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