Cerebrovascular atherosclerosis is the thickening and hardening of arterial walls due to plaque buildup. It primarily affects the large extracranial and intracranial arteries. Atherosclerosis is caused by endothelial injury and accumulation of lipids in the arterial wall over time. It is diagnosed using angiography, ultrasound, MRI/CT angiography. Treatment involves managing risk factors as severe atherosclerosis can cause strokes.
1) Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. While medical treatments like antithrombotics and statins are recommended, endovascular interventions may be considered for recurrent strokes.
2) Early studies of angioplasty and stenting for ICAD showed high complication rates. The SAMMPRIS trial found stenting plus medical therapy was worse than medical therapy alone. Subsequent studies using strict criteria saw lower complication rates.
3) Current recommendations are for medical management as first-line for ICAD. Endovascular treatments like submaximal angioplasty may be considered for recurrent strokes despite medical therapy, based on the underlying stroke mechanism
This document provides information on restrictive cardiomyopathy (RCM), including its definition, classification, etiology, symptoms, diagnosis, and treatment. Some key points:
- RCM is characterized by diastolic dysfunction with a stiffened myocardium that impairs ventricular filling. It is usually not associated with ventricular dilation or hypertrophy.
- Causes include infiltrative diseases of the myocardium (e.g. amyloidosis, sarcoidosis), endomyocardial fibrosis, and genetic/familial factors.
- Symptoms are related to reduced cardiac output and include dyspnea, fatigue, arrhythmias. Diagnosis involves echocardiogram, cardiac catheterization and MRI to evaluate
This document summarizes the treatment options for carotid artery stenosis, specifically carotid endarterectomy (CEA) versus carotid artery stenting (CAS). CEA has been shown to be superior to medical management alone in reducing stroke risk and is the gold standard treatment. CAS may be preferable for high-risk patients with conditions making CEA difficult, but is associated with a higher risk of perioperative stroke. The choice between CEA and CAS depends on patient characteristics, disease factors, and operator experience. While CAS can be performed less invasively, current evidence shows CEA remains the standard treatment for standard-risk patients.
1. Aortic stenosis can be caused by rheumatic heart disease, congenital abnormalities of the aortic valve, or age-related degeneration and calcification of the valve.
2. Obstructed left ventricular outflow due to aortic stenosis leads to increased pressure and compensatory hypertrophy of the left ventricle. While cardiac output is maintained at rest, it often fails to rise normally during exertion in severe aortic stenosis.
3. Symptoms of aortic stenosis include angina, syncope, exertional dyspnea, and heart failure, which typically appear when the aortic orifice is reduced to one third of its normal size. Valve replacement surgery is
This document discusses carotid artery disease and carotid stenting procedures. It provides background on carotid artery atherosclerosis and how vulnerable plaques can lead to strokes. It then summarizes guidelines for diagnosing and treating symptomatic and asymptomatic carotid stenosis, including the risks and benefits of medical therapy, carotid endarterectomy, and carotid artery stenting. The document concludes by outlining the key steps for performing carotid artery stenting, including patient selection, imaging, vascular access, stent placement, and complications to consider.
This document discusses risk factors, types, signs and symptoms, diagnosis, and treatment of stroke. It identifies the main types of stroke as hemorrhagic (20%) and ischemic (80%). Modifiable risk factors mentioned include hypertension, diabetes, dyslipidemia, obesity, oral contraceptive use, and migraine. Non-modifiable risk factors include age, sex, race, and genetic factors. The document outlines the classification, pathophysiology, warning signs, differential diagnosis and management of acute stroke and secondary prevention. It emphasizes the importance of controlling blood pressure, glucose, lipids and smoking to prevent first and recurrent strokes.
This document provides an overview of the approach to patients presenting with ataxia. It discusses the localization and causes of ataxia based on the involved neurological structures like the cerebellum and sensory pathways. Specific signs help to localize lesions within the cerebellum. A thorough history and examination along with targeted investigations can help identify acquired, genetic and other causes of ataxia. Neuroimaging, electrodiagnostic tests, ophthalmological and genetic testing are important to classify the type and guide management of ataxia.
1) Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. While medical treatments like antithrombotics and statins are recommended, endovascular interventions may be considered for recurrent strokes.
2) Early studies of angioplasty and stenting for ICAD showed high complication rates. The SAMMPRIS trial found stenting plus medical therapy was worse than medical therapy alone. Subsequent studies using strict criteria saw lower complication rates.
3) Current recommendations are for medical management as first-line for ICAD. Endovascular treatments like submaximal angioplasty may be considered for recurrent strokes despite medical therapy, based on the underlying stroke mechanism
This document provides information on restrictive cardiomyopathy (RCM), including its definition, classification, etiology, symptoms, diagnosis, and treatment. Some key points:
- RCM is characterized by diastolic dysfunction with a stiffened myocardium that impairs ventricular filling. It is usually not associated with ventricular dilation or hypertrophy.
- Causes include infiltrative diseases of the myocardium (e.g. amyloidosis, sarcoidosis), endomyocardial fibrosis, and genetic/familial factors.
- Symptoms are related to reduced cardiac output and include dyspnea, fatigue, arrhythmias. Diagnosis involves echocardiogram, cardiac catheterization and MRI to evaluate
This document summarizes the treatment options for carotid artery stenosis, specifically carotid endarterectomy (CEA) versus carotid artery stenting (CAS). CEA has been shown to be superior to medical management alone in reducing stroke risk and is the gold standard treatment. CAS may be preferable for high-risk patients with conditions making CEA difficult, but is associated with a higher risk of perioperative stroke. The choice between CEA and CAS depends on patient characteristics, disease factors, and operator experience. While CAS can be performed less invasively, current evidence shows CEA remains the standard treatment for standard-risk patients.
1. Aortic stenosis can be caused by rheumatic heart disease, congenital abnormalities of the aortic valve, or age-related degeneration and calcification of the valve.
2. Obstructed left ventricular outflow due to aortic stenosis leads to increased pressure and compensatory hypertrophy of the left ventricle. While cardiac output is maintained at rest, it often fails to rise normally during exertion in severe aortic stenosis.
3. Symptoms of aortic stenosis include angina, syncope, exertional dyspnea, and heart failure, which typically appear when the aortic orifice is reduced to one third of its normal size. Valve replacement surgery is
This document discusses carotid artery disease and carotid stenting procedures. It provides background on carotid artery atherosclerosis and how vulnerable plaques can lead to strokes. It then summarizes guidelines for diagnosing and treating symptomatic and asymptomatic carotid stenosis, including the risks and benefits of medical therapy, carotid endarterectomy, and carotid artery stenting. The document concludes by outlining the key steps for performing carotid artery stenting, including patient selection, imaging, vascular access, stent placement, and complications to consider.
This document discusses risk factors, types, signs and symptoms, diagnosis, and treatment of stroke. It identifies the main types of stroke as hemorrhagic (20%) and ischemic (80%). Modifiable risk factors mentioned include hypertension, diabetes, dyslipidemia, obesity, oral contraceptive use, and migraine. Non-modifiable risk factors include age, sex, race, and genetic factors. The document outlines the classification, pathophysiology, warning signs, differential diagnosis and management of acute stroke and secondary prevention. It emphasizes the importance of controlling blood pressure, glucose, lipids and smoking to prevent first and recurrent strokes.
This document provides an overview of the approach to patients presenting with ataxia. It discusses the localization and causes of ataxia based on the involved neurological structures like the cerebellum and sensory pathways. Specific signs help to localize lesions within the cerebellum. A thorough history and examination along with targeted investigations can help identify acquired, genetic and other causes of ataxia. Neuroimaging, electrodiagnostic tests, ophthalmological and genetic testing are important to classify the type and guide management of ataxia.
This document discusses acute aortic syndrome, including a case presentation of a 55-year-old female with chest pain. Key details include:
1. The patient presented with sudden onset chest pain and was found to have hypertension on examination.
2. Initial workup including ECG, labs and chest x-ray were non-diagnostic but showed a widened mediastinum.
3. Echocardiogram and CT angiogram revealed an aortic dissection involving the aortic arch and descending thoracic aorta.
4. She was referred urgently for cardiovascular surgery to treat this life-threatening condition within 24 hours of presentation.
localization of stroke, CVS, stroke, for post graduates Kurian Joseph
New localization of stroke syndromes
1.Clinical localization of the site of the lesion.
2.Identifying the vascular territory and the vessel involved.
3.Correlating with the imaging findings.
The aortic valve has three cusps that open and close to regulate blood flow from the heart to the aorta. Aortic stenosis occurs when the valve opening narrows due to calcium buildup on the cusps. In the elderly, aortic stenosis is usually caused by age-related degeneration and calcification of the valve. Symptoms include chest pain, shortness of breath, and fainting. Diagnosis involves echocardiogram, Doppler ultrasound and cardiac catheterization. Treatment options include medications, balloon valvuloplasty, open-heart surgery to replace the valve, and newer transcatheter aortic valve replacement procedures for high-risk elderly patients.
This document discusses different types of cerebral edema including cytotoxic, vasogenic, hydrostatic, osmotic, and hydrocephalic edema. It provides details on the causes, mechanisms, and management of each type. The key management strategies for cerebral edema discussed are head elevation, oxygenation, fluid management, seizure prophylaxis, fever control, nutrition, hyperventilation, osmotherapy using mannitol, and other adjunctive therapies.
Dr. Pradeep Mandal presented on the evidence-based management of haemorrhagic stroke. Haemorrhagic strokes account for 10-20% of all strokes and have a higher mortality than ischemic strokes. For the 74-year-old female patient presented with right-sided weakness and altered sensorium, her ICH scale score of 3 indicates a 30-day mortality risk of 26-72%. Medical management is recommended over surgery based on the STICH trials. Her blood pressure needs to be controlled below 180/130 mmHg to prevent hematoma growth. Seizure prophylaxis, deep vein thrombosis prevention, and glycemic control are also important aspects of conservative management. The presentation concluded that
Takotsubo cardiomyopathy (TC), also known as "broken heart syndrome", is an acute cardiac syndrome that presents similarly to acute coronary syndrome (ACS) but is caused by transient left ventricular dysfunction rather than coronary artery blockages. It often occurs in post-menopausal women in response to severe emotional or physical stress and is characterized by abnormal ventriculograms showing apical ballooning of the left ventricle. While difficult to distinguish from ACS initially, differentiating the two is important to avoid unnecessary thrombolysis in TC patients. The pathophysiology of TC involves excess catecholamine release and microvascular dysfunction resulting in reversible myocardial stunning.
The document discusses Long QT Syndrome (LQTS), an inherited heart condition characterized by an abnormally prolonged QT interval on electrocardiograms. It describes the causes and types of LQTS, including LQT1, LQT2 and LQT3, which are associated with different genetic mutations and ECG patterns. The main symptoms of LQTS are syncope and cardiac arrest, typically in children or teenagers. Diagnosis involves measuring the QT interval and identifying risk factors. Treatment focuses on beta-blockers, lifestyle changes and implantable cardioverter-defibrillators for high-risk patients.
1. Ischaemic heart disease is caused by an imbalance between myocardial oxygen supply and demand, usually due to atherosclerosis limiting blood flow in the coronary arteries.
2. The main types of ischaemic heart disease are stable angina, unstable angina, myocardial infarction (STEMI and NSTEMI), and sudden cardiac death. Clinical presentation and ECG/biomarker findings are used to distinguish these conditions.
3. Treatment involves lifestyle modifications and medications like nitrates, beta-blockers, and calcium channel blockers to reduce oxygen demand and increase supply. Revascularization procedures like PCI or CABG may also be used in certain patients.
Restrictive cardiomyopathy is characterized by stiff ventricles that do not fill properly, though systolic function is usually preserved initially. It can be caused by infiltrative diseases, fibrosis, or other processes that restrict ventricular filling. On echocardiogram, restrictive cardiomyopathy shows impaired ventricular filling and enlarged atria, while cardiac catheterization reveals elevated diastolic pressures and a distinctive "square root sign" pressure tracing. Treatment focuses on managing symptoms and underlying causes if identifiable, though prognosis is often poor without transplantation.
1) Cardiogenic shock is defined as hypotension, hypoperfusion, and elevated filling pressures caused by depressed left ventricular function following myocardial injury. Mortality from cardiogenic shock remains high at 50-70%.
2) Risk factors for cardiogenic shock include age over 65, female gender, large myocardial infarction, anterior infarction location, prior infarction history, diabetes, and hypertension. Post-mortem studies show extensive myocardial damage in patients who die from cardiogenic shock.
3) Early revascularization through percutaneous coronary intervention or coronary artery bypass grafting may improve survival outcomes for cardiogenic shock, especially in patients under age 75, according to the landmark SHOCK trial. Adjunctive therapies including intra
Atrial myxomas are the most common primary cardiac tumors. They typically arise from the interatrial septum and can cause obstruction of blood flow or embolic events. Clinical presentations include signs of congestive heart failure, systemic embolism, and constitutional symptoms. Echocardiography is the primary diagnostic tool and surgical resection is the only effective treatment. While most myxomas are sporadic, around 5% are familial with an inherited pattern and higher recurrence rates after surgery.
The document discusses various pericardial diseases including acute pericarditis, constrictive pericarditis, pericardial effusion, and cardiac tamponade. It provides details on the anatomy and functions of the pericardium, pathophysiology, clinical features, diagnostic tests, and management of these conditions. Key points include that pericardial diseases can present with non-specific symptoms, clinical suspicion is important for diagnosis, and treatment depends on underlying etiology and presence of hemodynamic compromise. Differentiating constrictive pericarditis from restrictive cardiomyopathy is important as treatment approaches differ significantly.
1. Myocardial infarction, also known as a heart attack, occurs when blood flow to part of the heart is blocked, damaging heart muscle.
2. It is usually caused by a buildup of fatty plaques in the coronary arteries that supply blood to the heart. When a plaque ruptures, a blood clot forms that blocks one of the arteries.
3. Symptoms of a heart attack include chest pain or discomfort that may travel to the arm, shoulder, or jaw. Early treatment is critical to reduce damage to the heart.
This document provides an overview of Moyamoya disease. It defines Moyamoya disease as a progressive stenosis of the intracranial arteries, typically the internal carotid arteries and proximal middle and anterior cerebral arteries, accompanied by a compensatory network of collaterals at the brain's base. The cause is unknown but genetic factors are believed to play a role. Clinically, it can present with transient ischemic attacks, strokes, or hemorrhage. Diagnosis is based on neuroimaging findings on MRI, MRA, CTA or DSA showing the characteristic vascular changes. Treatment involves medical management as well as surgical revascularization procedures. Prognosis depends on the extent of vascular involvement and collateral formation.
This document discusses cardioembolic stroke, which occurs when heart issues cause materials to enter the brain's blood vessels. Common causes include atrial fibrillation, heart failure, and mechanical heart valves. Diagnosis involves echocardiography and monitoring for embolic signals. Treatment depends on the specific heart condition but often includes anticoagulants to prevent clots. Anticoagulation reduces stroke risk from atrial fibrillation by 60-90% compared to placebo. Managing cardioembolic stroke risk requires identifying the underlying heart condition and addressing it with medications, surgery, or lifestyle changes.
This document provides information on cardiovascular symptoms, signs, and disease evaluation and management. It discusses:
1) Common cardiac symptoms like chest pain, palpitations, and dyspnea and what conditions they can indicate.
2) A comprehensive cardiac examination involves assessing the patient's general appearance, skin, head and neck, chest, abdomen, and extremities as well as measuring vital signs like jugular venous pressure and blood pressure.
3) Establishing a cardiac diagnosis involves considering etiology, anatomical abnormalities, physiological disturbances, and functional disability based on history, physical exam, ECG, imaging, and other tests. Management depends on whether heart disease is present and its severity.
Primary central nervous system vasculitis (PACNS) is a rare disorder characterized by inflammation of blood vessels in the brain and spinal cord. It presents with non-specific symptoms like headache, cognitive impairment, and focal neurological deficits. Diagnosis involves neuroimaging showing multifocal lesions, angiography revealing vessel narrowing and dilation, and brain biopsy detecting immune cell infiltration of vessel walls. While the cause is unknown, infectious agents may trigger PACNS. Treatment involves immunosuppression but prognosis depends on disease severity and response to treatment.
1. The document discusses the classification, diagnosis, and treatment of acute coronary syndromes including unstable angina and myocardial infarction.
2. Key points include definitions of unstable angina, NSTEMI, and STEMI; causes of acute coronary syndromes including plaque rupture and vasospasm; the importance of history, ECG, biomarkers in diagnosis; and the use of antiplatelet agents, beta blockers, nitroglycerin, and anticoagulants in treatment.
3. Primary percutaneous coronary intervention is recommended over thrombolysis when certain criteria are met for STEMI patients.
This document describes a study that uses intravascular ultrasound (IVUS), biplane coronary angiography, and blood flow measurements to characterize endothelial shear stress (ESS) in coronary arteries. It found that over 6 months, areas of low ESS demonstrated plaque progression, areas of normal ESS remained stable, and areas of high ESS developed outward remodeling. The technology allows in vivo determination of intracoronary flow velocity and ESS, which has not previously been possible. This provides a method to predict progression of atherosclerosis and vascular remodeling. A pilot study applied this technique in 8 patients at baseline and 6 months to analyze changes in native coronary artery disease and in-stent restenosis while taking candesartan vs fel
This document describes a study that uses intravascular ultrasound (IVUS), biplane coronary angiography, and blood flow measurements to characterize endothelial shear stress (ESS) in coronary arteries. It found that over 6 months, areas of low ESS demonstrated plaque progression, areas of normal ESS remained stable, and areas of high ESS developed outward remodeling. The technology allows in vivo determination of intracoronary flow velocity and ESS, which has not previously been possible. This provides a method to predict progression of atherosclerosis and vascular remodeling. A pilot study applied this technique in 8 patients at baseline and 6 months to analyze changes in native coronary artery disease and in-stent restenosis while taking candesartan vs fel
This document discusses acute aortic syndrome, including a case presentation of a 55-year-old female with chest pain. Key details include:
1. The patient presented with sudden onset chest pain and was found to have hypertension on examination.
2. Initial workup including ECG, labs and chest x-ray were non-diagnostic but showed a widened mediastinum.
3. Echocardiogram and CT angiogram revealed an aortic dissection involving the aortic arch and descending thoracic aorta.
4. She was referred urgently for cardiovascular surgery to treat this life-threatening condition within 24 hours of presentation.
localization of stroke, CVS, stroke, for post graduates Kurian Joseph
New localization of stroke syndromes
1.Clinical localization of the site of the lesion.
2.Identifying the vascular territory and the vessel involved.
3.Correlating with the imaging findings.
The aortic valve has three cusps that open and close to regulate blood flow from the heart to the aorta. Aortic stenosis occurs when the valve opening narrows due to calcium buildup on the cusps. In the elderly, aortic stenosis is usually caused by age-related degeneration and calcification of the valve. Symptoms include chest pain, shortness of breath, and fainting. Diagnosis involves echocardiogram, Doppler ultrasound and cardiac catheterization. Treatment options include medications, balloon valvuloplasty, open-heart surgery to replace the valve, and newer transcatheter aortic valve replacement procedures for high-risk elderly patients.
This document discusses different types of cerebral edema including cytotoxic, vasogenic, hydrostatic, osmotic, and hydrocephalic edema. It provides details on the causes, mechanisms, and management of each type. The key management strategies for cerebral edema discussed are head elevation, oxygenation, fluid management, seizure prophylaxis, fever control, nutrition, hyperventilation, osmotherapy using mannitol, and other adjunctive therapies.
Dr. Pradeep Mandal presented on the evidence-based management of haemorrhagic stroke. Haemorrhagic strokes account for 10-20% of all strokes and have a higher mortality than ischemic strokes. For the 74-year-old female patient presented with right-sided weakness and altered sensorium, her ICH scale score of 3 indicates a 30-day mortality risk of 26-72%. Medical management is recommended over surgery based on the STICH trials. Her blood pressure needs to be controlled below 180/130 mmHg to prevent hematoma growth. Seizure prophylaxis, deep vein thrombosis prevention, and glycemic control are also important aspects of conservative management. The presentation concluded that
Takotsubo cardiomyopathy (TC), also known as "broken heart syndrome", is an acute cardiac syndrome that presents similarly to acute coronary syndrome (ACS) but is caused by transient left ventricular dysfunction rather than coronary artery blockages. It often occurs in post-menopausal women in response to severe emotional or physical stress and is characterized by abnormal ventriculograms showing apical ballooning of the left ventricle. While difficult to distinguish from ACS initially, differentiating the two is important to avoid unnecessary thrombolysis in TC patients. The pathophysiology of TC involves excess catecholamine release and microvascular dysfunction resulting in reversible myocardial stunning.
The document discusses Long QT Syndrome (LQTS), an inherited heart condition characterized by an abnormally prolonged QT interval on electrocardiograms. It describes the causes and types of LQTS, including LQT1, LQT2 and LQT3, which are associated with different genetic mutations and ECG patterns. The main symptoms of LQTS are syncope and cardiac arrest, typically in children or teenagers. Diagnosis involves measuring the QT interval and identifying risk factors. Treatment focuses on beta-blockers, lifestyle changes and implantable cardioverter-defibrillators for high-risk patients.
1. Ischaemic heart disease is caused by an imbalance between myocardial oxygen supply and demand, usually due to atherosclerosis limiting blood flow in the coronary arteries.
2. The main types of ischaemic heart disease are stable angina, unstable angina, myocardial infarction (STEMI and NSTEMI), and sudden cardiac death. Clinical presentation and ECG/biomarker findings are used to distinguish these conditions.
3. Treatment involves lifestyle modifications and medications like nitrates, beta-blockers, and calcium channel blockers to reduce oxygen demand and increase supply. Revascularization procedures like PCI or CABG may also be used in certain patients.
Restrictive cardiomyopathy is characterized by stiff ventricles that do not fill properly, though systolic function is usually preserved initially. It can be caused by infiltrative diseases, fibrosis, or other processes that restrict ventricular filling. On echocardiogram, restrictive cardiomyopathy shows impaired ventricular filling and enlarged atria, while cardiac catheterization reveals elevated diastolic pressures and a distinctive "square root sign" pressure tracing. Treatment focuses on managing symptoms and underlying causes if identifiable, though prognosis is often poor without transplantation.
1) Cardiogenic shock is defined as hypotension, hypoperfusion, and elevated filling pressures caused by depressed left ventricular function following myocardial injury. Mortality from cardiogenic shock remains high at 50-70%.
2) Risk factors for cardiogenic shock include age over 65, female gender, large myocardial infarction, anterior infarction location, prior infarction history, diabetes, and hypertension. Post-mortem studies show extensive myocardial damage in patients who die from cardiogenic shock.
3) Early revascularization through percutaneous coronary intervention or coronary artery bypass grafting may improve survival outcomes for cardiogenic shock, especially in patients under age 75, according to the landmark SHOCK trial. Adjunctive therapies including intra
Atrial myxomas are the most common primary cardiac tumors. They typically arise from the interatrial septum and can cause obstruction of blood flow or embolic events. Clinical presentations include signs of congestive heart failure, systemic embolism, and constitutional symptoms. Echocardiography is the primary diagnostic tool and surgical resection is the only effective treatment. While most myxomas are sporadic, around 5% are familial with an inherited pattern and higher recurrence rates after surgery.
The document discusses various pericardial diseases including acute pericarditis, constrictive pericarditis, pericardial effusion, and cardiac tamponade. It provides details on the anatomy and functions of the pericardium, pathophysiology, clinical features, diagnostic tests, and management of these conditions. Key points include that pericardial diseases can present with non-specific symptoms, clinical suspicion is important for diagnosis, and treatment depends on underlying etiology and presence of hemodynamic compromise. Differentiating constrictive pericarditis from restrictive cardiomyopathy is important as treatment approaches differ significantly.
1. Myocardial infarction, also known as a heart attack, occurs when blood flow to part of the heart is blocked, damaging heart muscle.
2. It is usually caused by a buildup of fatty plaques in the coronary arteries that supply blood to the heart. When a plaque ruptures, a blood clot forms that blocks one of the arteries.
3. Symptoms of a heart attack include chest pain or discomfort that may travel to the arm, shoulder, or jaw. Early treatment is critical to reduce damage to the heart.
This document provides an overview of Moyamoya disease. It defines Moyamoya disease as a progressive stenosis of the intracranial arteries, typically the internal carotid arteries and proximal middle and anterior cerebral arteries, accompanied by a compensatory network of collaterals at the brain's base. The cause is unknown but genetic factors are believed to play a role. Clinically, it can present with transient ischemic attacks, strokes, or hemorrhage. Diagnosis is based on neuroimaging findings on MRI, MRA, CTA or DSA showing the characteristic vascular changes. Treatment involves medical management as well as surgical revascularization procedures. Prognosis depends on the extent of vascular involvement and collateral formation.
This document discusses cardioembolic stroke, which occurs when heart issues cause materials to enter the brain's blood vessels. Common causes include atrial fibrillation, heart failure, and mechanical heart valves. Diagnosis involves echocardiography and monitoring for embolic signals. Treatment depends on the specific heart condition but often includes anticoagulants to prevent clots. Anticoagulation reduces stroke risk from atrial fibrillation by 60-90% compared to placebo. Managing cardioembolic stroke risk requires identifying the underlying heart condition and addressing it with medications, surgery, or lifestyle changes.
This document provides information on cardiovascular symptoms, signs, and disease evaluation and management. It discusses:
1) Common cardiac symptoms like chest pain, palpitations, and dyspnea and what conditions they can indicate.
2) A comprehensive cardiac examination involves assessing the patient's general appearance, skin, head and neck, chest, abdomen, and extremities as well as measuring vital signs like jugular venous pressure and blood pressure.
3) Establishing a cardiac diagnosis involves considering etiology, anatomical abnormalities, physiological disturbances, and functional disability based on history, physical exam, ECG, imaging, and other tests. Management depends on whether heart disease is present and its severity.
Primary central nervous system vasculitis (PACNS) is a rare disorder characterized by inflammation of blood vessels in the brain and spinal cord. It presents with non-specific symptoms like headache, cognitive impairment, and focal neurological deficits. Diagnosis involves neuroimaging showing multifocal lesions, angiography revealing vessel narrowing and dilation, and brain biopsy detecting immune cell infiltration of vessel walls. While the cause is unknown, infectious agents may trigger PACNS. Treatment involves immunosuppression but prognosis depends on disease severity and response to treatment.
1. The document discusses the classification, diagnosis, and treatment of acute coronary syndromes including unstable angina and myocardial infarction.
2. Key points include definitions of unstable angina, NSTEMI, and STEMI; causes of acute coronary syndromes including plaque rupture and vasospasm; the importance of history, ECG, biomarkers in diagnosis; and the use of antiplatelet agents, beta blockers, nitroglycerin, and anticoagulants in treatment.
3. Primary percutaneous coronary intervention is recommended over thrombolysis when certain criteria are met for STEMI patients.
This document describes a study that uses intravascular ultrasound (IVUS), biplane coronary angiography, and blood flow measurements to characterize endothelial shear stress (ESS) in coronary arteries. It found that over 6 months, areas of low ESS demonstrated plaque progression, areas of normal ESS remained stable, and areas of high ESS developed outward remodeling. The technology allows in vivo determination of intracoronary flow velocity and ESS, which has not previously been possible. This provides a method to predict progression of atherosclerosis and vascular remodeling. A pilot study applied this technique in 8 patients at baseline and 6 months to analyze changes in native coronary artery disease and in-stent restenosis while taking candesartan vs fel
This document describes a study that uses intravascular ultrasound (IVUS), biplane coronary angiography, and blood flow measurements to characterize endothelial shear stress (ESS) in coronary arteries. It found that over 6 months, areas of low ESS demonstrated plaque progression, areas of normal ESS remained stable, and areas of high ESS developed outward remodeling. The technology allows in vivo determination of intracoronary flow velocity and ESS, which has not previously been possible. This provides a method to predict progression of atherosclerosis and vascular remodeling. A pilot study applied this technique in 8 patients at baseline and 6 months to analyze changes in native coronary artery disease and in-stent restenosis while taking candesartan vs fel
This document describes a study that uses intravascular ultrasound (IVUS), biplane coronary angiography, and blood flow measurements to characterize endothelial shear stress (ESS) in coronary arteries. It found that over 6 months, areas of low ESS demonstrated plaque progression, areas of normal ESS remained stable, and areas of high ESS developed outward remodeling. The technology allows in vivo determination of intracoronary flow velocity and ESS, which has not previously been possible. This provides a method to predict progression of atherosclerosis and vascular remodeling. A pilot study applied this technique in 8 patients at baseline and 6 months to analyze changes in native coronary arteries and in-stent restenosis with antihypertensive treatments.
057 coronary endothelial shear stress profilingSHAPE Society
This document summarizes a study that developed a new methodology for measuring endothelial shear stress (ESS) in coronary arteries in vivo. The methodology uses intravascular ultrasound, biplane angiography, and computational fluid dynamics to reconstruct coronary arteries in 3D and model blood flow/ESS. A pilot study applied this to 8 patients, finding areas of low ESS demonstrated plaque progression over 6 months while areas of normal ESS were stable. The technology may help predict disease progression and response to interventions based on local ESS environments.
Cardiac CT Angiography to detect Myocardial Bridging Han Naung Tun
CTCA is a reliable non-invasive tool for detecting myocardial bridging in coronary artery disease. [The study] found an 8.2% frequency of myocardial bridging in 219 patients with coronary artery disease who underwent CTCA. CTCA allows for visualization of the length and depth of the bridging artery and measurement of stenosis. While myocardial bridging can be clinically significant when associated with hemodynamic changes, in most cases it remains asymptomatic. CTCA is an emerging alternative to other invasive tests for diagnosing myocardial bridging.
Neurosurgical management of ischemic strokeDrkedirDekebi
This document summarizes neurosurgical management of cerebrovascular accidents (CVAs) and spontaneous intracerebral hemorrhage (sICH). It discusses the pathophysiology and clinical presentation of ischemic stroke and transient ischemic attacks. Imaging techniques for evaluation including CT, CTA, MRI, and MRA are outlined. Endovascular and surgical revascularization options for acute ischemic stroke are described, including limitations of intravenous thrombolysis. The document also reviews evaluation and management of atherosclerotic carotid artery stenosis, indicating criteria for medical management, carotid endarterectomy, and carotid angioplasty/stenting.
This document provides an overview of carotid occlusive disease and its treatment. It discusses the pathophysiology and risk factors of atherosclerosis and how it leads to carotid stenosis. For symptomatic patients, carotid endarterectomy is recommended for >70% stenosis to prevent stroke. Asymptomatic patients may benefit from carotid endarterectomy for >60% stenosis. Medical management focuses on controlling risk factors like hypertension, diabetes, and dyslipidemia. Antiplatelet drugs like aspirin are also used. Carotid artery stenting is an alternative to endarterectomy for high-risk patients. Clinical trials have established the benefits and guidelines for treatment of symptomatic and asymptomatic carotid stenosis.
Evaluation of Occlusive Diseases in Cervical Arteries in Patients of Acute Is...QUESTJOURNAL
This document summarizes a study that evaluated occlusive diseases in cervical arteries of patients with acute ischemic stroke using CT angiography. The study analyzed CTA images of 50 patients to determine the percentage with vascular stenosis or occlusion. It found that 76% of patients showed neck vessel involvement, with 26% having luminal narrowing and 8% having complete occlusion. While many vessels showed atherosclerotic changes, only 45 of 300 total vessels analyzed showed significant luminal narrowing or plaque formation. The study concludes there is a significant correlation between atherosclerotic changes in neck vessels and occurrence of acute ischemic stroke.
Trans-Cranial Doppler (TCD) is a non-invasive ultrasound technique used to evaluate cerebral blood flow velocities. There are two main types of TCD devices - non-duplex devices which identify arteries "blindly" based on Doppler shift and duplex devices which combine Doppler with B-mode imaging to directly visualize arteries. TCD allows evaluation of intracranial steno-occlusive disease, vasospasm, aneurysms, and other conditions. It can detect elevated velocities indicative of stenosis but has limitations including operator dependence and inability to image distal arteries. TCD is useful for monitoring conditions like sickle cell disease where elevated velocities increase stroke risk.
Coronary artery ectasia (CAE) is an inappropriate dilatation of the coronary arteries. It has an unknown etiology but may be due to genetic or inflammatory factors. CAE is detected in 3-8% of angiograms and can be diffuse or localized. It can cause angina due to turbulent blood flow. Diagnosis is typically made using angiography, CT, or MRI imaging. Treatment involves aspirin due to risk of thrombosis, with surgical revascularization for significant coronary artery disease.
Aterosclerosi il danno d'organo: vasculopatia periferica - di P. Buonamico MedOliveOil
Aterosclerosi il danno d'organo: vasculopatia periferica - di P. Buonamico. 7 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
How should recently symptomatic patients be treated urgent cea or casuvcd
Recent symptomatic patients with carotid artery stenosis can be treated with either urgent carotid endarterectomy (CEA) or carotid artery stenting (CAS). While early studies found CEA to have better outcomes, more recent trials like CREST showed comparable rates of stroke and death between CEA and CAS. For recently symptomatic patients specifically, CEA may still be preferred to CAS due to concerns about stabilizing carotid plaque after stenting. Operator experience also impacts outcomes, so treatment should be individualized based on each patient's clinical situation.
1) Atherosclerosis of the carotid arteries can lead to stenosis and cause 8-15% of ischemic strokes. Clinical trials found stenting carried a higher risk of non-disabling stroke compared to endarterectomy, but endarterectomy carried higher risks of other complications.
2) For symptomatic stenosis, both treatments effectively prevent future stroke in the medium to long term. Endarterectomy provides a modest benefit for preventing stroke in asymptomatic stenosis, while the role of stenting is still uncertain.
3) Advances in medical therapy have reduced atherosclerosis risks, making the benefits of invasive treatments uncertain. Risk modeling including plaque imaging will be important for selecting patients for interventions.
Non Atherosclerotic angina Final Doha Rasheedy.pptxDoha Rasheedy
This document discusses non-atherosclerotic angina, which refers to chest pain caused by reduced blood flow to the heart muscle due to conditions other than blockages in the coronary arteries. It defines several types of non-atherosclerotic angina and their causes, including vasospastic angina, coronary artery embolism, spontaneous coronary artery dissection, microvascular dysfunction, Takotsubo cardiomyopathy, and others. For each cause, the document describes characteristics, potential triggers, diagnostic techniques such as angiography and imaging, and treatment approaches. Overall, the document provides an overview of non-atherosclerotic angina by defining it, exploring various underlying conditions and their features, and outlining how each
The document describes the anatomy of the carotid arteries and their branches, evaluation and imaging of carotid artery disease, and treatment strategies including lifestyle modifications to reduce risk factors, carotid endarterectomy to remove plaques from significantly stenotic arteries, and outcomes data from clinical trials on endarterectomy for symptomatic and asymptomatic carotid stenosis. Imaging modalities like carotid duplex ultrasound, CTA, and MRA are described for evaluating the degree of carotid stenosis. The benefits of carotid endarterectomy are greater for symptomatic high-grade stenosis while more moderate for asymptomatic disease.
This document outlines the aim and methodology of a study investigating the impact of renal function, as measured by glomerular filtration rate (GFR), on outcomes in ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI). The study will enroll 100 STEMI patients undergoing primary PCI and divide them into groups based on creatinine clearance and estimated GFR. Baseline characteristics, PCI details, and outcomes will be compared between groups. The goal is to determine if decreasing renal function is associated with worse outcomes in STEMI patients treated with primary PCI.
- This case report presents a 25-year-old male who presented with ST elevation in the inferior wall and was found to have a decreased left ventricular ejection fraction on echocardiogram. He underwent coronary angiography which found non-significant stenosis.
- Smoking is a major risk factor for cardiovascular disease, especially in young males. Tobacco use increases the risk of death from vascular diseases by two to three times.
- The pathophysiology of acute myocardial infarction in young adults is varied and not usually due to atherosclerotic plaque rupture. Non-atherosclerotic causes should be considered in premature coronary artery disease.
1. Acute limb ischemia occurs due to a sudden decrease in blood flow to a limb, threatening the viability of the extremity. It requires prompt diagnosis and treatment to determine if the limb is viable, threatened, or irreversibly ischemic.
2. Initial management involves analgesia, oxygen, intravenous heparin, and urgent referral to a vascular specialist. Further imaging and either surgical or endovascular revascularization may be needed depending on the classification of ischemia.
3. The prognosis depends on factors like etiology and severity of ischemia. With timely treatment, limb salvage is possible in the majority of patients.
CONCEPT OF NODOPATHIES AND PARANODOPATHIES.pptxNeurologyKota
emergence of autoimmune neuropathies and role of nodal and paranodal regions in their pathophysiology.
Peripheral neuropathies are traditionally categorized into demyelinating or axonal.
dysfunction at nodal/paranodal region key for better understanding of patients with immune mediated neuropathies.
antibodies targeting node and paranode of myelinated nerves have been increasingly detected in patients with immune mediated neuropathies.
have clinical phenotype similar common inflammatory neuropathies like Guillain Barre syndrome and chronic inflammatory demyelinating polyradiculoneuropathy
they respond poorly to conventional first line immunotherapies like IVIG
NEUROLOGICAL SCALES FOR ASSESSMENT OF CONSCIOUSNESS.pptxNeurologyKota
The document discusses neurological scales used to assess consciousness. It describes the Glasgow Coma Scale (GCS), which evaluates best eye opening, best verbal response, and best motor response on a scale of 3 to 15. The Full Outline of UnResponsiveness (FOUR) score is also discussed, which measures eye responses, motor responses, brainstem reflexes, and respiratory patterns on a scale of 0 to 16. The FOUR score is presented as having advantages over the GCS in certain clinical situations. A new scale, the FIVE score, is also mentioned which builds upon the FOUR score.
LOCALISATION OF LESION CAUSING COMA.pptxNeurologyKota
1) The document discusses signs that can help localize lesions causing coma, including abnormalities in respiratory patterns, pupil size and response, eye movements, and corneal and limb reflexes.
2) Specific lesions like thalamic or brainstem hemorrhages can cause signs like wrong-way eyes or downward eye deviation.
3) Examining responses like the oculocephalic reflex or corneal reflex can help determine if the brainstem is intact and localize lesions.
Dr. Bharat Bhushan is a professor of medicine and interventional neurologist at Government Medical College in Kota, Rajasthan, India. He has over 18 years of experience and qualifications including MBBS, MD, DM in Neurology, and FICP. He has published over 35 research papers and contributed to several medical research projects. The document discusses the concept of a "treadmill for the brain" to improve cognitive fitness through a balanced routine of exercise, sleep, and diet in order to stimulate and exercise the brain. It emphasizes coordinating the adaptation of organs like the gut, muscles and brain for overall health and quality of life.
Remote robotic thrombectomy is a promising technique to expand access to endovascular thrombectomy for acute ischemic stroke. The Corindus robotic system allows neurointerventionists to perform thrombectomy procedures remotely using robotic arms. This could allow thrombectomy-capable centers to treat patients from further distances. Early studies show robotic thrombectomy is technically feasible and reduces radiation exposure compared to manual procedures. However, further research is still needed as robotic systems require additional training and have limitations such as lack of haptic feedback. Overall, remote robotic thrombectomy may help more patients receive timely endovascular treatment for stroke.
ASSESSMENT OF AUTONOMIC FUNCTION TEST.pptxNeurologyKota
The document discusses autonomic function tests which are used to evaluate autonomic nervous system disorders. It describes various cardiovascular, sudomotor and pupillary reflex tests to assess different aspects of autonomic function. Cardiovascular tests include postural challenge tests, Valsalva maneuver, deep breathing test and isometric handgrip test. Sudomotor tests include quantitative sudomotor axon reflex test and thermoregulatory sweat test. The tests help diagnose autonomic dysfunction, evaluate its severity and distribution. Management involves identifying and treating the underlying cause, along with medications and lifestyle changes to alleviate symptoms like orthostatic hypotension.
Transcranial Doppler (TCD) ultrasonography is a noninvasive technique used to evaluate cerebral blood flow velocities. It was originally introduced in 1982 to detect vasospasm in subarachnoid hemorrhage. TCD is now used for a variety of purposes including detection of stenosis, occlusion, emboli, shunts, and vasospasm. It provides diagnostic information for conditions such as stroke, sickle cell disease, brain death, and arteriovenous malformations. TCD utilizes Doppler effect to measure blood flow velocities in basal cerebral arteries which provides data to assess hemodynamics and diagnose various cerebrovascular diseases.
INTRACEREBRAL HEMORRHAGE IN YOUNG ADULTS.pptxNeurologyKota
1) The document discusses intracerebral hemorrhage (ICH) in young adults aged 18-50 years.
2) Risk factors for ICH in this age group include hypertension, smoking, alcohol, medications like anticoagulants and cocaine use.
3) Common causes of ICH in young adults are structural abnormalities like arteriovenous malformations, aneurysms, and cavernomas. Other causes include hypertension, coagulopathies, vasculitis and reversible cerebral vasoconstriction syndrome.
A 42-year-old male patient was admitted with repeated dizziness and right-sided weakness for over 3 months. Imaging showed a linear filling defect in the proximal left internal carotid artery, revealing over 90% stenosis and delayed blood flow. The patient underwent carotid endarterectomy and was discharged on medical therapy. Three months later, the patient experienced recurrent symptoms. Carotid web was considered a potential cause given the patient's age and lack of atherosclerosis history. Intervention may be a safe and effective option for symptomatic carotid web in addition to medical management, with recurrent risk up to 26.8% with medical management alone.
This document discusses immune reconstitution inflammatory syndrome (IRIS) in patients with HIV. It provides background on IRIS, defines the two types (paradoxical and unmasked), and lists risk factors. It then discusses the pathology of IRIS and various pathogens that can cause central nervous system IRIS, including PML, cryptococcal meningitis, VZV, CMV, and mycobacteria. Specific details are provided on the clinical manifestations and imaging findings of PML-IRIS and cryptococcal meningitis-IRIS.
Epileptic encephalopathies are a group of epileptic disorders that cause cognitive and behavioral impairments beyond what would be expected from seizures alone. They typically begin early in life and are characterized by frequent seizures and abnormal EEG patterns. Common types include early myoclonic encephalopathy, Ohtahara syndrome, West syndrome, Dravet syndrome, and Lennox-Gastaut syndrome. These disorders can cause developmental delays, intellectual disabilities, and in some cases early death. Treatment aims to control seizures, though many types are highly treatment resistant.
This presentation briefs out the approach of dementia assessment in line with consideration of recent advances. Now the pattern of assessment has evolved towards examining each individual domain rather than lobar assessment.
Young onset dementia (YOD) refers to dementia with an onset before age 65. About 5% of all dementias are YOD. Common causes include Alzheimer's disease, vascular dementia, frontotemporal lobar degeneration, and dementia with Lewy bodies. A thorough evaluation includes medical history, physical and neurological exams, imaging like MRI and PET, and may involve genetic testing. Management focuses on treating underlying causes if possible, addressing behavioral and psychiatric symptoms, and providing social support. Prognosis varies by the specific cause but on average YOD results in 10-15 years shorter life expectancy than later onset dementia.
This document provides an overview of encephalopathy, including:
- Encephalopathy is defined as an altered mental state caused by diffuse brain dysfunction. Common symptoms include confusion, memory loss, and personality changes.
- There are many potential causes of encephalopathy including metabolic disturbances, toxins, infections, liver failure, inflammation, drugs, demyelination, and lack of oxygen to the brain.
- EEG is often abnormal in encephalopathy, with features including triphasic waves and diffuse slowing correlating to severity of symptoms and impairment of consciousness.
NEWER INSIGHT IN FUNCTIONAL NEUROLOGICAL DISORDER NeurologyKota
1. Functional neurological disorder is characterized by neurological symptoms that cannot be fully explained by organic disease. It is associated with psychological stressors and symptoms are not intentionally produced.
2. Associated psychological features include gaining secondary benefits from illness and showing indifference to serious symptoms.
3. Common clinical features are functional limb weakness, seizures, facial spasms, and clenched fists or inverted feet. Diagnosis is made by a neurologist based on inconsistent or non-organic physical signs.
Hyperthermic syndrome in ICU and their management.pptxNeurologyKota
Based on the information provided, this patient is likely experiencing malignant hyperthermia (MH). Key signs include:
- Muscle rigidity developing post-operatively
- Increasing tachycardia, tachypnea, and rising temperature shortly after being admitted to PACU
- Recent exposure to inhalational anesthetic triggers for MH like halothane during surgery
The immediate steps in management should be:
1. Discontinue any triggering anesthetic agents
2. Administer dantrolene sodium 2-3 mg/kg IV to reduce calcium release and muscle rigidity
3. Initiate cooling measures and monitor for signs of multiple organ dysfunction as temperature rises further
Prompt diagnosis and
Entrapment Syndromes of Lower Limb.pptxNeurologyKota
This presentation contains information about the various Entrapment syndromes of Lower limb in descending order of topography. It also contains information about etiology, clinical features and management of each of these entrapment syndromes with special emphasis on electrodiagnostic confirmation.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
2. Cerebrovascular
Atherosclerosis
▪ Atherosclerosis – Athero=Fat
Sclerosis=Hardening
▪ Atherosclerosis - thickening & hardening of
arterial walls affecting primarily the intima of
large and medium-sized muscular arteries and
is characterized by the presence of fibro fatty
plaques or atheromas.
▪ Serious complications.
12. Cerebrovascular
Atherosclerosis
▪ Extracranial Vs Intracranial
▪ Symptomatic Vs Asymptomatic-Symptomatic carotid
disease is defined as focal neurologic symptoms that are
sudden in onset and referable to the appropriate carotid
artery distribution (I/L to significant carotid atherosclerotic
pathology), including one or more transient ischemic
attacks characterized by focal neurologic dysfunction or
transient monocular blindness, or one or more minor
(nondisabling) ischemic strokes
13. ▪ Atherothrombosis is multifactorial
▪ Comorbidities frequently overlap, and risk
factors are often additive
▪ The pathogenesis of stroke due to intracranial
arterial stenosis may be similar to stroke due to
extracranial arterial disease
14. Risk factor – Nonmodifiable
▪ Age(men >45, women>55)
▪ Gender - M>F(premenopausal)
▪ Race/ethnicity-
Intrcranial athero- Asians, blacks, Hispanics> whites
Extracranial- more in whites
▪ Family history
▪ Genetics- A/W Large artery ather. Dis.-HDAC9-1p13
(+CAD) and TSPAN2(-CAD)
17. Cerebrovascular
Atherosclerosis…
▪ Atherosclerosis primarily affects the larger
extracranial and intracranial vessels
eg.-
▪ Bifurcation of the common carotid artery
▪ Proximal internal carotid artery
▪ Carotid siphon
▪ MCA stem
▪ Origin of the vertebral arteries (V1)
▪ Intracranial segment of the vertebral arteries (V4)
▪ Basilar artery
18. ▪ ICAD - leading cause of ischemic stroke-8%-50%
of pts.
▪ Recent study from the US -
EICA atherosclerosis -11.5%
IICA atherosclerosis -1.1%
▪ Research from Korea -symptomatic
atherosclerosis of the EICA > IICA - 4:1
▪ A study from China -
symptomatic IICA atherosclerosis (4.1%)
symptomatic EICA atherosclerosis (3.8%).
Kposterior circulation disease. Stroke 2012;43:3313- 3318.
11. Flaherty ML, Kissela B, Khoury JC, et al. Carotid artery stenosis as a cause of stroke. Neuroepidemiology 2013;40:36-41
im JS, Nah HW, Park SM, et al. Risk factors and stroke mechanisms in atherosclerotic stroke: intracranial compared with extracranial and anterior compared
with
19. ▪ In an Indian study done by Dr. Trilochan
Srivastava- Out of 60 cases of stroke , 32
cases were positive for significant stenosis and
a total number of stenotic segments was 45.
▪ Out of 45 stenotic segments (single and
multiple), there were 24 (53.33%) intracranial
and 21 (46.67%) extracranial.
-CT Angiographic evaluation of pattern and distribution of stenosis and its association with risk factors among indian ischemic stroke patients Amit Shrivastava,
Trilochan Srivastava, Richa Saxena Pol J Radiol, 2016; 81: 357-362
20. Comparative Frequency of
ICAD in Patients With Stroke
▪ Chinese - 33–50
▪ Thai - 47
▪ Korean - 56
▪ South Asians - 54
▪ US Whites - 1
▪ US Blacks - 6
▪ US Hispanics - 11
-De Silva DA, Woon F-P, Lee M-P, Chen CPLH, Chang H-M, Wong M-C. South Asia patients with ischemic stroke. Intracranial large arteries are the
predominant site of disease. Stroke. 2007;38:2592–2594.
-Wong LKS. Global burden of intracranial atherosclerosis. Int J Stroke. 2006;1:158 –159
21. ▪ Early studies revealed that stroke patients with
IICA stenosis had very poor prognoses
▪ Mortality rate-was 7.8%-12.8% per year
▪ Rate of ipsilateral stroke - 7.6%-8.1% per year
▪ Cardiac disease –MC cause of death during
follow-up.
Klijn CJ, Kappelle LJ, Algra A, et al. Outcome in patients with symptomatic occlusion of the internal carotid artery or intracranial arterial lesions: a meta-analysis
of the role of baseline characteristics and type of antithrombotic treatment. Cerebrovasc Dis 2001;12:228-234.
22. ▪ Pt. with 50% to 99% stenosis of symptomatic
intracranial vessels -12% to 14% risk for a
recurrent stroke during a 2-year follow-up, in
spite of antiplatelet /anticoagulation therapy.
▪ The annual risk may > 20% in high-risk groups
▪ Silent MI in >50% of patients with ICAD
Gorelick PB,Wong KS, Bae HJ, et al. Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier. Stroke
2008;39:2396-2399.
-. Sacco RL, Kargman DE, Gu Q, et al. Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. TheNorthernManhattan Stroke Study.
Stroke 1995;26:14-20.
-Chimowitz MI, Lynn MJ, Derdeyn CP, et al. SAMMPRIS Trial Investigators. Stenting versus aggressive medical therapy in intracranial arterial stenosis. N Engl
J Med 2011;365:993-1003
25. Assessment of Carotid
Stenosis
Currently, three methods-
▪ NASCET-The North American Symptomatic
Carotid Endarterectomy Trial
▪ ECST-The European Carotid Surgery Trial
▪ CC-common carotid
26. NASCET
▪ Hemodynamically signi. carotid stenosis ≥60%
or a flow reduction distal to the lesion.
▪ Stenosis= (1-A/B) × 100%,
▪ A-diameter at the point of maximum stenosis
▪ B -diameter of the arterial segment distal to the
stenosis where the arterial walls first become
parallel
North American Symptomatic Carotid Endarterectomy Trial. Methods, patient characteristics, and progress. Stroke 1991; 22:711.
27. ▪ The European Carotid Surgery Trial (ECST)-
lumen diameter at the most stenotic portion
compared with the estimated probable original
diameter at the site of maximum stenosis.
▪ The common carotid (CC) method - lumen
diameter in the most stenotic portion
compared with the proxi. CCA.
-Rothwell PM, Gibson RJ, Slattery J, et al. Equivalence of measurements of carotid stenosis. A comparison of three methods on 1001 angiograms. European
Carotid Surgery Trialists' Collaborative Group. Stroke 1994; 25:2435.
-North American Symptomatic Carotid Endarterectomy Trial. Methods, patient characteristics, and progress. Stroke 1991; 22:711.
-MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid
Surgery Trialists' Collaborative Group. Lancet 1991; 337:1235.
-Wardlaw JM, Lewis SC, Humphrey P, et al. How does the degree of carotid stenosis affect the accuracy and interobserver variability of magnetic resonance
angiography? J Neurol Neurosurg Psychiatry 2001; 71:155.
28.
29. ▪ Equivalent measurements for the three
methods have been determined
▪ A 50% stenosis with the NASCET ≈ 65%
stenosis for both the ECST and CC methods
▪ A 70 % stenosis with the NASCET ≈ 82 percent
stenosis for both the ECST and CC methods
30. Assessment of thrombus burden-CBS
▪ CBS - for anterior circulation to quantify the extent of
ipsilateral intracranial thrombus,
▪ Allotting major arteries 10 points for the presence of
contrast opacification on CTA.
▪ Two points each were subtracted for absence of contrast
opacification in the complete cross-section of any part of
the proximal M1, distal M1 or supraclinoid ICA and 1 point
each for M2 branches, A1 segment and infraclinoid ICA
Puetz V, Dzialowski I, Hill MD, et al. Intracranial thrombus extent predicts clinical outcome, final infarct size and hemorrhagic transformation in ischemic stroke:
the clot burden score. Int J Stroke. 2008;3(4):230-236
31. CBS..
▪ Partial filling defects were rated as patent.
▪ A score of 10 - absence of a visible occlusion
▪ Score of 0 - occlusion of all major intracranial
anterior circulation arteries
32. Assessment of thrombus
burden-CBS
Ten-point clot burden score (CBS): one
or two points each (as indicated) are
subtracted for absent contrast
opacification on computed tomography
angiography (CTA) in the infraclinoid
internal carotid artery (ICA) (1),
supraclinoid ICA (2), proximal M1
segment (2), distal M1 segment (2),
M2branches (one each) and A1
segment (1).
The CBS applies only to the
symptomatic hemisphere.
33. CONVENTIONAL CEREBRAL
ANGIOGRAPHY
▪ Gold standard for imaging the carotid arteries.
▪ DSA has largely replaced conventional
angiography -less contrast/time & small cath.
▪ The quality of the angiogram depends upon
selective catheterization of the carotid artery with
at least two unimpeded views.
34. Cerebral angiography
Advantages —
▪ Permits an evaluation of the entire carotid artery
system
▪ Provides information about tandem atherosclerotic
disease, plaque morphology, and collateral
circulation which - may affect management
-Wolpert SM, Caplan LR. Current role of cerebral angiography in the diagnosis of cerebrovascular diseases. AJR Am J Roentgenol 1992; 159:191.
-Kappelle LJ, Eliasziw M, Fox AJ, et al. Importance of intracranial atherosclerotic disease in patients with symptomatic stenosis of the internal carotid artery. The
North American Symptomatic Carotid Endarterectomy Trail. Stroke 1999; 30:282
35. Disadvantages —
▪ Invasive nature,
▪ High cost/less availability
▪ Risk of morbidity and mortality.
▪ Risk of all neurologic complications -4 %
▪ Risk of serious neuro. complications or death -1%
▪ The risk of morbidity is increased with
cerebrovascular symptoms, advanced age,
diabetes, hypertension, elevated serum
creatinine, and peripheral vascular disease.
36. Disadvantages
▪ Limited number of projections, typically two or
three, depicting the carotid artery and
bifurcation-underestimation in asymmetrical
stenosis.
▪ Rotational angiography provides 16 to 32
projections and is better, but seldom used in
practice
Bendszus M, Koltzenburg M, Burger R, et al. Silent embolism in diagnostic cerebral angiography and neurointerventional procedures: a prospective study.
Lancet 1999; 354:1594
37. CAROTID DUPLEX
ULTRASOUND
▪ CDUS - detect focal increases in blood flow velocity - high
grade carotid stenosis .
▪ The peak systolic velocity is the most frequently used
measurement to assess the severity of the stenosis
▪ End-diastolic velocity and the carotid index (or peak internal
carotid artery velocity to common carotid artery velocity
ratio) provide additional information
38. ▪ A meta-analysis published in 2006 concluded that
CDUS compared with intra-arterial cerebral
angiography for the diagnosis of 70 to 99 percent
carotid stenosis
▪ Sensitivity of - 95%
▪ Specificity of - 95%
Wardlaw JM, Chappell FM, Best JJ, et al. Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a
meta-analysis. Lancet 2006; 367:1503.
39. Advantages —
▪ Noninvasive , safe, and relatively inexpensive
technique
▪ Carotid index (peak internal carotid artery velocity
÷ common carotid artery velocity) >4 provided the
highest accuracy (sensitivity 91 percent, specificity
87 percent)
40. ▪ Disadvantages — hairline residual lumens
can be missed on carotid duplex ultrasound
(CDUS) .
▪ In addition, several studies have found that
CDUS tends to overestimate the degree of
stenosis
Dawson DL, Zierler RE, Strandness DE Jr, et al. The role of duplex scanning and arteriography before carotid endarterectomy: a prospective study. J Vasc Surg
1993; 18:673.
41. TRANSCRANIAL DOPPLER
▪ TCD-As an adjunct to CDUS
▪ TCD examines the major intracerebral arteries through
the orbit and at the base of the brain.
▪ Improve the accuracy of CDUS in identifying surgical
carotid disease .
▪ Detection of middle cerebral artery microemboli that
arise from the heart or carotid artery .
▪ Visualized as high intensity signal transients (HITS)
Wilterdink JL, Furie KL, Benavides J, et al. Combined transcranial and carotid Duplex ultrasound optimizes screening for carotid artery stenosis. Can J Neurol
Sci 1993; 20:S205
Siebler M, Kleinschmidt A, Sitzer M, et al. Cerebral microembolism in symptomatic and asymptomatic high-grade internal carotid artery stenosis. Neurology
42. For the transorbital approach, the strongest
indicators of a residual lumen diameter <1.5 mm
are
▪ Reversed flow in the I/L ophthalmic artery
▪ >50 % PSV difference between the carotid siphons
(distal internal carotid arteries) in pts with unilateral
ICA origin stenosis.
▪ Specificity of 100 % for PSV >440 cm/sec, EDV
>155 cm/sec, or carotid index >10.
▪ Sensitivity- 31 percent and 26 percent
43. For the transtemporal approach in
patients with a unilateral stenosis
▪ >35 % difference in I/L MCA PSV relative to the C/L MCA
,or a >50 percent difference in C/L ACA PSV relative to
the I/L ACA were 100 percent specific for identifying a
residual lumen diameter of <1.5 mm.
▪ Sensitivities -32 % & 43 %.
▪ Regardless of C/ L stenosis, a >35 percent difference in
I/L MCA peak systolic velocity relative to the I/L PCA
▪ Specificity-100 %
▪ Sensitivity - 23 percent for detecting a <1.5 mm minimal
residual lumen diameter.
44. ADDITIONAL ULTRASOUND
MODALITIES
1-Contrast enhanced USG –
▪ IV inj. of a microbubble contrast agent.
▪ Useful for evaluating carotid plaque
neovascularization, a possible marker of plaque
instability
▪ May help distinguish complete carotid occlusion from
near occlusion in carotid arteries -technically
challenging by conventional CDUS.
-Partovi S, Loebe M, Aschwanden M, et al. Contrast-enhanced ultrasound for assessing carotid atherosclerotic plaque lesions. AJR Am J Roentgenol 2012;
198:W13.
-Staub D, Schinkel AF, Coll B, et al. Contrast-enhanced ultrasound imaging of the vasa vasorum: from early atherosclerosis to the identification of unstable
plaques. JACC Cardiovasc Imaging 2010; 3:761.
-Ten Kate GL, van den Oord SC, Sijbrands EJ, et al. Current status and future developments of contrastenhanced ultrasound of carotid atherosclerosis. J Vasc
Surg 2013; 57:539.
45. ▪ 2) 3D ultrasound-
▪ Improves visualization of vascular anatomy
▪ Advantages -quantitative monitoring of plaque
volume changes in all three directions [53].
▪ measurement of plaque volume change- a
more sensitive marker of plaque progression
Fenster A, Downey DB, Cardinal HN. Three-dimensional ultrasound imaging. Phys Med Biol 2001; 46:R67
Landry A, Spence JD, Fenster A. Measurement of carotid plaque volume by 3-dimensional ultrasound. Stroke 2004; 35:864.
46. 3) Compound ultrasound-
▪ compounding to average several images taken
from different perspectives [55].
▪ Advantages -improved visualization of plaque
texture and surface, as well as reduction of
artifacts
▪ Not widely utilized
Jespersen SK, Wilhjelm JE, Sillesen H. Multi-angle compound imaging. Ultrason Imaging 1998; 20:81
47. MRA
▪ MRA- most often employed for evaluating the
extracranial carotid arteries utilize either 2D/3D TOF
MRA or gadolinium-enhanced MRA (CEMRA).
▪ The use of a paramagnetic agent acting as a
vascular contrast allows for higher quality images
that are less prone to artifacts
▪ Accurate for high-grade carotid artery stenosis and
occlusion
48. MRA…
▪ Less accurate for detecting moderate stenosis
▪ Sensitivity - 91 to 99 %
▪ Specificities -88 to 99 %
▪ Compared with CDUS, MRA-less operator-
dependent and does produce an image of the
artery.
Debrey SM, Yu H, Lynch JK, et al. Diagnostic accuracy of magnetic resonance angiography for internal carotid artery disease: a systematic review and meta-
analysis. Stroke 2008; 39:2237.
49. MRA…
▪ More expensive and time-consuming than
CDUS
▪ Less readily available.
Contraindications –
▪ Critically ill pt.
▪ Unable to lie supine or has claustrophobia
▪ Pacemaker or ferromagnetic implants
50. CT ANGIOGRAPHY
▪ CTA- provides an anatomic depiction of the carotid
artery lumen, adjacent soft tissue and bony structures.
▪ 3D reconstruction - accurate measurements of residual
lumen diameter.
▪ CTA - particularly useful when CDUS is not reliable
(eg, in cases with severe kinking, severe calcification,
short neck, or high bifurcation) or when an overall view
of the vascular field is required
▪ Sensitivity -95%
▪ Specificity -95%
51. DIAGNOSIS OF COMPLETE
OCCLUSION
▪ No Sx. Rx has proven benefit for prevention of
subsequent stroke in complete carotid artery occlusion.
▪ Imp. to distinguish between completely occluded vessels
and those with some remaining flow
▪ In current practice the combi. of MRA and CDUS is
probably sufficient for pt. with carotid artery occlusion
▪ Complete occlusion in CDUS study and confirmed on
MRA- No further imaging is necessary
52. CHOICE OF IMAGING
TEST
▪ Conventional cerebral angiography - gold
standard for the evaluation of ECAD/ICAD
▪ However, angiography is associated with a
small but real risk of stroke, which makes it ill
suited for use as a screening test.
Rothwell PM. For severe carotid stenosis found on ultrasound, further arterial evaluation prior to carotid endarterectomy is unnecessary: the argument against.
Stroke 2003; 34:1817.
53. Patients are generally selected for angiography
using one of the noninvasive tests-
▪ Carotid duplex ultrasonography (CDUS)
▪ Time of flight magnetic resonance angiography
(TOF MRA)
▪ Contrast enhanced magnetic resonance
angiography (CEMRA)
▪ Computed tomography angiography (CTA)
54. ▪ CDUS, MRA, CEMRA, and CTA all have high
sensitivities and specificities for diagnosing 70 to
99 % ICA stenosis
▪ CEMRA may be marginally more accurate than
the other noninvasive methods
▪ The accuracy of the noninvasive tests for 50 to 69
% stenosis appears to be reduced compared with
79 to 99 percent stenosis.
Wardlaw JM, Chappell FM, Best JJ, et al. Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a
meta-analysis. Lancet 2006; 367:1503.
55. ▪ General approach -first perform CDUS.
▪ Stenosis <50 % - followed with serial annual exami.
▪ Stenosis ≥50%-evaluated with TCD and MRA.
▪ CTA –if MRA contraindicated & CDUS and MRA do
not agree.
56. ▪ Conventional angiography is rarely performed
Indications –
▪ Pt. who cannot tolerate an MRA
▪ Nonatherosclerotic disease -(eg, dissection,
vasculitis and aneurysm).
▪ Suspected disease affecting the proximal CCA or the
origins of the great vessels from the aortic arch
▪ Severe multi-vessel disease, such as combined
carotid and vertebral artery disease,
▪ Poor quality of noninvasive imaging
▪ Discordant results of noninvasive imaging
58. AHA/ASA Guideline-
Extracranial Carotid Disease
▪ For patients with a TIA or ischemic stroke within the past 6
months and ipsilateral severe (70%–99%) carotid artery
stenosis as documented by noninvasive imaging, carotid
endarterectomy (CEA) is recommended if the perioperative
morbidity and mortality risk is estimated to be <6% (Class
I; Level of Evidence A).
▪ For patients with recent TIA or ischemic stroke and
ipsilateral moderate (50%–69%) carotid stenosis as
documented by catheter-based imaging or noninvasive
imaging with corroboration (eg, MRA/CTA), CEA is
recommended depending on patient-specific factors, such
as age, sex, and comorbidities, if the perioperative
morbidity and mortality risk is estimated to be <6% (Class
I; Level of Evidence B).
59. AHA/ASA Guideline-
Extracranial Carotid Disease…
▪ When the degree of stenosis is <50%, CEA and CAS are
not recommended (Class III; Level of Evidence A).
▪ When revascularization is indicated for patients with TIA or
minor, nondisabling stroke, it is reasonable to perform the
procedure within 2 weeks of the index event rather than
delay surgery if there are no contraindications to early
revascularization (Class IIa; Level of Evidence B).
▪ CAS is indicated as an alternative to CEA for symptomatic
patients at average or low risk of complications associated
with endovascular intervention when the diameter of the
lumen of the internal carotid arteryis reduced by >70% by
noninvasive imaging or >50% by catheter- based imaging
or noninvasive imaging with corroboration and the
anticipated rate of periprocedural stroke or death is <6%
(Class IIa; Level of Evidence B). (Revised recomm.)
60. AHA/ASA Guideline-
Extracranial Carotid Disease…
▪ It is reasonable to consider patient age in choosing between
CAS and CEA. For older patients (ie, older than ≈70 years),
CEA may be associated with improved outcome compared
with CAS, particularly when arterial anatomy is unfavorable
for endovascular intervention. For younger patients, CAS is
equivalent to CEA in terms of risk for periprocedural
complications (ie, stroke, MI, or death) and long-term risk for
ipsilateral stroke (Class IIa; Level of Evidence B). (New
recommendation)
▪ Among patients with symptomatic severe stenosis (>70%) in
whom anatomic or medical conditions are present that
greatly increase the risk for surgery or when other specific
circumstances exist such as radiation- induced stenosis or
restenosis after CEA, CAS is reasonable (Class IIa; Level of
Evidence B). (Revised recommendation)
61. AHA/ASA Guideline-Extracranial
Carotid Disease…
▪ CAS and CEA in the above settings should be
performed by operators with established periprocedural
stroke and mortality rates of <6% for symptomatic
patients, similar to that observed in trials comparing
CEA to medical therapy and more recent observational
studies (Class I; Level of Evidence B). (Revised
recommendation)
▪ Routine, long-term follow-up imaging of the extracranial
carotid circulation with carotid duplex ultrasonography is
not recommended (Class III; Level of Evidence B). (New
recommendation)
62. AHA/ASA Guideline-Extracranial
Carotid Disease…
▪ For patients with a recent (within 6 months) TIA or ischemic
stroke ipsilateral to a stenosis or occlusion of the middle
cerebral or carotid artery, extracranial/intracranial (EC/IC)
bypass surgery is not recommended (Class III; Level of
Evidence A).
▪ Optimal medical therapy, which should include antiplatelet
therapy, statin therapy, and risk factor modification, is
recommended for all patients with carotid artery stenosis
and a TIA or stroke (Class I; Level of Evidence A).
63. Extracranial Vertebrobasilar
Disease
▪ Routine preventive therapy with emphasis on
antithrombotic therapy, lipid lowering, BP control, and
lifestyle optimization is recommended for all patients
with recently symptomatic extracranial vertebral artery
stenosis (Class I; Level of Evidence C).
▪ Endovascular stenting of patients with extracranial
vertebral stenosis may be considered when patients
are having symptoms despite optimal medical
treatment (Class IIb; Level of Evidence C).
64. Extracranial
Vertebrobasilar Disease…
▪ Open surgical procedures, including vertebral
endarterectomy and vertebral artery transposition,
may be considered when patients are having
symptoms despite optimal medical treatment
(Class IIb; Level of Evidence C).
65. Intracranial Atherosclerosis
▪ For patients with a stroke or TIA caused by 50% to
99% stenosis of a major intracranial artery, aspirin
325 mg/d is recommended in preference to warfarin
(Class I; Level of Evidence B). (Revised
recommendation)
▪ For patients with recent stroke or TIA (within 30
days) attributable to severe stenosis (70%–99%) of a
major intracranial artery, the addition of clopidogrel
75 mg/d to aspirin for 90 days might be reasonable
(Class Iib; Level of Evidence B). (New
recommendation)
66. ▪ For patients with a stroke or TIA attributable to 50%
to 99% stenosis of a major intracranial artery,
maintenance of SBP below 140 mm Hg and high-
intensity statin therapy are recommended (Class I;
Level of Evidence B). (Revised recommendation)
67. ▪ For patients with a stroke or TIA attributable to moderate
stenosis (50%–69%) of a major intracranial artery,
angioplasty or stenting is not recommended given the low
rate of stroke with medical management and the inherent
periprocedural risk of endovascular treatment (Class III;
Level of Evidence B). (New recommendation)
▪ For patients with stroke or TIA attributable to severe
stenosis (70%–99%) of a major intracranial artery,
stenting with the Wingspan stent system is not
recommended as an initial treatment, even for patients
who were taking an antithrombotic agent at the time of
the stroke or TIA (Class III; Level of Evidence B). (New
recommendation)
68. ▪ For patients with stroke or TIA attributable to severe
stenosis (70%–99%) of a major intracranial artery, the
usefulness of angioplasty alone or placement of stents
other than the Wingspan stent is unknown and is
considered investigational (Class IIb; Level of Evidence
C). (Revised recommendation)
▪ For patients with severe stenosis (70%–99%) of a major
intracranial artery and recurrent TIA or stroke after
institution of aspirin and clopidogrel therapy,
achievement of SBP <140 mm Hg, and high- intensity
statin therapy, the usefulness of angioplasty alone or
placement of a Wingspan stent or other stent is
unknown and is considered investigational (Class IIb;
Level of Evidence C). (New recommendation)
69. ▪ For patients with severe stenosis (70%–99%) of a major
intracranial artery and actively progressing symptoms
after institution of aspirin and clopidogrel therapy, the
usefulness of angioplasty alone or placement of a
Wingspan stent or other stents is unknown and is
considered investigational (Class IIb; Level of Evidence
C). (New recommendation
▪ For patients with stroke or TIA attributable to 50% to
99% stenosis of a major intracranial artery, EC/IC
bypass surgery is not recommended (Class III; Level of
Evidence B).
70. Conclusion
▪ Cerebovascular atherosclerosis are common cause of
stroke
▪ May be extra/intracranial
▪ ECAD More common in western popu. & ICAD in Asians
▪ May be symptomatic/asymptomatic
▪ DSA is gold standard
▪ Non invasive diagnostic measure are preferred
▪ Rx-Risk factor modification,Medical(IC) ,Sx-CEA and
CAS(EC)
72. References
▪ Bradley’s neurology in Clinical Practice;7th edi.
▪ Guidelines for the Prevention of Stroke in Patients With Stroke and Transient
Ischemic Attack A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke AssociationStroke. ;Walter N. Kernan, et al
;MD,2014;45:2160-2236.
▪ Intracranial large artery atherosclerosis – UpToDate; As'ad Ehtisham, MD, MBBS
et al; last updated: May 25, 2017
▪ Evaluation of carotid artery stenosis – UpToDate; Karen L Furie, MD, MPH et al;
last updated: Dec 30, 2016
▪ Large Artery Atherosclerosis: Carotid Stenosis, Vertebral Artery Disease, and
Intracranial Atherosclerosis Seemant Chaturvedi, MD, et al; Continuum (Minneap
Minn) 2014;20(2):323–334.
▪ North American Symptomatic Carotid Endarterectomy Trial Collaborators, Barnett
HJM, Taylor DW, et al. Beneficial effect of carotid endarterectomy in symptomatic
patients with high-grade carotid stenosis. N Engl J Med 1991; 325:445.
▪ Harrison texbook of internal medicine;18th edi.