MITCH VINDI DO

• Metabolic infx traumatic congenital hereditary
• vascular immune neoplastic drugs idiopathic
• degenerative/demylinating Other

• CVA
• stroke!!
• sudden neuro deficit resulting from cerebrovasc dz

• Ischemic
  • embolism
  • lacunar infarct
  • thrombosis
  • concurrent/unknown etiology
• Hemorrhagic
  • subarachnoid
  • intracerebral

• Normal
  • Inc pCo2 --> vessel dilates
  • dec Pco2 --> vessel constricts
  • dec sbp = vessel dilates maintains norm cbf down to sbp of 60 mm
• dz vessel (atherosclerosis/aging)
  • autoreg lost
  • dec sbp -> dec cbf
• manip co2 to dec storke = hyperventilate them!

• non modifiable
  • age gender race hereditary
• modifiable
  • medical conditions: htn, cardiac dz, a fib, hyperlipid, dm, carotid stenosis, prior tia or stroke, obstructive sleep apnea
  • behaviors: cig smoking alc abuse physical inactivity obesity

• homunculus!!!
• lateral portion = face
• middle = hand
• medial = leg

• Carotid
  • Ant Cerebral A
  • Middle Cerebral A
• vertebrobasilar
  • Post Cerebral A
  • Basilar A

• Carotid vascular syndrome
• medial portion of hemispheres
• contralateral hemiparesis & hemisensory deficit
  • Leg > Arm > face
    • face spared
  • CT - left frontal region = worst part

• carotid vascular syndromes
• lateral portion of hemispheres
• contralateral hemiparesis & hemisensory deficit
  • face > arm > leg
  • aphasia if dominant hemisphere inv

• vertebrobasilar vascular syndrome
• occipital & post temporal loves
• contralateral homonymous hemianopia
  • receptive aphasia if dominat hemisphere
  • worried about lang prob
  • can happen bL also supplies thalamus

• vertebrobasilar vascular syndrome
• pons mid brain occipital lobes
  • dizzy, diplopia, dysarthria
  • locked in syndrome, coma, death = dreadful

• average duration = 10-15min
• if defecit lasts > 6hrs neuronal death likely. sx lasting < 1hr & NO INFARCT ON IMAGING!!!
  • transient sx assoc w/ infarct

• mechanisms
  • ocular
    • ischemia to retinal circ. transient R eye blindness if R side occluded BUT have L sided body weakness
  • 4 D's
    
    • dizzy, dysphagia, diplopia, dysarthria

• 1/3 = no further tia
• 25% have storke w/in 5yrs
  • 5% OF STROKES OCCUR W/IN THE 1ST 48HRS
  • 8% occure w/in the 1st month
  • 12% within year
  • 3% after first year
• 1/3 have  continuing tia

• A = age > 60
  • 1pt
• B = bp >140 systolic, >90 diastolic
  • 1pt
• C = clinical features
  • UL weakness = 2
  • speech impaired w/o weakness = 1
• D =duration
  • > 60 min = 2
  • 10-59 min =2
• D= diabetes
  • 1pt
• scoring = 2 day stroke riske
  • 6-7 =8.1 %, 4-5 =4.1%, 0-3= 1%
• TSI - up to 16% in hospital stroke rate
• IF EVENT W/IN 72 HOURS & ABCD2 > 3PNTS ADMIT

• Hemodynamic
  • residual carotid lumen < 2mm
    • often assoc w/ carotid bruit
    • aka carotid stenosis
  • impairment in collateral circ
  • spells that are shortlived and stereotyped
    • each successive spell is successive in anatomic distribution
• emboli
  • may arise from ulcerated plaque
  • longer lasting spells
  • more heterogeneous
    • may travel to diff locations: may have blindness one timea and next time sx swithc or different
    • friable surface

TIA Medical therapy

• Antiplatelet Agents
  • ASA
  • ticlopidine/clopidogrel
  • aggrenox
• anticoags
  • heparin
  • coumadin
• sugery

• antiplatelet agent for TIA tx
• lower doses of aspirin as effective as higher doses
• little evidence to support use of ASA in primary prevention of storke in men. May be BENEFICIAL IN WOMEN
• Has highest risk reduction compared to ticlopidine & clopidrogrel

• aspirin is still good to use
• plavix & aggrenox modest benefit over ASA
• plavix is better than aggrenox
  • similar efficacy but less bleeding w/ plavix and once a day, better tolerated (no headach)
• asa & plavix not recommended for stroke prevention = INC bleeding

• T= adr = neutropenia, pancytopenia
• C
  • dec mortality from all cases of vasc dz
  • 1x day
  • PLAVIX
  • good! yay!

• antiplatelet
• ASA + dipyridamole = ER only
• ADR= headache
• 2x daily
• not as good as plavix

• Heparin
• Coumadin
  • Cardioembolic TIA
    • A fib
  • crescendo TIA
    • R arm weakness, goes away comes back
  • Antiplatelet failure
  • NO BENEFIT in noncardioembolic stroke

• ligate plaque removed stent - prob - riske = sto0rke
• SURGERY IS SUPERIOR TO MED THERAPY IN PT W/ CAROTID TIA AND MINOR STROKE & > 70% STENOSIS OF THE IPSILATERAL CAROTID ARTERY

• due to atherosclerosis of large and medium sized arteries
• clinical px
  • stroke preceded by TI
  • stepwise dev of storke (stroke in evolution)
  • abrupt dev w/ fluctuationg course
• watershed infarct

• due to hemodynamic hypoperfusion w/o occlusion
• ischemia occurs at border zones of vasc territories
  • MCA -ACA
  • MCA - PCA
• very fragile, BL

• dont know at the time what is recoverable
• hand is firts to have cell death!!!

• large clot
• origin
  • cardiac
    • afib, acute mi --> mural thrombosis, valve dz, congenital heart dz
  • artery to artery embolus
• sudden onset of deficit = no warning signs
• tx
  • anticoag dec reembolization
    • I&R 1.7 or less = thrombolysis candidate
  • early ct scan
    • No blood/no sig infarct = Heparin & long term coumadin
    • blood: wati 7-14days, long term coumadin
    • large deficit = delay anticoag or asa
  • dabigatran
    • direct thrombin inhib w/ dec bleed, storkes, no drug/food interactions = better than warfarin :)
• infarct w/ hemorrhage = really in danger of herniation