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CEREBROVASCULAR ACCIDENT. CLASSIFICATION Complete stroke Complete stroke T.I.A T.I.A R.I.N.D R.I.N.D Stroke in evolution Stroke in evolution.

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Presentation on theme: "CEREBROVASCULAR ACCIDENT. CLASSIFICATION Complete stroke Complete stroke T.I.A T.I.A R.I.N.D R.I.N.D Stroke in evolution Stroke in evolution."— Presentation transcript:

1 CEREBROVASCULAR ACCIDENT

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3 CLASSIFICATION Complete stroke Complete stroke T.I.A T.I.A R.I.N.D R.I.N.D Stroke in evolution Stroke in evolution

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5 Acute neurological injury which occurs as a result of ; 1—Embolism 1—Embolism 2---Thrombosis 2---Thrombosis 3---Haemorrhage 3---Haemorrhage 4---Demyelation 4---Demyelation 5---SOL { Space occupying lesion} 5---SOL { Space occupying lesion}

6 RISK FACTORS Age—advanced age Age—advanced age Sex—males more than females Sex—males more than females Hypertension Hypertension DM DM Hyperlipidemia Hyperlipidemia Smoking Smoking Excess alcohol consumption Excess alcohol consumption Polycythemia Polycythemia

7 O.C. pills O.C. pills Vasculitis Vasculitis Thrombophillia Thrombophillia Anticardiolipin antibody Anticardiolipin antibody Homocysteinurea Homocysteinurea

8 MANAGEMENT HISTORY May be helpful Headache + vomiting ---favour the Dx of IC hge or SAH Abrupt onset of impaired cerebral function without focal symptoms suggest SAH

9 EXAMINATION BP BP Breathing Breathing Fever----meningitis Fever----meningitis subdural haematoma subdural haematoma brain abcess brain abcess infective endocarditis infective endocarditis Neck---for bruits Neck---for bruits Pulses----in neck and arms Pulses----in neck and arms

10 CVS---valvular heart disease,AF CVS---valvular heart disease,AF Skin---signs of cholesterol embolism+IE Skin---signs of cholesterol embolism+IE Fundus Fundus

11 INVESTIGATIONS CBC, ESR CBC, ESR U+E, RBS U+E, RBS LFT, PT, PTT LFT, PT, PTT CT scan brain or MRI CT scan brain or MRI Doppler U.S of carotids Doppler U.S of carotids Echo Echo Hypercoagguable screen Hypercoagguable screen Screen for connective tissue disease Screen for connective tissue disease Toxicology screen Toxicology screen

12 D/D--Migraine --Head trauma --Brain tumour --Systemic infections --Toxic metabolic disturbance hypoglycemia hypoglycemia acute renal+ hepatic failure acute renal+ hepatic failure drug intoxication drug intoxication Todd,s paralysis

13 HAEMORRHAGE Intracranial hge can be caused by— Intracerebral hge {ICH} Intracerebral hge {ICH} also called parenchymal hge which involves bleeding directly into brain tissue. also called parenchymal hge which involves bleeding directly into brain tissue. SAH SAH involves bleeding into the CSF that surrounds the brain and the spinal cord involves bleeding into the CSF that surrounds the brain and the spinal cord Trauma Trauma causing subdural or extradural haematomas causing subdural or extradural haematomas

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17 COMMON CAUSES Hypertension Hypertension Trauma Trauma Bleeding diathesis Bleeding diathesis Amyloid angiopathy Amyloid angiopathy Illicit drug abuse {amphetamine, cocaine} Illicit drug abuse {amphetamine, cocaine} Vascular malformation Vascular malformation Rupture of aneurysm Rupture of aneurysm Vasculitis Vasculitis

18 SUBARACHANOID HAEMORRHAGE 1--Bleeding from aneurysm typically located in the anterior half of circle of willis at the base of the brain. 2—2 nd commonest causes A/V malformation A/V malformation bleeding diathesis bleeding diathesis drugs drugs amyloid angiopathy amyloid angiopathy

19 COMPLICATION OF SAH DUE TO ANEURYSM Rebleeding within 10 days Rebleeding within 10 days Vasospasm Vasospasm Systemic complications Systemic complications --hyponatremia --hyponatremia --MI --MI --CNS disturbance --CNS disturbance

20 TREATMENT Identify cause Identify cause Prevent rebleeding Prevent rebleeding Prevent brain damage due to delayed ischaemia related to vasoconstrictionof IC arteries Prevent brain damage due to delayed ischaemia related to vasoconstrictionof IC arteries --surgical removal --surgical removal --Calcium channel blocker - Nimodipine --Calcium channel blocker - Nimodipine

21 PROGNOSIS SAH from intra cranial aneurysm has a mortality of 50% SAH from intra cranial aneurysm has a mortality of 50% Prognosis is closely related to pts neurological condition on hospital arrival Prognosis is closely related to pts neurological condition on hospital arrival Pts who are alert and have no major focal defecit have a 70-80% chances of survival Pts who are alert and have no major focal defecit have a 70-80% chances of survival Those who are comatosed have 90%mortality Those who are comatosed have 90%mortalityPROGNOSIS SAH from intra cranial aneurysm has a mortality of 50% SAH from intra cranial aneurysm has a mortality of 50% Prognosis is closely related to pts neurological condition on hospital arrival Prognosis is closely related to pts neurological condition on hospital arrival Pts who are alert and have no major focal defecit have a 70-80% chances of survival Pts who are alert and have no major focal defecit have a 70-80% chances of survival Those who are comatosed have 90%mortality Those who are comatosed have 90%mortality

22 INTRACERBRAL HAOMORRHAGE Strongly associated with hypertension Hypertension leads to fibrinoid necrosis of arterioles + Long standing hypertension leads to hyaline changes in the muscular and elastic arterial layer-----leads to microaneurysim-----liable to rupture Middle cerbral artery and the lenticular branches are prone to develop these aneurysms Majority of ICH occur in the region of the internal capsule

23 FIVE COMMON AREAS OF HAEMORRHAGE Putamen Putamen White matter or lobe White matter or lobe Thalamous Thalamous Pons Pons Cerebellum Cerebellum

24 ICH usually presents abruptly when the pt. is awake ICH usually presents abruptly when the pt. is awake Severe headache Severe headache ½ of pts. Present with LOC and fits ½ of pts. Present with LOC and fits Since internal capsule is involved so there is hemiplegia Since internal capsule is involved so there is hemiplegia Massive bleeding---increase intracranial pressure---papilloedema- ---deep coma Massive bleeding---increase intracranial pressure---papilloedema- ---deep coma

25 GENERAL RULE If the bleeding is greater than 80 mls as estimated by CT scan, and is associated with deep coma------ chances of survival are very poor If the bleeding is greater than 80 mls as estimated by CT scan, and is associated with deep coma------ chances of survival are very poor ICH of moderate size >1.5 cm in diameter, surgical evacuation may be life saving ICH of moderate size >1.5 cm in diameter, surgical evacuation may be life saving

26 Bleeding forms localized haematoma Bleeding forms localized haematoma ---spreads along the white matter ---haematoma enlarges and continues to grow ---pressure surrounding it increases to limit its spread OR OR Decompresses itself into the ventricular system CSF

27 Any patient with sudden onset of severe headache should be considered to have SAH. Any patient with sudden onset of severe headache should be considered to have SAH. Headache with global impairement of conciousness is typical Headache with global impairement of conciousness is typical Focal neurological signs are rare Focal neurological signs are rare Diplopia + cranial nerve lesion may occur Diplopia + cranial nerve lesion may occur Neck stiffness Neck stiffness Subhyloid hge Subhyloid hge

28 PUTAMEN Majority of hgic strokes occur in this area Majority of hgic strokes occur in this area Hemiparesis or hemiplegia Hemiparesis or hemiplegia Sensory loss Sensory loss Aphasia if on dominant side Aphasia if on dominant side Surgery of questionable value Surgery of questionable value

29 PONS Rapid loss of conciousness Rapid loss of conciousness Pin point pupils Pin point pupils Periodic respiration Periodic respiration Quadriparesis Quadriparesis Surgery of no value

30 WHITE MATTER OR LOBE WHITE MATTER OR LOBE Same as putamin hge signs Same as putamin hge signs Distinguished only by neuroimaging Distinguished only by neuroimaging Surgical evacuation, if suitable Surgical evacuation, if suitable

31 EMBOLIC STROKE Usually occur abruptly Usually occur abruptly Occasionally present with stuttering fluctuating symptoms Occasionally present with stuttering fluctuating symptoms Either the anterior (carotid) or posterior (vertibobasilar ) circulation may be involved Either the anterior (carotid) or posterior (vertibobasilar ) circulation may be involved

32 CLASSIFCATION ACCORDING TO LOBES FRONTAL LOBE Personality and emotional disorders Expressive dysphasia Contralateral hemiparesis Primitive reflexes

33 PARITAL LOBE -Spatial disorientation -Apraxia +acalculia +agraphia +alexia -Sensory inattention,neglect of non dominant side -Contralateral hemisensory loss -Lower quadrantonopia

34 TEMPORAL LOBE -Receptive dysphasia -De ja vu phenomena -Hallucination of taste and smell -Excessive lip smacking -Micropsia -Upper quandrantonopia

35 OCCIPITAL LOBE -Homonymous hemianopia with sparing of the macula -Thalamic syndrome

36 LOCALIZING FEATURES OF MOTOR LESIONS CEREBRAL CORTEX Flaccid weakness--- flexors+extensors equally affected (global weakness) Flaccid weakness--- flexors+extensors equally affected (global weakness)

37 INTERNAL CAPSULE INTERNAL CAPSULE Spastic weakness Spastic weakness Extensors more than flexors Extensors more than flexors Distal muscles affected more than proximal Distal muscles affected more than proximal Patient looks away from the lesion (paralysis of head and eye movement ) Patient looks away from the lesion (paralysis of head and eye movement )

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39 BRAIN STEM --crossed hemiplegia i.e ipsilateral cranial nerve palsy with contralateral limb palsy limb palsy ROOT AND PERIPHERAL LESION --peripheral nerve lesions usually affect both motor and sensory function in muscles and skin supplied by the nerve

40 l LOCALIZING ACCORDING TO BLOOD SUPPly MIDDLE CEREBRAL ARTERY Supplies majority of the internal capsule, larger part of frontal, parietal and temporal lobe) Contralateral spastic weakness Contralateral spastic weakness Hemianopia Hemianopia May have signs of frontal, temporal or parietal lobes May have signs of frontal, temporal or parietal lobes

41 ANTRIOR CEREBRAL ARTERY (Supplies the frontal lobe, superior portion of cerebral cortex and anterior portion of internal capsule) --Motor dysphasia --Cortical flaccid weakness of the opposite leg --Cortical sensory loss in opposite leg --Frontal lobe signs

42 POSTERIOR CEREBRAL ARTERY (supplies occipital lobe, branch to thalamous and mid brain) --homonomous hemianopia with sparing of the macula --thalamic syndrome --if both cerebral arteries are occluded— cortical blindness (pt is blind but all the pupillary reflexes are intact

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44 CNS LOCALIZATION CNS LOCALIZATION HEMIPLEGIA HEMIPLEGIA CORTICAL CORTICAL speech disturbances speech disturbances UMNL 7 th N palsy UMNL 7 th N palsySUBCORTICAL multiple cranial nerve multiple cranial nerve palsy palsy

45 SPINAL CORD SPINAL CORD Bilateral pyramidal signs Bilateral pyramidal signs Higher function intact Higher function intact No cranial nerve palsy apart from occasional 11 th nerve palsy No cranial nerve palsy apart from occasional 11 th nerve palsy

46 WEAKNESS OF LOWER LIMBS With pyramidal signs With pyramidal signs cord lesion cord lesion MND MND Without pyramidal signs Without pyramidal signs neuropathy either sensory or neuropathy either sensory or motor motor muscle disease muscle disease

47 CRANIAL NERVES Single Single DM or Bell,s palsy DM or Bell,s palsy Multiple Multiple brain stem, with or without brain stem, with or without long tract signs----SOL long tract signs----SOL ----vascular ----vascular

48 EXTRAPYRAMIDAL With pyramidal signs With pyramidal signs vascular like atherosclerosis vascular like atherosclerosis Without pyramidal signs Without pyramidal signs degenarative group degenarative group

49 CEREBELLAR Wings Wings look for pes cavus look for pes cavus Tract signs Tract signs SOL (acoustic neuroma) SOL (acoustic neuroma) PICA PICAMUSCLES Dystrophies Dystrophies

50 CEREBELLUM Headache Headache Vertigo Vertigo Atxia Atxia Lethargy Lethargy No focal weakness No focal weakness Surgical evacuation for all except small haemorrhages

51 CLASSIFICATION Within the cavernous sinus (infraclinoid) It may compress structures like 3,4,5 and 6 th nerve palsy It may compress structures like 3,4,5 and 6 th nerve palsy ----dilated pupil ----facial pain ----variable loss of facial sensation

52 Above the cavernous sinus (supraclinoid) Most frequently compress the occulomotor nerve, optic tracts and chiasm Most frequently compress the occulomotor nerve, optic tracts and chiasm May extend into the frontal lobe May extend into the frontal lobe

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