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Questions and Answers
What is the most common cause of ischemic infarcts in preterm very low body weight infants?
What is the most common cause of ischemic infarcts in preterm very low body weight infants?
Which clinical feature is associated with a left hemisphere stroke?
Which clinical feature is associated with a left hemisphere stroke?
During which timeframe does acute infarct grossly appear as necrosis with neutrophilia?
During which timeframe does acute infarct grossly appear as necrosis with neutrophilia?
Which option represents a less common cause of ischemic infarcts?
Which option represents a less common cause of ischemic infarcts?
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What changes characterize the subacute phase (5 - 14 days) of an infarct?
What changes characterize the subacute phase (5 - 14 days) of an infarct?
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Which symptom is typical for a right hemisphere stroke?
Which symptom is typical for a right hemisphere stroke?
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Which of the following is NOT a typical clinical feature of stroke?
Which of the following is NOT a typical clinical feature of stroke?
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What characterizes the chronic phase (15 days - years) of an infarct?
What characterizes the chronic phase (15 days - years) of an infarct?
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Which imaging technique is primarily used to visualize the vascular structures in cases of suspected intracranial hemorrhage?
Which imaging technique is primarily used to visualize the vascular structures in cases of suspected intracranial hemorrhage?
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What is a common cause of subdural hemorrhage in elderly patients?
What is a common cause of subdural hemorrhage in elderly patients?
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Which type of intracranial hemorrhage is most frequently associated with trauma and middle meningeal artery rupture?
Which type of intracranial hemorrhage is most frequently associated with trauma and middle meningeal artery rupture?
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What is the most common cause of subarachnoid hemorrhage?
What is the most common cause of subarachnoid hemorrhage?
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Which of the following factors does NOT affect prognostic outcomes for patients experiencing a CVA?
Which of the following factors does NOT affect prognostic outcomes for patients experiencing a CVA?
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Which laboratory test is essential to rule out coagulation disorders before thrombolysis in acute ischemic stroke?
Which laboratory test is essential to rule out coagulation disorders before thrombolysis in acute ischemic stroke?
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What type of intracranial hemorrhage involves bleeding within the brain tissue itself?
What type of intracranial hemorrhage involves bleeding within the brain tissue itself?
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Which condition is least likely to cause intraparenchymal hemorrhage?
Which condition is least likely to cause intraparenchymal hemorrhage?
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What is the primary cause of ischemic stroke?
What is the primary cause of ischemic stroke?
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Which site in the CNS is most commonly affected by ischemic stroke?
Which site in the CNS is most commonly affected by ischemic stroke?
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Which risk factor for stroke is considered modifiable?
Which risk factor for stroke is considered modifiable?
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What classification of stroke does not include ischemic or hemorrhagic types?
What classification of stroke does not include ischemic or hemorrhagic types?
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Which of the following best explains the pathophysiological process in ischemic stroke?
Which of the following best explains the pathophysiological process in ischemic stroke?
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Which of the following statements about the epidemiology of stroke is true?
Which of the following statements about the epidemiology of stroke is true?
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Which of the following is a common clinical feature of ischemic stroke?
Which of the following is a common clinical feature of ischemic stroke?
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What is the main goal of treatment principles for stroke?
What is the main goal of treatment principles for stroke?
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What is a less common clinical feature associated with a left hemisphere stroke?
What is a less common clinical feature associated with a left hemisphere stroke?
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Which factor does NOT contribute to the pathology of ischemic infarcts?
Which factor does NOT contribute to the pathology of ischemic infarcts?
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What type of infarct morphology is characterized by blurring of the gray-white matter junction?
What type of infarct morphology is characterized by blurring of the gray-white matter junction?
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In which stage of an infarct do macrophages become significantly present?
In which stage of an infarct do macrophages become significantly present?
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What is the primary clinical diagnosis feature for right (non-dominant) hemisphere strokes?
What is the primary clinical diagnosis feature for right (non-dominant) hemisphere strokes?
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Which process predominantly occurs during the chronic phase (15 days - years) of an infarct?
Which process predominantly occurs during the chronic phase (15 days - years) of an infarct?
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Which of the following describes a common clinical symptom for both types of hemisphere strokes?
Which of the following describes a common clinical symptom for both types of hemisphere strokes?
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Which condition might NOT lead to ischemic injury in utero among very low birth weight infants?
Which condition might NOT lead to ischemic injury in utero among very low birth weight infants?
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What does not describe an acute phase symmetry of an infarct's gross appearance?
What does not describe an acute phase symmetry of an infarct's gross appearance?
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What is the primary mechanism leading to cell death in CNS infarction?
What is the primary mechanism leading to cell death in CNS infarction?
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Which demographic is associated with a higher incidence of cerebrovascular accident?
Which demographic is associated with a higher incidence of cerebrovascular accident?
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What characterizes the pathophysiological impact of ischemic stroke on cerebral tissue?
What characterizes the pathophysiological impact of ischemic stroke on cerebral tissue?
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Which of the following is a common clinical feature exhibited during ischemic stroke?
Which of the following is a common clinical feature exhibited during ischemic stroke?
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What is the most common site of occurrence for embolic strokes in the brain?
What is the most common site of occurrence for embolic strokes in the brain?
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Which risk factor is categorized as modifiable in relation to stroke occurrence?
Which risk factor is categorized as modifiable in relation to stroke occurrence?
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In terms of prognosis following a stroke, which factor plays a decisive role?
In terms of prognosis following a stroke, which factor plays a decisive role?
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Which type of intracranial hemorrhage is primarily associated with a vascular insult?
Which type of intracranial hemorrhage is primarily associated with a vascular insult?
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What diagnostic method is most reliable for assessing CNS infarction?
What diagnostic method is most reliable for assessing CNS infarction?
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Which of the following statements best describes the epidemiology of stroke?
Which of the following statements best describes the epidemiology of stroke?
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What condition is MOST commonly associated with epidural hemorrhage?
What condition is MOST commonly associated with epidural hemorrhage?
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Which of the following is a leading cause of subarachnoid hemorrhage?
Which of the following is a leading cause of subarachnoid hemorrhage?
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Which factor does NOT contribute to a worse prognosis in patients with cerebral vascular accidents (CVAs)?
Which factor does NOT contribute to a worse prognosis in patients with cerebral vascular accidents (CVAs)?
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What type of intracranial hemorrhage is characterized by diffuse injury at the gray-white matter junction?
What type of intracranial hemorrhage is characterized by diffuse injury at the gray-white matter junction?
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In which demographic are subdural hemorrhages MOST commonly found?
In which demographic are subdural hemorrhages MOST commonly found?
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Which of the following laboratory tests is critical for assessing coagulation status before thrombolysis in acute ischemic stroke?
Which of the following laboratory tests is critical for assessing coagulation status before thrombolysis in acute ischemic stroke?
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What is a key characteristic of intraparenchymal hemorrhage?
What is a key characteristic of intraparenchymal hemorrhage?
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Which type of intracranial hemorrhage primarily occurs in the context of trauma?
Which type of intracranial hemorrhage primarily occurs in the context of trauma?
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Which of the following can be a cause of intracerebral hemorrhage?
Which of the following can be a cause of intracerebral hemorrhage?
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Which of the following imaging techniques is NOT typically associated with the diagnosis of intracranial hemorrhage?
Which of the following imaging techniques is NOT typically associated with the diagnosis of intracranial hemorrhage?
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Study Notes
CNS Pathology: Cerebro-Vascular Accident
- Cerebrovascular accident (CVA) is also known as cerebrovascular disease (CVD) or stroke
- Stroke is defined as an acute neurological deficit due to vascular insult. Possible causes include thrombosis, embolism, or hemorrhage
- Stroke is associated with low blood supply/hypoxia ("Low O2")
- CNS infarction is cell death due to ischemic injury in the CNS. Determination is based on imaging, neuropathology, or clinical assessment
Learning Outcomes
- Students will define ischemic stroke
- Students will describe the epidemiology of stroke
- Students will identify the most common sites of stroke
- Students will explain stroke pathophysiology
- Students will identify the etiology of stroke
- Students will list common stroke clinical features.
- Students will describe the gross and microscopic features of stroke
- Students will describe methods for diagnosing stroke
- Students will define treatment principles in stroke
- Students will identify prognostic factors in stroke
- Students will describe different types of intracranial hemorrhages
CVA Lecture Outlines
- Definition
- Epidemiology
- Sites of stroke
- Pathophysiology
- Etiology of stroke
- Clinical features
- Macro and microscopic descriptions of stroke lesions
- Stroke diagnosis
- Stroke treatment
- Stroke prognosis
- Intracranial hemorrhage
Epidemiology of Stroke
- Stroke is the second leading cause of neurological disability after Alzheimer's disease globally
- Approximately 12 million strokes occur annually worldwide, resulting in around 4 million deaths
- Stroke is the third most common cause of death worldwide
Risk Factors
- Non-modifiable: Age, gender (male), race, hereditary factors, and stress
- Modifiable: Hypertension (HT), Diabetes Mellitus (DM), Smoking, Hyperlipidemia, Excessive alcohol consumption, Cardiac diseases (e.g., atrial fibrillation (AF)), Oral contraceptives, Hypercoagulability, Diet/Sedentary lifestyle
Sites of Ischemic Stroke
- Ischemic stroke can affect any site in the central nervous system (CNS)
- The middle cerebral artery (MCA) is frequently affected, leading to various neurological consequences
- Thromboembolism, atherosclerotic plaque fragmentation, and atrial fibrillation are potential causes of MCA blockage
Pathophysiology
- Decreased blood flow: Liquefactive necrosis
- Increased intracranial pressure (ICP) and herniation: Due to edema or hemorrhage
- Additional details of pathophysiology, such as diagrams/images of various stages, may also be helpful.
Etiology of CVA
- Most common: Atherosclerosis, cardiac pathology, and hypertension
- Less common: Vasculitis, coagulation disorders, arterial dissection, reversible vasoconstriction syndrome, HIV-associated arteriopathy, Moyamoya disease, and fat embolism
- Ischemic insults in utero are the most frequent cause of cerebral injury among preterm/very low birthweight infants
Clinical Features of CVA
-
Symptoms depend on the location of the ischemic brain tissue
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Common symptoms:
- Contralateral hemiparesis (weakness on opposite side of the body)
- Hemianesthesia (loss of sensation on one side of the body)
- Aphasia (language impairment)
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Left hemisphere stroke: Aphasia, right-sided hemiparesis, right-sided sensory loss, poor visual attention
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Right hemisphere stroke: Left-sided visual field defect, extinction of left-sided stimuli, left-sided hemiparesis, left-sided sensory loss, spatial disorientation
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Additional detailed clinical features (symptoms and signs) based on location of stroke should also be added.
Gross Description of Stroke Lesions
- Acute infarct (1-4 days): Neurons more susceptible to ischemia than glia, necrosis, and neutrophilia.
- Subacute (5-14 days): More necrosis, increased macrophages.
- Chronic (15 days - years): Cavitated lesion, vessels present, macrophages, glial scar.
Macro & Microscopic Description
- Infarct morphology depends on the time interval between stroke onset and brain examination.
- Acute: blurring of gray-white matter junction, edema, and red neurons (microscopically)
- Subacute: cracking artifact,(gross), dense macrophage infiltration, and neovascularization (micro)
- Chronic: cavitated lesions (gross) with macrophages, and surrounding gliosis (micro)
Diagnosis
- Clinical assessment: Identifying neurological signs and symptoms
- Imaging: CT, CT angiography, MRI, PET, ECG, X-ray
- Laboratory: CBC, Platelet count, coagulation tests (aPTT, PT, TT) are useful to rule out coagulation disorders. Other tests include blood glucose, serum electrolytes, renal function tests (RFT), and liver function tests (LFT).
Treatment
- For acute ischemic stroke (within 6-8 hours of onset):
- Systemic thrombolysis
- Thrombectomy
Prognostic Factors in Stroke
- Age at presentation
- Degree of neurological impairment
- Infarct volume and location
Intracranial Hemorrhages
- Bleeding within the skull.
- Different subtypes include intracerebral, subarachnoid, epidural, and subdural hemorrhages
- These can be caused by trauma or various un-traumatic conditions
Types of Intracranial Hemorrhage: Learning Objectives
- Describe various types of intracranial hemorrhage
- List common causes for each type of intracranial bleeding
Types of Intracranial Hemorrhages
- Epidural
- Subdural
- Subarachnoid
- Intraparenchymal
Epidural Hemorrhage
- Typically from trauma, most commonly from a temporal bone fracture and rupture of the middle meningeal artery
Subdural Hemorrhage
- May or may not follow trauma
- Most frequent in elderly persons with cerebral atrophy or individuals with systemic cancer/CNS tumors
Subarachnoid Hemorrhages
- Commonly caused by the rupture of a saccular (Berry) aneurysm.
- Additional causes include vascular malformations, trauma, hematological disorders, and tumors.
Hemorrhage into Parenchyma
- Massive hemorrhage displaces and compresses surrounding brain tissue. Smaller hemorrhages can be subacute or chronic.
- Common causes: Hypertension, Arteriovenous Malformations (AVMs), Subarachnoid aneurysms
Intracerebral Hemorrhage
- Bleeding within the brain tissue, often due to high blood pressure.
- Can subdivide into intraventricular and intraparenchymal hemorrhages
Causes of Intracranial Hemorrhage
- Traumatic: Most common cause
- Non-traumatic: Hypertension, cerebral amyloid angiopathy, hemorrhagic conversion of ischemic infarction, cerebral aneurysms, dural arteriovenous fistulae, cerebral venous sinus thrombosis, cerebral vasculitis, mycotic aneurysm
Complications of Intracranial hemorrhage
- Coma
- Persistent vegetative state
- Cardiac arrest
- Death
Classification of Stroke
- Transient
- Evolving
- Completed
- Ischemic (thrombotic/embolic, hemorrhagic)
- Focal or global
- Arterial or venous
- Variable severity, depending on location and type
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Description
This quiz explores the essential aspects of cerebrovascular accidents (strokes), including their definition, causes, and effects on the body. Students will learn to identify various types of strokes, their common clinical features, and the methods of diagnosis and treatment. A comprehensive understanding of stroke pathophysiology and epidemiology is aimed for.
