Cerebrovascular Disease RTC Conference Resident Presenter: Dr. Christina Bailey Faculty: Dr. Jeff Dattilo October 2, 2009
Cerebrovascular Disease Stroke is the 3 rd leading cause of death and the leading cause of long-term disability in the US. 700,000 cases per year Defined as any acute brain injury that results in a neurologic deficit of 24 hours or more (TIA <24 hours). Ischemic (85%) Hemorrhagic (15%)
Etiology of Ischemic Stroke Atherosclerotic disease of extracranial cerebrovascular vessels (aortic arch, carotid artery, and vertebral arteries) Embolization of mural thrombus Atrial fibrillation Valvular heart disease Chonic HTN Diffuse intracerebral small vessel disease
Carotid Disease Pathophysiology
Risk Factors Non-modifiable risk factors Age (>55) Male African American and Asian Family history Modifiable risk factors HTN (most prominent modifiable risk factor) Smoking Hyperlipidemia Atrial fibrillation DM
Symptoms Focal symptoms related to ischemia of the ipsilateral cerebral hemisphere or retina Right-sided symptoms Left hemiplegia or monoparesis and right eye visual loss Left-sided symptoms Right hemiplegia or monoparesis and left eye visual loss Aphasia
Symptoms Visual symptoms are due to ischemia of the retina. Amaurosis fugax Transient visual loss Window shade, flashing lights, or sparks Hollenhurst plaques (indication for evaluation for carotid disease) Retinal artery emboli
Indications for Workup Symptomatic patients Hemispheric stroke TIA Amaurosis fugax Asymptomatic patients Cervical bruit Vascular disease (i.e. CAD, PVD) Family history of stoke
Diagnostic Tests Duplex ultrasound Conventional angiography Gold standard, rarely used Essential in the endovascular treatment of carotid disese Magnetic resonance angiography (MRA) Computed tomography angiography (CTA)
Duplex Ultrasound
Duplex Scan Criteria
Indications for Treatment North American Symptomatic Carotid Endarterectomy Trial (NASCET) NEJM, 1991 Aug 15;325(7):445-53. Demonstrated that CEA with medical management is superior to medical management alone for patients with symptomatic, high grade, ICA stenosis. Endarterctomy for Asymptomatic Carotid Artery Stenosis (ACAS)--JAMA, 1995 May 10; 273(18): 1421-28. Demonstrated that CEA with medical management is superior to medical manangement alone for asymptomatic patients with high grade ICA stenosis (>60%). Pt have reduced 5-year risk of ipsilateral stroke if CEA performed with <3% perioperative M&M.
Operative Options Open carotid endarterectomy (CEA) Standard of care Carotid angioplasty and stenting SPACE (Stent-Protected Angioplasty vs CEA) trial 30-day stroke or death rate was 6.9% after stenting and 6.3% after endarterectomy. Results did not justify widespread use of angioplasty for the treatment of carotid stenosis.
CEA Complications Stroke Ischemia during carotid artery clamping Post op thrombosis or embolization ICH Cranial nerve injury Cerebral hyperperfusion syndrome Vein patch rupture Post op hematoma Infectious complications MI
Summary Ischemia is the most common cause of stroke Stroke Neurologic symptoms > 24 hours TIA Neurologic symptoms < 24 hours Visual symptoms are ipsilateral CEA is standard treatment for carotid stenosis Optimal treatment is primary prevention
Case Presentation CC: Visual loss. HPI: 57m presents c/o intermittent L eye visual loss. Pt states vision goes hazy and green. Lasts approximately 5-10 minutes. Episodes are associated with numbness in his R face, RUE, and RLE. Symptoms started in April 08.
Case Presentation PMHx: R eye blindness s/p ski accident in 1984 HTN GERD Impotence PSHx: RIH repair B carpal tunnel release Left shoulder bone graft FHx: Non-contributory SHx: +h/o tobacco (quit 2 years ago) Allergies: Sulfa drugs Meds: None ROS: neg except HPI
Case Presentation PE: Vitals: T-98.1 F, HR-66, BP-172/100, RR-18 HEENT: No facial droop. Neck: +right carotid bruit Neuro: CN intact, strength 5/5, sensation grossly intact, no focal deficits
Work-up CBC, BMP, and coags WNL CT Head: Small foci of low density change in the subcortical white matter of both cerebral hemispheres consistent with chronic ischemia. Carotid Duplex: Right proximal ICA velocity: 643/242 Left proximal ICA velocity: 553/126
Work-up Angiogram 95% stenosis of the left proximal ICA 80% stenosis of the right proximal ICA
Conclusion Diagnosis: Symptomatic left carotid artery stenosis Procedure: Left carotid endarterectomy (CEA) POC uncomplicated, d/c POD#1
A pt presents with an episode of L arm weakness. Arteriogram revealed 60% stenosis of R ICA and complete occlusion of the L ICA. Appropriate treatment would be: 1. ASA 325 mg bid 2. R CEA with shunt 3. L CEA followed by R CEA 2 weeks later 4. R CEA followed by L CEA 2 weeks later 5. R CEA without shunt 0% 0% 0% 0% 0% ASA 325 mg bid R CEA with shu... L CEA followed... R CEA followed... R CEA without...
2. R CEA with shunt Left carotid is occluded and asymptomatic, surgical intervention not warranted. Right side is stenotic and symptomatic, therefore surgical repair is advisable. Patients with contralateral occlusion or h/o stroke in the past should be shunted.
The most common cranial nerve injury after CEA is: 1. Vagus nerve 2. Hypoglossal nerve 3. Glossopharyngeal nerve 4. Spinal accessory nerve 5. Marginal mandibular nerve 0% 0% 0% 0% 0% Vagus nerve Hypoglossal ne... Glossopharynge... Spinal accesso... Marginal mandi...
1. Vagus nerve Overall incidence of CN injuries can be as high as 16% Vast majority are aymptomatic or temporary (usually reslove w/in 6 wk) Vagus is most commonly injured Symptoms: hoarseness (secondary to paralysis of the vocal cord on the side of the injury) 2 nd most commonly injured is the hypoglossal nerve Deviation of patient s tongue to the side ipsilateral to the injury
Five days after an uncomplicated R CEA, a 69m presents with sudden onset of a severe R sided HA. He is HDS and neurologically intact. The next step in management should be: 1. IV heparin 2. Carotid duplex US 3. Cerebral imaging study 4. Carotid arteriogram 5. To OR for carotid reexploration 0% 0% 0% 0% 0% IV heparin Carotid duplex... Cerebral imagi... Carotid arteri... To OR for caro...
3. Cerebral imaging study Hyperperfusion of the brain is rare but a potentially dangerous complication of CEA. Pt presents with severe ipsilateral HA and can progress to seizure and cerebral hemorrhage. Observed in 0.4% to 7.7% pt after CEA. Represent increased cerebral blood flow in a territory with disturbed autoregulation. A cerebral imaging study (CT or MRI) should be obtained to detect edema or hemorrhage.
A pt underwent L CEA one year ago and presents for routine f/u. Duplex reveals recurrent L ICA stenosis. Which of the following is TRUE? 1. This most likely represents myointimal hyperplasia. 2. Majority of lesions are asymptomatic. 3. Treatment is best performed by repeat CEA with primary closure. 4. Repeat operation carries lower risk of CN injury. 5. Recurrent stenosis occurs more often with the use of a patch than during primary repairs. This most like... 0% 0% 0% 0% 0% Majority of le... Treatment is b... Repeat operati... Recurrent sten...
1. Most likely represents myointimal hyperplasia. Etiology of recurrent carotid stenosis differs depending on the time interval b/w operation and restenosis. Restenosis w/in 2 years is most often due to myointimal hyperplasia (collagen proliferation in the arterial wall) Usually asymptomatic. Don t treat unless stenosis is >80% Restenosis after 2 years is most often due to atherosclerotic disease. Treat under the same guidelines as primary carotid stenosis