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Questions and Answers
What is the primary factor that determines the classification of a CNS infarction as ischemic?
What is the primary factor that determines the classification of a CNS infarction as ischemic?
Which of the following is a non-modifiable risk factor for stroke?
Which of the following is a non-modifiable risk factor for stroke?
What type of necrosis is primarily associated with decreased blood flow during an ischemic stroke?
What type of necrosis is primarily associated with decreased blood flow during an ischemic stroke?
Which site is most commonly affected by thromboembolic events in ischemic strokes?
Which site is most commonly affected by thromboembolic events in ischemic strokes?
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Which of the following factors contributes to the increased intracranial pressure during an ischemic stroke?
Which of the following factors contributes to the increased intracranial pressure during an ischemic stroke?
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What is the third most common cause of death worldwide related to stroke?
What is the third most common cause of death worldwide related to stroke?
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Which of the following is NOT considered a modifiable risk factor for stroke?
Which of the following is NOT considered a modifiable risk factor for stroke?
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What is the main type of stroke associated with the embolism from atrial fibrillation?
What is the main type of stroke associated with the embolism from atrial fibrillation?
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Which of the following is a less common cause of ischemic infarcts?
Which of the following is a less common cause of ischemic infarcts?
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What is the most common clinical feature associated with a stroke in the left hemisphere?
What is the most common clinical feature associated with a stroke in the left hemisphere?
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In the context of acute infarcts, what is indicated by the presence of neutrophilia?
In the context of acute infarcts, what is indicated by the presence of neutrophilia?
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Which of the following features is characteristic of a chronic ischemic infarct?
Which of the following features is characteristic of a chronic ischemic infarct?
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What is the primary cause of cerebral injury in preterm/very low body weight infants?
What is the primary cause of cerebral injury in preterm/very low body weight infants?
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Which cerebral infarct morphology indicates a subacute stage?
Which cerebral infarct morphology indicates a subacute stage?
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Which of the following symptoms is associated with right (non-dominant) hemisphere stroke?
Which of the following symptoms is associated with right (non-dominant) hemisphere stroke?
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How is the diagnosis of a stroke primarily made?
How is the diagnosis of a stroke primarily made?
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Which type of intracranial hemorrhage is most commonly associated with a temporal bone fracture?
Which type of intracranial hemorrhage is most commonly associated with a temporal bone fracture?
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What is the most frequent cause of subarachnoid hemorrhage?
What is the most frequent cause of subarachnoid hemorrhage?
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Which of the following factors is least likely to affect prognosis for patients presenting with a cerebrovascular accident (CVA)?
Which of the following factors is least likely to affect prognosis for patients presenting with a cerebrovascular accident (CVA)?
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What type of hemorrhage is characterized by diffuse injury at the gray-white matter junction, commonly due to high-velocity injuries?
What type of hemorrhage is characterized by diffuse injury at the gray-white matter junction, commonly due to high-velocity injuries?
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Which condition is NOT commonly associated with subdural hemorrhage?
Which condition is NOT commonly associated with subdural hemorrhage?
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Which of the following conditions is least likely to cause intracerebral hemorrhage?
Which of the following conditions is least likely to cause intracerebral hemorrhage?
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Which test is NOT relevant for ruling out coagulation disorders in the context of thrombolysis in acute ischemic stroke?
Which test is NOT relevant for ruling out coagulation disorders in the context of thrombolysis in acute ischemic stroke?
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Which type of intracranial hemorrhage typically does NOT follow trauma?
Which type of intracranial hemorrhage typically does NOT follow trauma?
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Study Notes
CNS Pathology: Cerebrovascular Accident (CVA)
- CVA, also known as stroke or cerebrovascular disease (CVD), is an acute neurological deficit resulting from vascular insult. The insult can be from thrombosis, embolism, or hemorrhage.
- Stroke is associated with reduced blood supply (hypoxia).
- CNS infarction is cell death due to ischemic injury in the central nervous system (CNS), identified through imaging, neuropathology, or clinical assessments.
Classifications
- Transient, evolving, and completed ischemic or hemorrhagic CVA.
- Focal or global.
- Arterial or venous.
- Varying severity based on location and type.
Epidemiology
- Stroke is the second leading cause of neurological disability after Alzheimer's disease.
- Globally, there are approximately 12 million strokes annually, resulting in roughly 4 million deaths.
- Globally, stroke is the third leading cause of death.
Risk Factors
- Non-modifiable: Age, male sex, race, heredity.
- Modifiable: Hypertension (HT), diabetes mellitus (DM), smoking, hyperlipidemia, excess alcohol, cardiac diseases (e.g., atrial fibrillation), oral contraceptives, hypercoagulability states, diet/sedentary lifestyle/stress.
Sites
- Ischemic stroke can affect any site in the CNS.
- The middle cerebral artery (MCA) is frequently affected in ischemic stroke.
- Possible causes of MCA damage include thromboembolism (e.g., internal carotid atherosclerotic plaque, atrial fibrillation).
Pathophysiology
- Decreased blood flow leads to liquefactive necrosis.
- Increased intracranial pressure (ICP) results from edema or hemorrhage, causing herniation.
Etiology
- Most common causes of stroke include atherosclerosis, cardiac pathology, and hypertension.
- Other less common causes include vasculitis, coagulation disorders, arterial dissection, reversible vasoconstriction syndrome, HIV-associated arteriopathy, Moyamoya disease, and fat embolism (especially in preterm/low-birth-weight infants).
Clinical Features
- Symptoms vary depending on the affected region. Common symptoms include contralateral hemiparesis (unilateral weakness of upper and lower limbs), hemianesthesia (absence of unilateral sensations), and aphasia (inability to understand or express oral language). Symptoms differ for left-hemisphere and right-hemisphere strokes.
Gross Description
- Acute infarct (1-4 days): Neurons are more susceptible to ischemia than glia; necrosis with neutrophilia.
- Subacute (5-14 days): More necrosis and more macrophages.
- Chronic (15+ days): Cavitated lesion with vessels and macrophages surrounded by glial scar tissue.
Macro & Microscopic Description
- Infarct morphology varies with time post-onset.
- Acute: Blurring of gray-white matter junction, edema, red neurons.
- Subacute: Cracking artifact, dense macrophage infiltration, neovascularization.
- Chronic: Cavitated lesions, macrophages, gliosis.
Diagnosis
- Clinical: Physicians initially make a diagnosis based on clinical examination.
- Imaging: CT, CT angiography, MRI, PET, ECG, and CX-rays aid in the diagnosis.
- Laboratory: CBC, platelet count, and coagulation tests (aPTT, PT, TT) rule out coagulopathies (important for thrombolysis contraindications). Blood glucose, electrolytes, liver function tests (LFT), and renal function tests (RFT).
Treatment
- Acute ischemic stroke (within 6-8 hours of onset): Systemic thrombolysis or thrombectomy.
Prognostic Factors
- Age at presentation.
- Degree of neurologic impairment.
- Infarct volume and location.
Intracranial Hemorrhages
- Intracranial hemorrhage (ICH) involves bleeding within the skull.
- Types include intracerebral (intraventricular and intraparenchymal), subarachnoid, epidural, and subdural.
Epidural Hemorrhage
- Typically results from trauma, primarily temporal bone fractures causing middle meningeal artery rupture.
Subdural Hemorrhage
- Often associated with trauma, but also with cerebral atrophy in the elderly, and systemic cancer or CNS tumors.
Subarachnoid Hemorrhage
- Most frequently caused by rupture of saccular aneurysms.
- Other potential causes include vascular malformations, trauma, hematological disturbances, and tumors.
Hemorrhage into Brain Parenchyma
- Massive hemorrhage displaces brain tissue; smaller hemorrhages can be subacute or chronic. Common causes include hypertension, arteriovenous malformations (AVMs), and ruptured aneurysms.
Causes of Intracranial Hemorrhage
- Trauma is the most common cause.
- Non-traumatic causes: Hypertension, cerebral amyloid angiopathy, hemorrhagic conversion of ischemic infarct, cerebral aneurysms, dural arteriovenous fistulae, cerebral venous sinus thrombosis, cerebral vasculitis, and mycotic aneurysm.
Complications of Intracranial Hemorrhage
- Coma.
- Persistent vegetative state.
- Cardiac arrest.
- Death.
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Description
This quiz covers the key elements of cerebrovascular accidents (CVA), including types, classifications, and epidemiology. Understand the risk factors and learn how strokes are identified and assessed in the context of central nervous system pathology. Test your knowledge on this critical topic in neurological health.
