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Cerebrovascular Disease(simple introduction)
Lecture classPratap Sagar Tiwari, MD, Lecturer,
NGMC
Cerebrovascular disease ?
Stroke
Definition of Stroke
• A stroke or Cerebrovascular accidents is defined by abrupt onset of a neurological deficit that is attributable to a focal vascular cause.
• Stroke is the third most common cause of death in the developed world after cancer and ischaemic heart disease, and is the most common cause of severe physical disability.
References : Harrison 18th ed
Stroke types
• Stroke is classified into two major types:1. Ischemic stroke: Brain ischemia due to thrombosis,
embolism, or systemic hypoperfusion2. Hemorrhagic stroke: Brain hemorrhage due to
intracerebral hemorrhage or subarachnoid hemorrhage.• Approximately 80 % of strokes are due to ischemic cerebral
infarction and 20 % to brain hemorrhage.
Stroke types ?
BRAIN ISCHEMIA 1• Thrombosis generally refers to local in situ obstruction of an artery. • Embolism refers to particles of debris originating elsewhere that block
arterial access to a particular brain region .• Systemic hypoperfusion is a more general circulatory problem,
manifesting itself in the brain and perhaps other organs.
• References 1: Caplan LR. Basic pathology, anatomy, and pathophysiology of stroke. In: Caplan's Stroke: A Clinical Approach, 4th ed, Saunders Elsevier, Philadelphia 2009. p.22.
Hemorrhagic stroke
Hemorrhagic stroke: types1. Intracerebral hemorrhage refers to bleeding directly into
the brain parenchyma2. Subarachnoid hemorrhage refers to bleeding into the
cerebrospinal fluid within the subarachnoid space that surrounds the brain
• Note: Hemorrhage is characterized by too much blood within the closed cranial cavity, while ischemia is characterized by too little blood to supply an adequate amount of oxygen and nutrients to a part of the brain.1
• Reference 1: Caplan LR. Intracranial branch atheromatous disease: a neglected, understudied, and underused concept. Neurology 1989; 39:1246.
Diagnosis ?
• Clinical• Investigation
Clinical ?
• Is there any neurological deficit ?• Is there any risk factor for vascular disease ?
STROKE RISK FACTORS
• Age • Gender (male > female)• Race (Afro-Caribbean > Asian > European) • Heredity • Previous vascular event, e.g. MI, stroke or
peripheral embolism • High fibrinogen
STROKE RISK FACTORS
• High blood pressure • Heart disease (atrial fibrillation, HF,
endocarditis) • Diabetes mellitus • Hyperlipidaemia • Smoking, Excess alcohol consumption • Polycythaemia • Oral contraceptives
• Cerebral infarction is mostly due to thromboembolic disease secondary to atherosclerosis in the major extracranial arteries (carotid artery and aortic arch).
• About 20% of infarctions are due to embolism from the heart, and a further 20% are due to intrinsic disease of small perforating vessels (lenticulostriate arteries), producing so-called 'lacunar' infarctions.
Hemorrhagic stroke : Risk Factor
Cincinnati Prehospital Stroke Scale1. Facial droop: Have the person smile or show his or her teeth. •Normal: Both sides of face move equally•Abnormal: One side of face does not move as well as the other (or at all)2. Arm drift: •Normal: Both arms move equally or not at all•Abnormal: One arm does not move, or one arm drifts down compared with the other side3. Speech: •Normal: Patient uses correct words with no slurring•Abnormal: Slurred or inappropriate words or mute
Patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke. If all 3 findings are present the probability of an acute stroke is more than 85%
Hurwitz AS, Brice JH, Overby BA, Evenson KR (2005). "Directed use of the Cincinnati Prehospital Stroke Scale by laypersons". Prehosp Emerg Care 9 (3): 292–6
Investigations ?
• Imaging
7 questions ?
1. Is this a vascular lesion ?
CT/MRI
CT HEAD
• Imaging
7 questions ?
2. Is it ischaemic or haemorrhagic?
CT/MRI
7 questions ?
3. Is it a subarachnoid haemorrhage?
CT/MRI
SubArachnoid Hemorrhage
7 questions ?
4. Is there any cardiac source of embolism?
ECG/ECHO
ECG: Afib
7 questions ?
5. What is the underlying vascular disease?
• Duplex ultrasound of carotids• Magnetic resonance angiography(MRA)
• CT angiography (CTA)• Contrast angiography
7 questions ?
6. What are the risk factors?
Full blood countCholesterol
Blood glucose
7 questions ?
7. Is there an unusual cause?
Rule out Bleeding Disorders/ ESR
References
• Harrison’s 18th edition• Davidsons 20th ed• Uptodate 20.3• Emedicine.com