Pathophysiology Stroke
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| What is another name for stroke? | Cerebrovascular Disease; Cerebrovascular accident
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| Strokes hit what type of people more? | African American, women, people with HTN, diabetes and obesity.
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| What is the greatest risk of stroke? | Hypertension.
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| Why do most strokes occur in women? | Probably because women live longer and the risk of stroke increases with age (also atherosclerosis).
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| Women who __________ and ______________ have a higher risk of stroke than those who don't. | Women who smoke AND take high-strength oral contraceptives
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| Stroke is a _________________ disease. | Vascular
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| Modifiable risk factors include (4) | Smoking, Diabetes, atrial fibrillation, and hypertensions (HTN is the number one risk factor).
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| Cerebral arteries are either ______________ or ________________. | Conducting (run on the surface) or penetrating (deeper in the brain).
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| Loss of cerebral blood flow for a few seconds produces ______________________. Ischemia lasting a few minutes can produce _________________________. | For a few seconds produces symptoms. Ischemia lasting a few minutes can lead to irreversible damage to affected nerves in the brain.
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| At rest, the brain receives _______ of Cardiac Output and uses _______ of the body's oxygen. | 1/6 and 20%
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| Severity of stroke depends on ________________. | Whether artery or vein is superficial or deep within the vein.
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| ____________ is a huge feature of CBF. | Collateral Circulation.
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| People with more ________________ have less damage done by stroke. | More collaterals = less damage.
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| Most built-in collaterals originate a result of the __________________. | Circle of Willis.
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| Give some aspects of the circle of willis: | Manifold Structure. Sources get split. The base of the brain has one, it allows blood to find alternate ways to get to tissues. (backup plans)
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| What determines whether people have collaterals or not? | Really luck of the draw - some people have collaterals some people don't. People with more collaterals will have less damage done by strokes.
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| Can we grow new blood vessels in the CNS? | Yes. We can grow new blood vessels - if a person survives a stroke, they can develop new CNS blood vessels and this acts as compensation.
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| Cerebral Arterioles exhibit myogenic responses to what? This helps maintain what? | Changes in pressure. This helps maintain relatively constant vascular pressure despite large swings in pressure that supply them.
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| When your head is below the heart, pressure increases in your head. What happens then to young, healthy individuals? What happens to individuals with HTN or the elderly? | Young individual's blood vessels vasoconstrict and help control blood pressure. In elderly persons or persons with HTN, myogenic response is muted or lost entirely. Their blood vessels can pop with postural change.
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| Pressure at the brain should be around __________. | 60 mmHg.
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| Strokes occur when ______________________. | When arterial blood supplying the brain tissues gets interrupted or reduced.
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| Two main types of stroke: Explain them: | 1. Ischemic (blood vessel is blocked or restricted) 2. Hemorrhagic (blood vessel bursts and bleeds).
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| 80-85% of all strokes are ________________. | Ischemic Strokes.
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| Occlusion of a particular artery doesn't necessarily mean that the tissue it supplies will die. Why? | Collaterals can take up the slack. But if you're not getting enough blood, you will stroke.
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| What is Transient Ischemic Attack (TIA)? | "Mini-Stroke." Neurological deficits caused by cerebral ischemia that last just a matter of hours.
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| TIA's are usually a sign of _______________. | A warning that a bigger stroke is coming on. Also a sign that someone has cerebrovascular problems, vascular disease (which is a sign of atherosclerosis).
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| If you have vascular disease, that is a sign of what? | Atherosclerosis. Doc may send you to the cath lab to get your heart checked.
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| What is an ischemic stroke? | Something plugs or clots inside a cerebral artery.
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| Thrombotic obstruction occurs from ____________________. (Like _____________________.) | Occurs from something right there in the vessel (like a blood clot or atherosclerotic plaque). Usually this arises from atherosclerotic disease.
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| What heart problem can lead to ischemic stroke? | A-Fib
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| Embolic Obstruction occurs from _________________________. | obstruction elsewhere (like in the heart) and then they get carried to the brain, where they lodge in the artery.
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| Embolic obstructions usually happen when clots formed in ____________________ or _______________ and get carried __________________________. | Embolic obstructions usually happen when clots formed in large arteries or the heart itself break off and get carried "downstream."
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| Clinical signs of a stroke show up when blockage of a blood vessel hits ________________% of the cross-sectional area. | 80-85% of cross sectional area.
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| Functioning damage from strokes depends on what? | What part of the brain the stroke occurred at.
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| Subtypes of Ischemic strokes: | 1. Lacunar. 2. Large vessel thrombotic strokes. 3. Embolic Strokes.
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| What is a lacunar stroke? Caused by ______________. Causes ________________. This causes _____________. | small arteries penetrating into the brain become obstructed due to HTN. Causes infarction in the brain. Infarction will cause patches of liquifactive necrotic material.
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| In lacunar strokes, the blood vessels damaged penetrate into _________________ so ________________________________________. Damage depends on what? | These blood vessels penetrate deep into the cerebrum and brainstem, so infarction in these areas can lead to serious deficits, depending on how deep the obstruction occurs.
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| Large vessel thrombotic strokes usually occur during ______________, when _________________. | Sleep when blood volume is a bit lower.
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| Large vessel thrombotic strokes are due to ________________________________________________________. They happen where? | Obstruction of internal carotid due to atherosclerotic disease. They happen in carotid artery.
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| Large vessel thrombotic strokes develop over ___________________. may stutter, meaning ______________________________. | develop over hours/days. Stutter meaning symptoms appear in spurts as they get worse. This is a warning sign. We know not enough blood is coming through.
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| The embolic stroke hits the ____________ artery. What happens? | Cerebral artery. Something floats in and plugs a cerebral artery.
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| What is the source of the plug in embolic strokes? | Usually blood clots that form originally on the inner wall of the heart (during infarcts, fibrillation, valve disease etc....) then peel off and get swept downstream.
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| ________________________ is the most common reason for cardiac clots being produced and lodged in the brain. | A-fibrillation.
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| Ischemic stroke increases your risk of _____________________________. | hemorrhagic stroke.
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| Symptoms of embolic strokes occur ____________________, during some form of _______________. | Symptoms of embolic strokes occur quickly, during some form of activity.
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| Clots can plug one part of a vessel at first, then ___________________________________. | then dislodge again and lodge farther downstream.
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| Blood vessels distal to the plug become _______________ (due to _____________________) and are more likely to __________________ (causing ____________________). | Distal (away from center). Blood vessels distal to plug become fragile (due to ischemia) and are much more likely to rupture later.
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| Nerve cells that get _________% or less of CBF for a few minutes will die. | 20% or less will die.
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| Dead nerve cells from stroke are referred to as what? | Ischemic core.
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| Cells surrounding the ischemic core are called what? | Penumbra.
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| Ischemic penumbra gets __________________% of CBF. These cells may be able to heal if _______ is restored within some time (hours.) | 20-50% CBF. These cells may be able to heal if perfusion is restored within some period of time.
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| Are we treating the penumbra or the ischemic core? | Penumbra - core is already dead.
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| Dead tissue disrupts ______________, causes __________, releases _____________________ which can harm __________________. | Dead tissue disrupts blood brain barrier, causes swelling, releases bad things (proteases), which can harm nearby cells.
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| _______________ mechanisms may also be damaged in ischemic tissues, which means _______________________. | Autoregulatory mechanisms may also be damaged in ischemic tissues, which means changes in BP will be more damaging to brain tissue from that point on.
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| What are some basic signs and symptoms of stroke? | Abrupt onset of focal neurological deficits. Weakness of arms, leg and or face (especially on one side of the body). Visual disturbances (blurry, double vision, partial fields), dizziness, problems with walking and sudden, severe headache.
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| Hemorrhagic stroke is ___________________. ________________% of all strokes are hemorrhagic. | Bleeding in the brain. 15-20% of all strokes.
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| What is a secondary effect of hemorrhage? | Ischemia.
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| In a hemorrhagic stroke, the bleed can produce an _____________ in pressure in the ____________, which can do what? | increase in pressure in the cranium, which can squeeze other blood vessels shut.
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| In hemorrhagic stroke, blood on the _______ of blood vessels can stimulate them to ___________. | Blood on the outside of blood vessels can stimulate them to contract.
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| In hemorrhagic stroke, bleeding can occur in the outermost layers of the ______________, between the __________________ and the __________ and within the ________________. | Layers of the meninges, between the arachnoid mater and the brain, and within the brain (intracerebral)
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| Bleeding in the outermost layers (subdural and epidural) are usually caused by ___________________. | Trauma.
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| Are hemorrhagic strokes a result of trauma? | No
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| Does cranial bleeding always mean stroke? | No.
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| Intracerebral hemorrhage affects __________________________________. | Blood vessels which penetrate deep into the brain parenchyma.
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| Intracerebral hemorrhage is usually a result of ________________- induced damaged to vessel walls. | hypertension-induced wall damage
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| If the vessels are supplying things like brain stem or basal ganglia (which regulate ________________________), symptoms can be _________________. | Regulate voluntary, motor functions. Symptoms can be very severe and can occur very rapidly (minutes).
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| Mortality rate for intracerebral hemorrhage is ______%, due especially to the likelihood of ____________________________. | 50% due to likelihood of bleeding producing swelling on important areas like the brainstem.
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| Main treatment for intracerebral hemorrhage: | Drop blood pressure and stop anticoagulation therapy if it's being used. Otherwise nothing can help the damage that has been done. Of course, dropping BP too much may cause an increase in damage due to lack of perfusion.
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| Subarachnoid hemorrhage occurs right under the ______________, essentially between _______________ and its _____________. | Occurs right under the cranium. Essentially between the brain and its coverings (the meninges).
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| Subarachnoid hemorrhage can occur as a result of _______, but also as a result of _______________________. | Trauma, but also as a result of rupture of aneurysms which can develop, usually in relatively large vessels of the Circle of Wilis.
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| Subarachnoid hemorrhage mortality is _________% especially due to the fact that ___________________________. | 50% within a month. due especially to the fact that stuff can continue to do harm even after the bleeding stops.
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| ________________ happens often with subarachnoid hemorrhages. | Re-Rupture of blood vessels.
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| Blood vessels constrict in response to ___________________, leading to ________________. | extravascular blood, leading to infarction.
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| Brain aneurysms usually _______________ hurt. Problems arise when ____________. They occur in ________________, such as ________________________________. | don't. problems arise when they pop. They occur in weakened section of blood vessels, such as branched arteries at the fork.
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| The first thing to do with a stroke is what? | Determine whether stroke is ischemic or hemorrhagic - treatment is very different.
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| Treatment for ischemic stroke relies on _______________ and its ability to _____________. | aspirin and its ability to reduce clotting.
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| When does ASA have to be administered for it to be effective? | Administered before clot gets too thick (48 hours) does wonders.
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| Other than aspirin, what is given to treat ischemic stroke? What is this window of effect? | Thrombolytic therapy (tissue plasminogen activator) (TPA) is helpful, but the window for effect is short - 3 hours.
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| Some surgical stuff can help with stroke, such as _________________ and ___________________________. | Carotid endarterectomy and aneurisms clipped or painted with glue-like structure.
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| Carotid endarterectomy can help ______________________. | Clear the carotids of atherosclerotic buildup.
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| There really is no actual treatment for _______________. | Intracerebral hemorrhage.
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| Explain how some functions can come back after a stroke. | cells which haven't died already can start to heal (cells in penumbra). Functions can reappear. Also, brain can re-learn things (neural plasticity)
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| ________________ explains why lost functions can/may come back in someone with neurological damage. | Neural plasticity.
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| Primary prevention of stroke. | Control of blood pressure. treatment for isolated systolic hypertension (ISH). A-fib in elderly or in HTN should be treated with oral anticoagulants to prevent stroke.
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| Secondary Prevention of stroke. | Control hypertension. Anti-platelet anti-aggregation medicines. Carotid endarterectomy.
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