Signs and symptoms of cerebrovascular disease

Most common type of stroke

Ischemic

Atherosclerosis causes stenosis which leads to decreased blood supply and cerebral _________

Ischemia

ICA stenosis presents the highest risk of …

TIA/Stroke

Mechanisms of stroke

Embolization of the atherosclerosis material lodges in a distal artery and leads to cerebral ischemia

Can also be caused by cardiac embolus

Vasospasm, intracranial hemorrhage, dissection, HTN, Polycythemia vera

HTN

Strongest risk factor for stroke

Shearing forces of the blood can exert too much pressure on intracranial vessels leading to hemorrhage

Polycythemia Vera

Thickening of the blood reduces flow and may lead to ischemia distally; increased risk of thrombus/embolus formation

Atherosclerosis Formation

#1 cause of vascular disease

Accumulation of atheroma, collagen, fibrin and platelets

Forms within and beneath the intima

>1.2mm IMT indicates increased risk for stenosis

MOST common cerebrovascular site: CCA bifurcation

2nd most common cerebrovascular site: Origin of CCA

Strokes are more common in:

Men, African Americans, Older age, family Hx

Brain infarction

Insufficient blood supply to brain due to stenosis or occlusion

Subarachnoid hemorrhage

Rupture of intracranial vessels

Hemispheric symptoms

Specific symptoms are related to right and left brain with loss of functionality

Right brain controls left side of body -

RICA stenosis = LT paresis, paresthesia

Left brain controls Right side of the body -

LICA stenosis = RT paresis, paresthesia

85% of strokes are caused by

Ischemia

Atheroma in the carotid bifurcation is -

Most common cause of embolic stroke

• Cardiac emboli is #2 cause

Palpation

Most arteries are palpated by placing two fingers over the artery

For carotid eval, the carotid can be palpated

Bounding pulses refers to normal, easily palpable pulses that are in sync with the heartbeat

Auscultation

Place stethoscope over carotid at level of bifurcation to identify a bruit

Ask the pt to hold their breath while listening for the sounds

Stenosis can cause a bruit

Bruit is a noise heard with a stethoscope caused by turbulent flow

>90% stenosis will NOT cause a bruit

A bruit can be missed if there is ___________

Low cardiac output

The ___________ is the most commonly assessed artery for the presence of a bruit

Carotid artery

Blood pressure

Blood pressure in the arms should not differ more than 20mmHg or a subclavian steal is suspected in the arm with the LOWER pressure

Carotid sinus message

Used to assess the cause of syncope

Carotid artery is massaged at the level of the cricoid cartilage for 5-10 seconds

Will lead to bradycardia and hypotension if carotid sinus hypersensitivity is present

Should NOT be performed on pts with an occluded carotid or recent TIA/CVA

Non-specific Cerebrovascular disease symptoms

Carotid bruit

Headache

Syncope

Dysarthria

Dizziness

ICA disease symptoms

Unilateral symptoms with contralateral ICA stenosis

Paresthesia - tinging of skin

Hemiparesis - Weakness

Paralysis - Unable to move

Broca Aphasia - AKA Expressive Aphasia, can understand others and follow directions, but unable to speak

Hollenhorst Plaques: Cholesterol emboli originate from the atherosclerotic lesions in the ipsilateral carotid artery or aorta and lodge into the small branches of the retinal artery - asymptomatic

Homonymous Hemianopia - Visual defect in half of the eye - more common with posterior circulatory issues and occipital lobe infarcts, but can occur in the anterior circulation and parietal lobe infarcts

Amaurosis Fugax - Temporary or total monocular blindness (TIA of eye)

MCA disease symptoms

Wernicke Aphasia - Receptive aphasia; totally incomprehensible, unable to understand speech, speak, or follow directions

Dysphasia

Behavioral changes

Severe hemiparesis in contralateral face/arms

ACA disease symptoms

Loss of coordination

Incontinence

Severe leg hemiparesis or hemiplegia in contralateral leg

Facial drooping or asymmetry

PCA disease symptoms

Dyslexia

Coma

Vertebral/Basilar Disease symptoms

Vertigo: Unable to maintain equilibrium

Syncope: Fainting

Ataxia: lack of coordination

Bilateral visual blurring or double vision

Bilateral homonymous hemianopia - Medial or lateral half of the field of view disrupted in each eye → most commonly associated with occipital infarcts

Bilateral paresthesia

Drop attack - Falling to ground without loss of consciousness

Dysphasia - trouble swallowing

Most common cause of stroke

Ischemia

Where does atherosclerosis form?

Between the intima and media layer

Which of the following causes a bilateral bruit?

Aortic valve stenosis

_____________ is a visual defect that affects half of the field of vision and _________ is a visual defect that affects the entire eye

Homonymous Hemianopia; Amaurosis fugax

Broca aphasia is a symptom typically seen with ___________ disease, while Wernicke aphasia is a symptom typically seen with ________ disease

ICA; MCA

Symptoms of ICA disease typically affect:

The contralateral extremities and the ipsilateral eyes

Bilateral visual symptoms are most commonly seen with disease in the:

Vertebrobasilar system