Cerebrovascular disease Dr.Nathasha Luke

Epidemiology 3rd leading cause of death and disability in the world 3rd leading cause of death and disability in the world

Major risk factors Age, Gender, Race, Prior Stroke, and Heredity Age, Gender, Race, Prior Stroke, and Heredity Hypertension Hypertension Smoking Smoking Abnormal cardiac rythumn (atrial fibrillation) Abnormal cardiac rythumn (atrial fibrillation) Hyperlipidemia Hyperlipidemia Diabetes Diabetes Alcohol abuse Alcohol abuse Oral contraceptives Oral contraceptives

Classification of Stroke Ischemic (80%) Ischemic (80%) -Embolic –vessel occluded by a substance which is brought from other part of circulation -Thrombosis-abnormal clot formation within the vessel obstructing the lumen Hemorrhagic- Intracerebral hemorrhage Hemorrhagic- Intracerebral hemorrhage - sub arachnoid hemorrhage - sub arachnoid hemorrhage

Definitions of Stroke Transient Ischemic Attack Transient Ischemic Attack Stroke Stroke

TIA Brief episodes of focal neurological deficits lasting less than 24 hours leaving no residual deficits with complete recovery. Brief episodes of focal neurological deficits lasting less than 24 hours leaving no residual deficits with complete recovery. Ex-Mr. S a 59 year old retired clerk noticed sudden onset left sided face,arm, leg weakness and speech difficulty. He was very much distressed by these symptoms, but with in 15 minutes all his symptoms recovered on its own with out residual defect.

Completed Stroke Acute onset neurological signs and symptoms leading to death or persistent neurological deficit, occurring due to a vascular accident Acute onset neurological signs and symptoms leading to death or persistent neurological deficit, occurring due to a vascular accident

Blood supply of the brain Brain is supplied by 4 arteries Brain is supplied by 4 arteries 2 internal carotids and 2 vertebral arteris supply the brain 2 internal carotids and 2 vertebral arteris supply the brain Internal carotid arteries divide to form middle cerebral and anterior cerebral arteris Internal carotid arteries divide to form middle cerebral and anterior cerebral arteris Vertebral arteries give rise to the basillar artery.The basillar artery ends as two posterior cerebral arteries Vertebral arteries give rise to the basillar artery.The basillar artery ends as two posterior cerebral arteries

Blood supply of the brain

Circle of Willis Situated at the base of the brain It is an anastomosis between various artereis

Presentation depends on the affected vessel

Stroke Syndromes Internal Carotid Artery occlusion Internal Carotid Artery occlusion ACA occlusion ACA occlusion MCA occlusion MCA occlusion PCA occlusion PCA occlusion Vertebrobasilar occlusion Vertebrobasilar occlusion Lacunar Infarct Lacunar Infarct Spinal stroke Spinal stroke

Functions of cortex Frontal lobe-personality, continence, memory,eye movements,speech area(Brocas area),motor cortex Frontal lobe-personality, continence, memory,eye movements,speech area(Brocas area),motor cortex Temporal lobe – memory, hearing, music processing Temporal lobe – memory, hearing, music processing Parital lobe- sensory cortex, writing, dressing Parital lobe- sensory cortex, writing, dressing Occipital lobe-vision Occipital lobe-vision

Brocas speech area Motor cortex sensory cortex Sensory speech area Auditory area

MCA occlusion Contralateral hemiplegia in face-arm Contralateral hemiplegia in face-arm aphasia aphasia Visual field defects Visual field defects

ACA occlusion Sensori motor deficit in contralateral foot and leg Sensori motor deficit in contralateral foot and leg Eye movement defects Eye movement defects

Spinal Stroke Rare Rare Anterior spinal artery Anterior spinal artery Paralysis and sensory loss below the level of the lesion Paralysis and sensory loss below the level of the lesion

Posterior Circulation TIA and Stroke Vertigo Vertigo Diplopia/ dysconjugate gaze, ocular palsy Diplopia/ dysconjugate gaze, ocular palsy Dysarthria Dysarthria ataxia ataxia

Hemorrhagic stroke Subarachnoid Hemorrhage(5%) Subarachnoid Hemorrhage(5%) Intracerebral Hemorrhage(15%) Intracerebral Hemorrhage(15%) In general patients with hemorrhagic stroke present seriously ill.

Subarachnoid Hemorrhage Rupture of an artery with bleeding unto the surface of the brain Rupture of an artery with bleeding unto the surface of the brain Aneurysms, Arterio venous malformations and bleeding disorders are the causes Aneurysms, Arterio venous malformations and bleeding disorders are the causes

Subarachnoid Hemorrhage Intractable headache Intractable headache Neck stiffness Neck stiffness Altered mental status Altered mental status

Intracerebral hemorrhage Rupture of an artery with bleeding into the brain matter Rupture of an artery with bleeding into the brain matter Main cause- Hypertension, Main cause- Hypertension, These patients can present with any of the signs and symptoms of ischemic stroke These patients can present with any of the signs and symptoms of ischemic stroke

Investigations ECG ECG Lab investigations Lab investigations CT or MR head scan CT or MR head scan blood glucose blood glucose

Medical Management In the initial state primary aim is to prevent death- Airway/breathing/circulation In the initial state primary aim is to prevent death- Airway/breathing/circulation Fibrinolytic therapy (TPA) Fibrinolytic therapy (TPA) Aspirin Aspirin

Patient kept nil orally Patient kept nil orally Once stable assess swallowing and other disabilities assessed Once stable assess swallowing and other disabilities assessed Care given for paralyzed-turning, air mattresses Care given for paralyzed-turning, air mattresses Nutrition Nutrition

Chronic management Multidisciplinary approach Multidisciplinary approach Psychiatric Services Psychiatric Services PT/OT/Speech-Language PT/OT/Speech-Language Skilled nursing facility Skilled nursing facility Social Services Social Services Family support Family support

Prevention is better than cure… Prevention - Lifestyle Modification/treating underlying disorders Prevention - Lifestyle Modification/treating underlying disorders

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