40 Questions
What is the approximate percentage of Transient Ischemic Attacks (TIAs) that last greater than 1 hour?
25%
What is the percentage of strokes that are hemorrhagic?
15%
What is the time frame within which half of the strokes occur after a Transient Ischemic Attack (TIA)?
48 hours
What is the site of Extracranial atherosclerosis?
Carotid / Vertebral / Aortic Arch
What is the reported prevalence of prior TIA among those who present with a stroke?
7-40%
What is the time frame within which someone dies of a stroke in the United States?
Every 4 minutes
What is the definition of a Transient Ischemic Attack (TIA) based on tissue?
Brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction.
What percentage of TIAs will be followed by a stroke within 3 months?
10-20%
What percentage of individuals have a symmetrical Circle of Willis?
20%
What is the primary mechanism responsible for episodes of TIA/STROKE in carotid artery disease?
Cerebral emboli
What is the recommended treatment for hypertension in carotid artery disease management?
Treatment of hypertension
What is the goal of carotid interventions in carotid artery disease management?
All of the above
What is the recommended technique for carotid endarterectomy closure?
All of the above
What is the purpose of embolic protection filters in carotid stenting?
To prevent cerebral emboli
What is the difference between CEA and CAS in terms of 30-day stroke or death in symptomatic patients?
CEA is superior to CAS
What is the role of transcranial doppler in carotid endarterectomy?
To monitor for cerebral emboli
What is the most appropriate management strategy for a patient with a minor stroke and 70% stenosis of the left internal carotid artery, with a good 3-5 year life expectancy?
Carotid Endarterectomy of the left internal carotid artery
What is the significance of a 4/5 right-sided weakness in this patient?
It is a sign of a major stroke
What is the benefit of statin therapy in this patient?
It reduces the risk of stroke with best medical therapy
What is the role of biomarkers in carotid disease management?
They are used to identify carotid plaque vulnerability
What is the indication for Carotid Endarterectomy in this patient?
The patient has a minor stroke and 70% stenosis of the left internal carotid artery
What is the significance of a Left Carotid bruit in this patient?
It is a sign of carotid stenosis
What is the role of aspirin in this patient's management?
It is used to reduce the risk of stroke with best medical therapy
What is the benefit of Carotid Stenting in this patient?
It is a less invasive alternative to Carotid Endarterectomy
What is the consideration for patients with life expectancy exceeding 5 years?
CEA should be considered
What is the average annual risk of ipsilateral stroke in Asx >50% stenosis?
3.5%
What is the 5-year risk of carotid territory ischaemic stroke in patients 75+ years old?
8.79%
What is the difference in the 5-year risk of carotid territory ischaemic stroke between immediate and deferred treatment?
3.29% (CI -1.86-8.44)
What is the role of CAS in patients with Asx CAD >60%?
CAS is an alternative to CEA
What is the benefit of CAS in the elderly?
The benefit is questionable
What is the indication for considering CEA in patients with Asx CAD >60%?
Life expectancy exceeding 5 years
What is the presentation of the 67-year-old male in the case scenario?
Acute weakness of his right arm and leg
What is the primary consideration for technique selection in revascularization?
Stage of ischemia
What is the preferred choice of conduit in open surgery?
Autologous venous conduit
In which patients is open surgery likely better?
Low surgical risk patients with good life expectancy and a good quality saphenous vein conduit
What is the criterion for selecting endovascular techniques over open surgery?
All of the above
What is the advantage of covered self-expanding stents?
Highest patency rates
What is the primary goal of risk factor control in PAD treatment?
All of the above
What is the purpose of cilostazol in PAD treatment?
To improve exercise performance
What is the significance of Factor V Leiden in PAD treatment?
It increases the risk of thrombosis
Study Notes
Cerebrovascular Event Classification
- Transient Ischemic Attack (TIA):
- No infarct (cell death)
- Time-based definition: sudden, focal neurologic deficit lasting less than 24 hours
- Tissue-based definition: brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, without evidence of acute infarction
- Stroke (infarct = cell death)
Transient Ischemic Attack Facts
- 10-20% of TIAs will be followed by a stroke within 3 months, half of them within 48 hours
- Among those who present with a stroke, the prevalence of prior TIA is reported to be 7-40%
Stroke
- Infarction of the central nervous system tissue related to hypoperfusion, embolization, thrombosis, or intracranial hemorrhage
- Types:
- Ischemic (85%)
- Hemorrhagic (15%)
Extracranial Atherosclerosis
- Sites:
- Carotid/Vertebral/Aortic Arch
- Types:
- Lacunar (small vessel)
- Cardioembolic
- Miscellaneous (e.g. hypercoagulability, cryptogenic)
Carotid Artery Disease
- Degree/progression of atherosclerotic stenosis
- Plaque quality (stable vs unstable)
- Embolization: primary mechanism responsible for TIA/STROKE
- Vulnerable carotid plaque:
- Unstable plaques are mainly associated with TIA/STROKE
- Identifying vulnerable carotid plaque: clinical information, family history, genetics, imaging, and biological markers
Take Away Messages
- Amaurosis fugax, TIA, or minor stroke are typically a warning sign of a major stroke in the setting of carotid stenosis ≥50%
- Imaging techniques and biomarkers can identify carotid plaque vulnerability
- Risk of stroke with BMT is declining (statins, antiplatelets, antihypertensives, etc.)
- Sx patients with >50% stenosis will benefit from an intervention to prevent a new stroke
- Asx patients with >70% stenosis will benefit from an intervention (to prevent a stroke) provided they have a good 3-5 year life expectancy
- Risk of perioperative stroke with intervention is also declining
This quiz covers the classification of cerebrovascular events, including transient ischemic attacks and strokes. Learn about the differences between these two conditions and their definitions.
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