRA
CT angio
Arteriography
Carotid Duplex
What is the single best initial test to
evaluate Carotid occlusive disease?

Carotid Duplex
Describe the Two diagnostic
modalities of carotid duplex
scanning:
Current indications for Carotid
Endarterectomy include:
1)
2)
3)
4)
Carotid stenosis of 50% or greater with
ipsilateral TIA’s
Amaurosis fugax
Large stroke
Recurrent, symptomatic carotid stenosis
Current indications for Carotid
Endarterectomy include:

1,2 and 4
What is the risk of stroke in the
first three years after TIA?

1) 50%
 2) <5%
 3) 10-30%
 4) >80%
Risk of stroke after TIA

Answer 10-30% in first year
 At 5years 30-50%
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
Neurological deficits after
CEA?

Answer all of the above
During CEAs nerve injury occurs
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?

Answer: Recurrent>Hypoglossal>Marginal
Mandibular>Sup. Laryngeal>Spinal
Accessory
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
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
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