Ischemic Stroke

by Carlo Raj, MD

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    00:01 Now, with the ischemic stroke, what we'll do here is divide it into focal versus your global.

    00:06 What do you mean by focal? Focal means that you have an individual blood vessel that is undergoing some type of compromise of blood flow to the brain.

    00:17 How did it occur? Oh maybe, the patient had some type of thrombi formation taking place in the heart secondary to, let's say, atrial fibrillation.

    00:29 And if you remember, atrial fibrillation would be one of the criteria for developing the thrombi, and in essence, the Virchow triad.

    00:38 Imagine now that you have a thrombus formation taking place in left atrium.

    00:42 What may then happen? At some point in time if there's, let's say, AFib, then the thrombi will break off.

    00:49 You embolize into left ventricle and there you go.

    00:52 And 10% of the time, you might end up in the carotids.

    00:56 And if you do, focally, the embolized thrombus might then become lodged in a smaller cerebral blood vessel and occlude it. This would create an ischemic type of stroke.

    01:08 It could be.

    01:09 Embolic, meaning artery to artery or maybe the patient started having a DVT, maybe who's a female who's obese and is smoking, also taking estrogen therapy, develops a deep vein thrombosis.

    01:24 But how is that going to result in having a stroke which is on the systemic side? Obviously, there has to be communication taking place from the systemic veins to the systemic artery.

    01:37 So you begin with a deep vein thrombosis, think of that please.

    01:41 You will then embolize to the right side of the heart.

    01:44 And then, maybe, there was an atrial septal defect.

    01:47 And so, therefore, paradoxically, will then embolize to the left side and end up in your -- focally, a blood vessel bringing about stroke-like symptoms.

    01:58 Some more topic.

    02:01 Ischemic stroke, specifically, focusing upon one blood vessel at a time.

    02:07 How did it become pathological is the question that we're answering, aren't we? How about thrombotic? Once again, you have a thrombus formation, but this time, it's not in the deep vein of your leg, nor is it in the left atrium, but maybe it's actually taking place in a blood vessel in the brain due to, well, years have gone by and the patient has hyperlipidemia, so atherosclerosis, and it might be atherosclerosis therefore causing decrease blood flow profusion to the brain, or a combination of lipohyalinosis.

    02:48 What does that mean to you? You know what hyaline is, an aggregation of protein.

    02:52 Oftentimes, you know that a patient may have hypertension and diabetes mellitus at the same time and so therefore lipohyalinosis.

    03:01 What's happening here? There is a thrombus formation taking place in your blood vessel, Therefore, resulting in decrease blood supply to the brain and giving our patient, unfortunately, a focal cerebral type of ischemic stroke.

    03:14 Or the patient has vasculitis.

    03:17 And by vasculitis we refer to something like temporal arteritis, you've heard it before.

    03:23 Arteritis or maybe something like your granulomatosis with polyangiitis, formerly known as Wegener.

    03:31 Microscopic polyangiitis, you get the point.

    03:33 Or even something like IgA vasculopathy formerly known as Henoch-Schönlein purpura.

    03:40 All of those conditions have one in common.

    03:43 They're causing inflammation in the blood vessel.

    03:46 Then what then happens to caliber of the lumen? Uh-oh. It is getting compromised.

    03:51 This is not good.

    03:52 They result in what? Good.

    03:55 A focal type of ischemic stroke.

    03:57 Are you seeing this now? Or could it be cryptogenic.

    04:01 In other words, not exactly sure as to what the cause is.

    04:03 So, on this side, it would be focal type.

    04:06 And then on this side, globally.

    04:08 What may happen? Well, global, your patient maybe suffering from hypotension.

    04:13 Globally versus focally.

    04:16 So, if the entire body is undergoing hypotension, then there's going to be decrease blood supply obviously to the brain.

    04:24 Once again, causing an ischemic-type of stroke but this is global in nature.

    04:28 Keep that in mind.

    About the Lecture

    The lecture Ischemic Stroke by Carlo Raj, MD is from the course Stroke (Cerebrovascular Accident).

    Included Quiz Questions

    1. Acute hypotension
    2. Paradoxical embolus
    3. Atherosclerosis
    4. Vasculitis of the middle cerebral artery
    5. Lipohyalinosis
    1. Atrial septal defect
    2. Dilated cardiomyopathy
    3. Ventricular aneurysm
    4. Mitral regurgitation
    5. Eisenmenger syndrome
    1. Hypotension resulting from acute blood loss
    2. Embolization of internal carotid artery
    3. Lipohyalinosis of small blood vessels
    4. Pulmonary thromboembolism
    5. Atherosclerosis of middle meningeal artery

    Author of lecture Ischemic Stroke

     Carlo Raj, MD

    Carlo Raj, MD

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    Very clear explanation, thank you so much!
    By Luca S. on 01. November 2018 for Ischemic Stroke

    Very clear and concise definitions of stroke vs TIA. I appreciate that Dr. Raj underlines the importance of TIA treatment as a risk factor for a stroke.