Cerebrovascular disease Halmat M. Jaafar (MSc. Clinical pharmacy) Hawler Medical University/ College of Pharmacy Department of Pharmacology Halmat.jaafar@pha.hmu.edu.iq

Out line of this lecture What is Cerebrovascular disease? Epidemiology. Etiology Classification of Cerebrovascular disease. Causes of Cerebrovascular disease Clinical presentation Management of cerebrovascular disease

Cerebrovascular disease Cerebrovascular disease is a broad term encompassing many disorders of the blood vessels of the central nervous system (CNS). These disorders result from either inadequate blood flow to the brain (i.e., cerebral ischemia) with subsequent infarction of the involved portion of the CNS or hemorrhages into the parenchyma or subarachnoid space of the CNS and subsequent neurologic dysfunction. This group of disorders is the third leading cause of deaths among adults in the United States.

Types of Stroke Ischemic Hemorrhagic

TRANSIENT ISCHEMIC ATTACK A transient ischemic attack (TIA) describes the clinical condition in which a patient experiences a temporary focal neurologic deficit such as slurred speech, aphasia, weakness or paralysis of a limb, or blindness. These symptoms appear rapidly and are temporary, lasting less than 24 hours (usually only 2–15 minutes).

TRANSIENT ISCHEMIC ATTACK The clinical presentation depends on the portion of the cerebrovascular tree affected by diminished or absent blood flow. TIAs frequently result from small clots breaking away from larger, distant blood clots. These emboli are then dissolved by the fibrinolytic system, allowing re-establishment of blood flow and return of neurologic function.

STROKE vs TIA Transient ischemic attack (TIA): A clinical syndrome characterized by an acute loss of focal brain or monocular function with symptoms lasting less than 24 hrs and which is thought to be due to inadequate cerebral or ocular blood supply, without ischemic changes Stroke: Clinical syndrome characterized by an acute loss of focal brain or monocular function with symptoms lasting greater than 24 hrs and which is thought to be due to inadequate cerebral or ocular blood supply.

CEREBRAL INFARCTION A cerebral infarction is a permanent neurologic disorder characterized by symptoms similar to a TIA. The patient with a cerebral infarction presents with neurological deficits caused by the death of neurons in a focal area of the brain. The two primary causes of infarction and persistent ischemia are atherosclerosis of cerebral blood vessels and an embolus to cerebral arteries from a distant clot.

A stable infarction describes the condition in which the neurologic deficit is permanent, will not improve, and will not deteriorate. An improving infarction is marked by return of previously lost neurologic function over the course of several days or weeks. A progressing infarction is one in which the patient’s neurologic status continues to deteriorate after the initial onset of focal deficits. CEREBRAL INFARCTION

Ischemic Stroke 85% of strokes Arterial occlusion of an intracranial vessel leads to hypoperfusion of the brain region it supplies Two etiological types Thrombotic Embolic

Cerebral hemorrhage involves escape of blood from blood vessels into the brain and its surrounding structures. The leakage of blood causes clinical symptoms similar to those associated with a TIA or cerebral infarction. In a cerebral hemorrhage, the initial neurologic deficits are attributable to the direct irritant effects of blood that is in direct contact with brain tissue. Primary causes of a cerebral hemorrhage include cerebral artery aneurysm, arteriovenous malformation, hypertensive hemorrhage, and trauma. The terms apoplexy, stroke, and paralytic stroke are commonly used by laypersons to describe a sudden neurologic affliction that usually is related to the cerebral blood supply. The term stroke is used to describe a cerebral vascular event when neurologic deficits persist for at least 24 hours. CEREBRAL HEMORRHAGE

Primary causes of a cerebral hemorrhage include cerebral artery aneurysm, arteriovenous malformation, hypertensive hemorrhage, and trauma. The terms apoplexy, stroke, and paralytic stroke are commonly used to describe a sudden neurologic affliction that usually is related to the cerebral blood supply. The term stroke is used to describe a cerebral vascular event when neurologic deficits persist for at least 24 hours. CEREBRAL HEMORRHAGE

Hemorrhagic Stroke Two types Intracerebral hemorrhage(ICH) Subarachnoid hemorrhage(SAH) Higher mortality rates when compared to ischemic stroke

Annually, approximately 700,000 individuals in the United States experience a cerebral infarction, and approximately 160,000 will die as a result of the stroke. Cerebrovascular disease is the third most common cause of death in adults and is one of the more commonly encountered causes of neurologic dysfunction Third most common cause of death after cancer and ischeamic heart disease EPIDEMIOLOGY

There are important racial and ethnic differences in incidence and mortality rates for ischemic stroke. The precise reasons for these differences are unclear, but genetic, geographic, dietary, and cultural factors have been considered. In addition, the incidence of risk factors for stroke such as hypertension, diabetes, and hypercholesterolemia differ among racial groups. ischemic stroke 85% is the most common type of infarction and Hemorrhagic stroke 15%. EPIDEMIOLOGY

There are important racial and ethnic differences in incidence and mortality rates for ischemic stroke. The precise reasons for these differences are unclear, but genetic, geographic, dietary, and cultural factors have been considered. In addition, the incidence of risk factors for stroke such as hypertension, diabetes, and hypercholesterolemia differ among racial groups. United States, ischemic stroke is the mostcommontype of infarction. EPIDEMIOLOGY

Primary causes of a cerebral hemorrhage include cerebral artery aneurysm, arteriovenous malformation, hypertensive hemorrhage, and trauma. The terms apoplexy, stroke, and paralytic stroke are commonly used to describe a sudden neurologic affliction that usually is related to the cerebral blood supply. The term stroke is used to describe a cerebral vascular event when neurologic deficits persist for at least 24 hours. CEREBRAL HEMORRHAGE

management of cerbrovascular disease

management of cerebrovascular disease Goals of Therapy • The immediate goal of therapy is to reestablish adequate blood flow to affected cerebral vessels. Longer-range objectives are to prevent reoclusion, decrease the risk of future symptomatic TIAs, and prevent cerebral infarction. management of cerebrovascular disease

History Ask for onset and progression of neurological symptoms – completed stroke or stroke in evolution History of previous TIAs History of hypertension & diabetes mellitus History of heart conditions like arrhythmias & prosthetic valves History of seizures, migraine, anticoagulant therapy& oral contraceptive use History of any hypercoagulable disorders like sickle cell anemia & polycythemia vera Substance abuse: cocaine, amphetamines

• Rapid recognition of stroke symptoms and immediate initiation of treatment are essential to the management of ischemic or hemorrhagic stroke. • Proper education regarding the symptoms of stroke is essential for any patient at increased risk for stroke. Patients should be instructed to seek immediate medical attention if they experience any weakness or paralysis, speech impairment, numbness, blurred vision or sudden vision loss, or altered level of consciousness. Patient Assessment

• Prognosis after ischemic stroke depends on factors including age, hypertension, coma, cardiopulmonary complications, hypoxia, and neurogenic hyperventilation. Neurologic deficits in stroke patients are not considered stable or fixed until at least 8 to 12 months have elapsed. Patient Assessment

Stroke Warning Signs Sudden weakness, paralysis, or numbness of the face, arm and the leg on one or both sides of the body Loss of speech, or difficulty speaking or understanding speech Dimness or loss of vision, particularly in only one eye Unexplained dizziness (especially when associated with other neurologic symptoms), unsteadiness, or sudden falls Sudden severe headache and/or loss of consciousness

Symptoms

Investigation Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Cerebral Angiography: identify responsible blood vessel Electrocardiogram (ECG): underlying heart conditions Echocardiogram: blood clot from heart Carotid Duplex: carotid artery stenosis Heart monitors, blood work and many more tests!! Investigation

primary prevention in AF

Drugs used in primary prevention

Treatment of acute stroke

Treatment of acute stroke

Treatment of hemorrhagic stroke

QUETIONS