Cerebrovascular disorders

One of the leading causes of mortality & morbidity

Stroke Rapidly developing loss of brain function,

lasting >24 hours or causing death Due to impaired blood supply A medical emergency- ‘Brain Attack’ Can be ischemic or hemorrhagic Risk factors- Advanced age HT, smoking, DM, raised LDL Previous h/o stroke or TIA A-fib, RHD, IE, post-MI mural thrombi

Classification & causes Ischemic- ~80% Thrombotic- atherosclerosis, lipohyalinosis,

vasculitis, dissection of aorta/carotid/vertebral artery Embolic- cardiac source- A-fib, RHD, IE, prosthetic

valve, post-MI mural thrombus Systemic hypoperfusion- watershed areas- shock Venous thrombosis- thrombophilia, pregnancy, OCP,

nephrotic syndrome, SLE, meningitis/mastoiditis Hemorrhagic- intracerebral- ~20% HT, aneurysm, AV malformation, amyloid angiopathy

Clinical features FAST- Facial weakness, Arm drift, Speech

impairment, don’t waste Time Symptoms depend on area of brain affected

by impaired blood supply Mostly unilateral symptoms- Cerebrum- C/L weakness, paresthesia, visual defect,

aphasia/apraxia/agnosia Brain stem- C/L long tract & I/L cranial nerve defect Cerebellum- vertigo, ataxia Associated altered sensorium, headache,

vomiting- more common with h’gic stroke

Management- urgent Time is of essence Dx- clinical + CT scan- h’age yes/no Ischemic stroke- within 3(?6) hours,

no risk factors for bleeding- thrombolysis with tPA

Others- no CT, no h’age on CT, duration >6 hours- aspirin + clopidogrel

Hemorrhagic stroke- surgery, if required depends on age, deficit, location & volume of bleed

Control blood sugar, adequate O2, IV fluids Reduce ICP- mannitol, dexamethasone, rest

Management- later Ischemic stroke- carotid US doppler or angio-

if severe stenosis, carotid stenting or endarterectomy or bypass

Hemorrhagic stroke- angiography- treat aneurysm/AV malformation

Identify & manage risk factors- Control HT, DM, weight Statins Low-dose aspirin ± clopidogrel Anticoagulants, if indicated Quit smoking & alcohol, active lifestyle

Treatment of HT in stroke HT causes stroke & stroke causes HT Unwanted overzealous reduction of BP may

worsen ischemia Ischemic- If tPA planned- reduce BP to <180/110 mm Hg If not- BP improves spontaneously over days, monitor Anti-HTives used if associated LVF/ACS/ARI/aortic dissection Long-term target- <130/80 mm Hg Hemorrhagic- Acutely- reduce BP by 20% Long-term target- <130/80 mm Hg

Rehabilitation Disability affects majority of stroke survivors Rehabilitation helps them return to

as normal a life as possible Components- Good nursing care- skincare, feeding, positioning Physiotherapy- to prevent complications & mobilise Speech & language therapy Occupational therapy- relearn activities of daily living Px- ~50% independent after 1 year

Transient ischemic attack- TIA Focal ischemic cerebral neurologic deficit,

that recovers completely within 24 hours TIA precede ~30% patients with stroke Cause- majority embolic, from IC artery/heart Manifestation- Carotid- pure motor hemiparesis of C/L face/arm/leg

± dysphasia, paresthesia, monocular vision loss Vertebrobasilar- vertigo, ataxia, diplopia, dysarthria Management- as for stroke

Lacunar stroke Due to occlusion of deep penetrating arteries Classic syndromes- Pure motor hemiparesis- posterior limb of internal capsule or

basis pontis Ataxic hemiparesis- posterior limb of IC/basis pontis &

corona radiata Dysarthria/clumsy hand- basis pontis Pure sensory- ventrolateral thalamus Mixed sensorimotor- thalamus & posterior limb of IC Management- as for stroke Px- better- ~3/4th independent at 1 year

Cerebral venous sinus thrombosis Rare stroke Due to thrombosis of dural venous sinuses s/s- headache, hemiparesis/dysarthria,

seizures, altered sensorium, raised ICP Dx- CT/MRI, with contrast Rx- heparin/LMWHwarfarin,

± thrombolysis, AEDs, reduce ICP, ?Abx Px- ~10% die & ~60% recover fully in 1 year

Hypertensive ICH Site & manifestation- Putamen- C/L hemiparesis, C/L conjugate gaze

paresis, altered sensorium, raised ICP Thalamus- C/L sensory loss, C/L hemiparesis,

aphasia/agnosia, eyes deviated down & inwards, unequal pupils, I/L ptosis & miosis

Pons- quadriparesis, altered sensorium-coma, decerebrate rigidity, pinpoint pupils that react to light

Cerebellum- ataxia, vertigo, raised ICP-vomiting, occipetal headache, I/L conjugate gaze paresis

Sub-arachnoid hemorrhage Bleed between arachnoid memb. & pia mater Majority due to rupture of aneurysm Characteristic ‘thunderclap’ headache ±

vomiting, seizure, altered sensorium, neck stiffness, neurologic deficit

Dx- CT scan, MRI, LP, angiography Rx- ABC, monitor, oral nimodipine for vasospasm,

urgent surgery or coiling/clipping of aneurysm, AED for seizure

Px- mortality ~40-50%