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Clerkship

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Neurology Student Education Director
Maike Blaya, M.D.
131 S. Robertson St.
Suite 1340, Room 1369
Office: 504-988-3888
Fax: 504-988-9197
Email: mblaya1@tulane.edu

Program Coordinator
Zenobia Colón
131 S. Robertson St.
Suite 1340, Room 1345
Office: 504-988-3888
Fax: 504-988-9197
Email: zcolon@tulane.edu

 

Neurology Clerkship
Neurology > Programs > Stroke Management Studies

Stroke Management Studies

Download printable version 17 pages (requires Adobe Acrobat Reader)

 

  • Conflicting
  • Confusing
  • Less than compelling data

What is clear about stroke data
-need to study homogeneous groups of patients

Poor heterogenous
-all TIA or completed stroke patients lumped together without specific stroke subtype

Ideal homogeneous
-hypertensive, Afro-American male who presents with typical lacunar syndrome, without warning TIA, CT/MRI delineates lacunes, normal vascular imaging studies, no clinical evidence of PVD or CAD
-Some situations in which controlled clinical studies will never be done!


CASE 1


52 y.o. Caucasian man goes to his PCP for yearly evaluation and has no vascular symptoms


   

 Medical History
- mild hypertension treated with diuretic only
- mild obesity
- glucose intolerance
- dyslipidemia
- heavy smoker

 Summary:
Asymptomatic, but with heavy vascular burden of risk factor

PE
BP 160/100
P 80 & regular
cardiac and respiratory system normal
left neck noise

Characteristics of this neck sound
louder in neck than upper mediastinum
no change in sound intensity with patient supine

Also
left Hollenhorst plaque visualized on funduscopic examination

Laboratory
CBC - normal
ESR - 42
CRP - elevated
Lipid profile
Total cholesterol - 300
LDL - 270
HDL - 30
Homocysteine - 14
EKG - normal
Chest x-ray - mild cardiomegaly
EBT - no calcification

Significance and Source of neck noise
- Carotid artery
- Jugular vein
- Cardiac system

This sound indicates carotid bruit
- Turbulent flow
- Does not imply carotid stenosis of any degree

Since the patient is asymptomatic, what brain
and vascular imaging studies are indicated?

Carotid duplex ultrasound
MRA
MRA with gadolinium
CT angiogram
Conventional catheter angiogram

What is the role of brain imaging studies in this patient?
CT
MRI
DWI (diffusion weighted imaging)
PWI (perfusion weighted imaging)



What is the likely pathological basis of the
carotid bruit?

Multifocal atherosclerotic plaque
--Concentric
--Eccentric
Stenosis
Plaque rupture
--Thrombosis
--Fibrosis
--Calcification

Conclusion
Atherosclerosis is disorder of arterial wall and not lumen

What is the appropriate therapy if carotid ultrasound shows 60% extracranial carotid stenosis and this is confirmed by angiogram?

Surgical
--CEA
--Angioplasty and stent

Maximal medical management
--(Discussed later)

Vascular protection strategies

    Maintain perfusion
    Antiplatelets
    Anticoagulation

Statin
ACE inhibitor
Homocysteine lowering strategy
Antihypertensive medication
Tight glucose control
Alter bad habits

What is stroke risk in this patient?

Correlates with degree of stenosis
Different from cardiac status
- (acute coronary syndromes)
- hot vessel with 40 to 50% stenosis leads to
ruptured plaque and coronary thrombosis

Atherosclerosis

Multifocal disorder

Pattern of progression
Lower extremities
--ankle-brachial index
Coronary arteries
--EBT
Aortic arch
--TEE
Extracranial carotid and vertebral vessels
--Angiogram
--MRA
Intracranial vessels
--TCD
--MRA
--Angiogram
--CTA
Arterioles
--Not visualized

Does this patient have a high vascular risk?

    Locations

        Peripheral vascular disease
        Coronary artery disease
        Cerebrovascular disease


Stroke risk factors
Hypertension
Cardiac disease
Diabetes mellitus
Dyslipidemia
Bad habits
--Alcohol
--Smoking
--Illicit drugs
--Obesity
--Physical inactivity
Homocysteine
Hypercoagulable states
Nonmodifiable factors
--Family history
--Age
--Race
--Gender

Virchow triad for vascular thrombosis
Blood vessel wall abnormality
Flow disturbances
Blood element coagulation disturbances
--Hypocoagulable
--Hypercoagulable

Examples of coagulation disorders
Hemoglobin abnormalities
White blood cell hyperviscosity states
Red blood cell hyperviscosity states
Platelet abnormalities
Inflammatory markers
--ESR, CRP, fibrinogen
Antiphospholipid antibody syndrome
Procoagulation disorders
--Factor S C and anti-thrombin III
--Van Leiden factor
--Plasminogen inhibitor

Patterns

    Arterial
    Venous

 

 

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