Unit five- Cerebrovascular History and Physical

Unit five- Cerebrovascular History and Physical

What are the 4 vessels that supply blood to the Brain?

• The two Internal Carotid Arteries (right and left)

• The two Vertebral Arteries (right and left)

What are we doing with a cerebrovascular ultrasound?

We differentiate normal from diseased, see if it is acute or needs intervention, and identify collateral pathways

What 3 things do we do in a cerebrovascular exam?

detect, localize, and quantify cerebral embolism

What are some things we are looking for on a cerebrovascular ultrasound?

• Predict stroke risk

• Subclavian steal

• Monitor autoregulation

• Intracranial steal

• Monitor vasospasms

• Intracranial pressure

The 2 Vertebral Arteries

Posterior Circulation

The 2 Internal Carotid Arteries

Anterior Circulation

How to we predict stroke risk?

Carotid Exams

STROKES: Currently, the ____ leading cause of death in the United States

5th

STROKES: Approximately _______ new stroke occur yearly in the United States

610,000

STROKES: Leading cause of _________ __________

Permanent Disability

STROKES: BRAIN: ____ of the body weight, received _____ of the cardiac output and consumes _____) of body’s Oxygen supply in basal, resting state

2%; 15%; 20%

Causes of strokes:

• Cardiogenic (caused by the heart)

• Large Vessel Atherothrombotic

• Lacunar

• Other

• Unknown

• May be caused by a narrowing of the vessel OR may be hemorrhagic

What percentage of strokes are caused by Cardiogenic?

35%

What percentage of strokes are cause by Large Vessel Atherothrombotic?

30%

What percentage of strokes are caused by Other?

10%

What percentage of strokes caused by Unknown?

15%

What percentage of strokes caused by Lacunar?

10%

Lacunar:

When an artery that supplies blood to the DEEPER portions of the brain becomes blocked (thalamus, basal ganglia, or pons…)

Risk Factors of Strokes:

• Age

• Gender

• Hypertension

• Tobacco Use

• Diabetes

• Obesity

• High Cholesterol

• Sedentary Lifestyle

• PVD

• CAD

• Family or personal history

Stroke and symptom classifications:

• Asymptomatic

• Transient Ischemic Attack (TIA)

• Cerebrovascular Accident (CVA)

• Reversible Ischemic Neurological Deficit (RIND)

TIA

Transient Ischemic Attack

CVA

Cerebrovascular Accident

RIND

Reversible Ischemic Neurological Deficit

Asymptomatic Stroke:

• Without symptoms

• Patient presents with a BRUIT

Asymptomatic Stroke: Patient presents with a BRUIT:

• Noise heard during auscultation

• Caused by turbulent blood flow that set up vibratory response in the tissue

• “Cervical Bruit” (C.B.)

C.B. will often be an indication for a ___________________

Cerebrovascular Exam (Carotid Duplex)

Cervical Bruits ar caused by:

• Stenosis in the CCA, ICA, or ECA

• Tortuous Carotid Vessel or Vessels

• Aortic Valve Stenosis

(occlusion)

CERVICAL BRUIT: You cannot tell what is causing the bruit without during further tests:

• Carotid Duplex

• Echocardiogram

C.B.: Cannot distinguish if a stenosis is in ___, ____, or ____

CCA, ICA, or ECA

BRUIT CHARACTERISTICS:

• Location

• Intensity

• Duration

• Frequency

• Quality

Bruit Characteristics: Location

Bell of stethoscope at Innominate, Subclavian, CCA Bifurcation, Vertebral

Bruit Characteristics: Intensity

• “Loudness”

• Increases between no stenosis and moderate stenosis

• Decreases between moderate range and occlusion

• Many bruits disappear when stenosis is > 90% diameter reduction

Bruit Characteristics: Duration

• Increases with increasing degree of stenosis

• Short systolic, systolic, or pan-systolic/continuous

Bruit Characteristics: Frequency

• “Pitch”

• Increases with degree of stenosis

Bruit Characteristics: Quality

Soft blowing, harsh blowing, coarse, gruff, moaning, whining, seagull

TYPES OF STROKES:

• TIA

• CVA

• RIND

Characteristics of a transient ischemic attack (TIA)

• brief, fleeting

• lasts only 1-30 mins

• symptoms often ignored

• transient neurological deficit that lasts <24 hours

What is another name for a TIA?

Mini stroke

Iif a mini stroke is ignored, what percent of patients will go on to a full stroke within 5 years?

30-35%

What causes a TIA?

Typically embolic in nature from the heart or due to ulcerative plaque in the ICA

What are the characteristics of a CVA?

• STROKE

• Lasts >24 hours

• Permanent damage

• Symptoms persist

• Symptoms may improve, but never completely resolve

What is an Acute CVA?

symptoms are sudden, considered unstable

What is a stroke in Evolution CVA?

Symptoms come and go, crescendo

What is a Completed stroke CVA?

No progression OR resolution of symptoms

What is another name for CVA?

Stroke

What are the characteristics of a RIND?

• >24 hours but resolves in less than 3 weeks

• Brain tissue is damages but recovers completely

• Between TIA and CVA

What are the etiologies of a stroke?

• Atherosclerosis

• Embolus from heart

• HTN

• Dissection

• Prothrombotic state

• Vasospasm

Atherosclerosis

Intimal disruption or lumen stenosis

What is the most common cause for atherosclerosis?

Arteriosclerosis

What age is atherosclerosis most common in?

> 45 years old

What percent of patients with atherosclerotic disease had a TIA prior to stroke?

60%

Which of the following is NOT true regarding atherosclerosis?

-Atherosclerosis starts within the intima

-Atherosclerosis typically occurs at bifurcations

-Atherosclerosis is a red blood cell disease

-Atherosclerosis is a generalized disease

-Intimal disease may begin in adolescence

-Atherosclerosis is most common cause of carotid artery occlusion

Atherosclerosis is a red blood cell disease

What is the second leading cause of stroke?

Embolus from the heart

Embolus from the heart

• May affect any age patient

• Rhythm abnormalities

  • Atrial Fibrillation

• Damaged endocardium

  • LA or LV

• Valve damage

  • Mitral or Aortic

What is the number 1 leading cause of stroke?

HTN

Why is hypertension the leading cause of a stroke?

Narrows blood vessels with super high velocities, causing them to burst

Arteriolar sclerosis or lipohyalinosis results in what?

The formation of small localized areas of infarction called lacuna

What are Lacunar Strokes?

Small, localized areas of brain damage caused by blockages of the SMALL Blood Vessels

Liop:

“Condition that affects the small blood vessels in the brain (CEREBRAL ARTERIES)– accumulation of luipds and protein like sybstances in the vessel walls, which leads to thickening and narrowing

HTN: Injures small vessels of the Brain and Kidneys is called what?

arteriolar sclerosis or lipohyalinosis

What is a Dissection?

Hemorrhage and thrombus formation within arterial walls; also causes narrowing of the lumen

A Dissection is a tear between the:

• Intima and Media

• Media and Adventitia

What causes Dissections?

• Trauma

• HTN

• Marfan's Syndrome

Dissections located in the following areas may head to stroke:

• Aorta (ascending → arch)

• Carotid Arteries: CCA Origin or mid-distal ICA

• Vertebral Arteries

What is a Prothrombotic State?

Increased state of coagulability/ hypercoagulability/ abnormality in coagulation

What is a Vasospasm?

Sudden constriction of a blood vessel, reducing its diameter and flow rate

What is a Vasospasm usually associated with?

Subarchnoid Hemorrhage

When do spasms start to occur with a vasospasm?

3rd day of hemorrhage

Degree of spasm depends on:

Amount of blood present around the arteries and time

What arteries are the Anterior Circulation of the brain?

ICA, MCA, ACA

What arteries are the Posterior Circulation?

Vertebral Arteries, Basilar Artery, PCA

Disease in the Innominate and CCA also lead to:

Anterior Circulation symptoms

Anterior Circulation (AC)

Hemispheric

Anterior Circulation:

Left ICA feeds ____ Ophthalmic Artery

Right ICA feeds ____ Ophthalmic Artery

Left, Right

Characteristics of Anterior Circulation symptoms:

• left hemisphere side of brain = right side of body symptoms

• right hemisphere side of brain = left side of body symptoms

Bodily signs and symptoms originate from the ______ side of the body

Opposite

Signs and symptoms of the EYE originate from the ____ side

Same

Left eye symptoms occur from which hemisphere?

Left

Right eye symptoms occur from which hemisphere?

Right

What is transient monocular blindness (amaurosis fugax AF)? (AC)

Temporary partial or complete loss of vision in one eye

What does TMB/AF implicate?

Carotid system on same side as visual disturbance

What is transient monocular blindness (AF) caused by?

Hollenhorst plaques

What circulation is transient monocular blindness (AF)?

Anterior

Hollenhorst Plaques

Atheromatous plaques that have lodged into the retinal vessels; causes dark spots → embolic Event

What is Aphasia or Dysphasia?

Absent or impaired ability to communicate either through speech, writing or signs

What does Aphasia or Dysphasia implicate?

Implicates the carotid system perfusing the dominant hemisphere

What are the different types of Aphasia?

• Auditory

• Visual

• Sensory

• Motor

• Global

If a right handed person has a aphasia, what hemisphere is affected?

Left

If a left-handed person is affected by aphasia, which hemisphere is likely affected?

Either

What is Auditory Aphasia?

Word deafness/inability to understand the spoken word

What is Visual Aphasia?

Word blindness/Inability to understand the written word

What is Sensory Aphasia?

Combination or auditory and visual; will not understand spoken or written word

What is Motor Aphasia (Expressive aphasia brocas)?

Patients know what they want to say, but cannot get the words out; unable to coordinate the muscles controlling speech

What is Global Aphasia?

“Total Aphasia;” Involves ALL form of communication

Is Paresthesia due to the anterior or posterior circulation?

Anterior Circulation

What is Paresthesia? (AC)

Numbness, prickling, tingling, or heightened sensitivity

Paresthesia: Monoparesthesia/Hemiparesthesia

One sided paresthesia

Left side symptoms implicate right carotid system disease and visa versa

Is Paresis anterior or posterior circulation?

Anterior

Paresis (AC)

Paralysis

Monoparesis/Hemiparesis

• One sided paresthesia

• Left side symptoms implicate right carotid system disease and visa versa

What are the main Anterior Circulation symptoms?

• MCA lesions

• ACA lesions