Case cva by dr guruprasad shetty

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Case cva by dr guruprasad shetty

  1. 1. By….. Dr Guruprasad shetty. Padubidri.. Cerebro vascular accident
  2. 2. Definitions <ul><li>Cerebro vascular accident (CVA): a syndrome characterized by the gradual or rapid, onset of neurological deficits that fits a known vascular territory </li></ul><ul><ul><li>Transient ischemia attack (TIA): </li></ul></ul><ul><ul><li>Stroke in evolution: </li></ul></ul>
  3. 3. Blood Supply to the Brain
  4. 4. Anterior Circulation <ul><li>Int. Carotid </li></ul><ul><ul><li>Arises from common carotid </li></ul></ul><ul><ul><li>Branches : </li></ul></ul><ul><ul><li>Anterior cerebral, </li></ul></ul><ul><ul><li>Anterior communicating, </li></ul></ul><ul><ul><li>Middle cerebral, </li></ul></ul><ul><ul><li>Posterior communicating. </li></ul></ul>
  5. 5. Posterior Circulation <ul><li>Verebral </li></ul><ul><ul><li>arises from subclavian and joins at lower border of pons to form basilar </li></ul></ul><ul><ul><li>Branches : </li></ul></ul><ul><ul><li>posterior cerebral, </li></ul></ul><ul><ul><li>superior cerebellar, </li></ul></ul><ul><ul><li>posterior inferior cerebellar, </li></ul></ul><ul><ul><li>anterior spinal </li></ul></ul>
  6. 6. <ul><li>Circle of Willis </li></ul><ul><ul><li>Anastomosis of arteries at base of brain </li></ul></ul><ul><ul><li>Permits collateral circulation </li></ul></ul><ul><ul><li>Formed by 6 vessels </li></ul></ul><ul><ul><ul><li>Internal carotid A. </li></ul></ul></ul><ul><ul><ul><li>Anterior and posterior cerebral A. </li></ul></ul></ul><ul><ul><ul><li>Anterior communicating A </li></ul></ul></ul><ul><ul><ul><li>Two posterior communicating A. </li></ul></ul></ul>
  7. 7. <ul><li>Anterior Cerebral (blue) </li></ul><ul><ul><li>Basal ganglia, corpus callosum, medial surface of cerebral hemispheres; superior surface frontal and parietal lobes </li></ul></ul><ul><li>Middle Cerebral (red) </li></ul><ul><ul><li>Frontal lobe, parietal lobe, cortical surface of the temporal lobe </li></ul></ul><ul><li>Posterior Cerebral (green) </li></ul><ul><ul><li>Part of diencephalon and temporal lobe, occipital lobe </li></ul></ul>
  8. 9. Conditions Caused by Occlusion <ul><li>Anterior Cerebral </li></ul><ul><li>Middle Cerebral </li></ul><ul><li>Posterior Cerebral </li></ul><ul><li>Contralateral hemiplegia (leg greater than arm) </li></ul><ul><li>Aphasia (dominant hemisphere) </li></ul><ul><li>Contralateral hemiplegia (arm, face greater than leg), sensory loss, visual loss </li></ul>
  9. 10. SMA Primary Motor cortex Primary Visual cortex (Broca’s area) Primary auditory ortex (Wernicke’s area) Angular gyrus (Arcuate Fasciculus) Brain areas involved
  10. 11. <ul><li>Corticospinal Damage </li></ul><ul><ul><ul><li>Hemiparesis : Weakness </li></ul></ul></ul><ul><li>Cerebellar Damage </li></ul><ul><ul><ul><li>Ataxia </li></ul></ul></ul><ul><ul><ul><li>Timing Issues </li></ul></ul></ul><ul><ul><ul><li>Motor Learning </li></ul></ul></ul><ul><li>Basal Ganglia Damage </li></ul><ul><ul><ul><li>Parkinson’s Disease </li></ul></ul></ul><ul><ul><ul><li>Huntingdon’s Chorea </li></ul></ul></ul><ul><li>Cortical Damage </li></ul><ul><ul><ul><li>Apraxia : loss of ability to carry out purposeful movements in the absence of sensory or motor impairment </li></ul></ul></ul>
  11. 12. Classification of Stroke Stroke Primary Hemorrhagic (20% of Strokes) Primary Ischemic (80% of Strokes) Thrombotic 53% Embolic 31% Intracerebral Hemorrhage 10% Subarachnoid Hemorrhage 6%
  12. 13. Primary Ischemic Stroke
  13. 14. <ul><li>Obstruction </li></ul><ul><ul><li>Hypertension, </li></ul></ul><ul><ul><li>Diabetes, </li></ul></ul><ul><ul><li>Cardiac disease, </li></ul></ul><ul><ul><li>Hypercholesterolemia, </li></ul></ul><ul><ul><li>Atherosclerosis, </li></ul></ul><ul><ul><li>Vasculitis </li></ul></ul>Thrombus
  14. 15. Embolus <ul><li>Atrial fibrillation, </li></ul><ul><li>Valvular heart disease, </li></ul><ul><li>Cardiomyopathy, </li></ul><ul><li>Heart disease, </li></ul><ul><li>Air/Fat/Infectious fragments </li></ul>Debris detaches  flows and lodges in artery
  15. 16. C E R E B R A l A N E U R Y S M s
  16. 17. Pathogenesis Ischemic Cascade
  17. 18. <ul><li>Blockage of a cerebral blood vessel reduces CBF </li></ul><ul><li>Ischemic-hypoxic brain damage </li></ul><ul><li>Disturbance in glucose utilization </li></ul><ul><li>Depletion of ATP </li></ul><ul><li>Depletion of neurotransmitter substances </li></ul><ul><li>Membrane depolarization </li></ul><ul><li>Influx of sodium and water and calcium </li></ul><ul><li>Release of glutamate </li></ul><ul><li>Cell death </li></ul>
  18. 19. Effects of Reduced CBF Normal ml/100g/min 50 – 55 25 20 15 8 Ischemia Edema Loss of Na/K+ pump ↑ lactate electrical failure; ↓ ATP activity Penumbra Infarction Cell Death
  19. 20. Cerebral Infarction
  20. 21. Facial Weakness? Where is my lesion: summary? Spinal cord No Yes FW same side as limb W? Pons No Internal Capsule Yes Yes Leg and arm equal? No Cortical signs? Ipsilateral damage Contralateral damage Cortex Corona Radiata Yes No
  21. 22. Stroke Management <ul><li>Patient presents with change in LOC, focal neurological deficit and severe headache </li></ul><ul><li>Obtain history and physical </li></ul><ul><ul><li>Duration of symptoms </li></ul></ul><ul><ul><li>Time from onset </li></ul></ul><ul><li>Evaluate airway, breathing and circulation </li></ul><ul><li>Emergency non-contrast head Ct scan </li></ul>
  22. 23. Stroke Mimickers <ul><li>Seizures </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Systemic infections </li></ul><ul><li>Toxic encephalopathy </li></ul><ul><li>Presyncope or syncope </li></ul><ul><li>Vertigo </li></ul><ul><ul><li>Benign positional vertigo </li></ul></ul><ul><li>Intracranial tumors/ hematomas </li></ul><ul><li>Migraine </li></ul>
  23. 24. Diagnostic Studies <ul><li>Laboratory: PT/PTT, CBC, serum glucose </li></ul><ul><li>Cerebral angiography: identifies aneurysms, vasospasm and vessel abnormalities </li></ul><ul><li>MRI: identifies hemorrhage, edema or causative factors depending on etiology </li></ul><ul><li>Doppler Studies: reveals carotid disease </li></ul><ul><li>EEG: reveals focal areas of decreased function around lesion </li></ul><ul><li>ECG: arrhythmias, myocardial infarction </li></ul>
  24. 25. Initial Management <ul><li>Ischemic Stroke </li></ul><ul><ul><li>Begin IV hydration </li></ul></ul><ul><ul><li>Supplemental O2 </li></ul></ul><ul><ul><li>Manage BP </li></ul></ul><ul><ul><li>Treat hyperglycemia </li></ul></ul><ul><ul><li>Treat hyperthermia </li></ul></ul><ul><ul><li>Treat seizures </li></ul></ul><ul><ul><li>Treat if T-PA therapy planned </li></ul></ul><ul><li>Hemorrhagic Stroke </li></ul><ul><ul><li>SAH vs. ICH </li></ul></ul><ul><ul><ul><li>Neurosurgical consult </li></ul></ul></ul><ul><ul><li>Begin IV hydration </li></ul></ul><ul><ul><li>Supplemental O2 </li></ul></ul><ul><ul><li>Treat intracranial pressure </li></ul></ul><ul><ul><li>Manage BP </li></ul></ul><ul><ul><li>Treat hyperglycemia </li></ul></ul><ul><ul><li>Treat hyperthermia </li></ul></ul><ul><ul><li>Treat seizures </li></ul></ul><ul><ul><li>Begin Nimodipine (SAH) </li></ul></ul><ul><ul><li>Angiogram (SAH) </li></ul></ul>
  25. 26. Management of Blood Pressure <ul><li>Ischemic </li></ul><ul><ul><li>Treat SBP > 220 or DBP > 120 mmHg after repeated measurements </li></ul></ul><ul><ul><li>Treat if cardiac ischemia, heart failure or aortic dissection is present </li></ul></ul><ul><ul><li>Treat if T-PA therapy planned </li></ul></ul><ul><li>Hemorrhagic </li></ul><ul><ul><li>Treat severe elevations with IV drip </li></ul></ul><ul><ul><ul><li>SBP > 230 or DBP > 120 mmHg </li></ul></ul></ul><ul><ul><li>Treat moderate elevations with IVP </li></ul></ul><ul><ul><ul><li>SBP > 180 or DBP > 105 mmHg </li></ul></ul></ul><ul><ul><li>Treat elevated blood pressure to approximate premorbid BP </li></ul></ul>
  26. 27. Intravenous Thrombolysis Tissue Plasminogen Activator (tPA) <ul><li>Inclusion Criteria </li></ul><ul><ul><li>Age < 18 </li></ul></ul><ul><ul><li>Ischemic stoke by clinical presentation </li></ul></ul><ul><ul><li>Persistent deficits beyond an isolated sensory deficit or ataxia </li></ul></ul><ul><ul><li>CT scan negative for hemorrhage </li></ul></ul><ul><ul><li>Treatment initiated within 3 hours of symptom onset </li></ul></ul><ul><li>Exclusion Criteria </li></ul><ul><ul><li>More than 3 hours since symptom began </li></ul></ul><ul><ul><li>Rapidly improving deficits </li></ul></ul><ul><ul><li>CT scan shows substantial edema, mass effect or shift </li></ul></ul><ul><ul><li>PT > 15 seconds; INR > 1.7 or prolonged PTT </li></ul></ul><ul><ul><li>Platelet count < 100, 000 </li></ul></ul><ul><ul><li>SBP > 185 or DBP > 110 </li></ul></ul><ul><ul><li>Prior stoke or serious head trauma within 3 months </li></ul></ul><ul><ul><li>Prior ICH </li></ul></ul><ul><ul><li>History of GI/GU bleeding </li></ul></ul><ul><ul><li>Seizures at onset of stroke </li></ul></ul><ul><ul><li>Symptoms suggest SAH </li></ul></ul>
  27. 28. Administration of t-PA <ul><li>Treatment should begin immediately </li></ul><ul><li>Dosing: 0.9 mg/kg IV over one hour </li></ul><ul><ul><li>10% IV bolus over 1 minute </li></ul></ul><ul><ul><li>Maximum dose is 90 mg </li></ul></ul><ul><li>Aspirin recommended 160 – 325 mg/day for those unable to receive t-PA </li></ul>
  28. 29. Complications of t-PA <ul><li>Intracranial hemorrhage </li></ul><ul><li>Systemic bleeding </li></ul><ul><li>Reocclusion </li></ul><ul><li>New stroke </li></ul><ul><li>Death </li></ul>
  29. 30. Surgical Treatment Craniotomy Aneurysm Clipping Aneurysm Coiling Endovascular Procedures
  30. 31. Complications <ul><li>Neurological </li></ul><ul><ul><li>Seizures 10% </li></ul></ul><ul><ul><li>Increased ICP </li></ul></ul><ul><li>Pulmonary </li></ul><ul><ul><li>Aspiration </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><li>Cardiovascular </li></ul><ul><ul><li>Cardiac arrhythmias </li></ul></ul><ul><ul><li>DVT </li></ul></ul><ul><li>GI </li></ul><ul><ul><li>GI bleeding </li></ul></ul><ul><ul><li>Urinary tract infection </li></ul></ul><ul><ul><li>Bowel impaction </li></ul></ul><ul><ul><li>Malnutrition </li></ul></ul><ul><li>Musculoskeletal </li></ul><ul><ul><li>Impaired mobility </li></ul></ul><ul><ul><li>Contractures </li></ul></ul><ul><ul><li>Heterotrophic ossification </li></ul></ul><ul><ul><li>Spasticity </li></ul></ul><ul><li>Psychosocial </li></ul><ul><ul><li>Depression – 60% </li></ul></ul><ul><ul><li>Loss of self esteem </li></ul></ul>
  31. 32. Major Risk Factors Risk Factor Prevalence HTN Heart Disease 35% 10 – 120 % Previous CVA Carotid Bruit 2% 4% Diabetes Smoking 4-6% 25%
  32. 33. Unmodifiable Risk Factors for Stroke Age Incidence of stroke more than doubles each decade after age 55 Sex Incidence is about 30% higher for men than women
  33. 34. Rehabilitation <ul><li>Goals </li></ul><ul><ul><li>Regain patient independence </li></ul></ul><ul><ul><li>Maximize abilities in all ADL </li></ul></ul><ul><li>Assessment of disability </li></ul><ul><ul><li>Cognition and level of consciousness </li></ul></ul><ul><ul><li>Swallow and nutritional status </li></ul></ul><ul><ul><li>Speech </li></ul></ul><ul><ul><li>Motor strength and coordination </li></ul></ul><ul><ul><li>Gait </li></ul></ul>
  34. 35. Emerging Therapies <ul><li>Intra-arterial t-PA </li></ul><ul><li>Other antithrombotic agents </li></ul><ul><ul><li>IV heparin </li></ul></ul><ul><ul><li>Abciximab: platelet glycoprotein antagonist </li></ul></ul><ul><ul><li>Argatroban: direct thrombin inhibitor </li></ul></ul><ul><li>Neuroprotective agents </li></ul><ul><ul><li>Glutamate antagonists - Calcium antagonists </li></ul></ul><ul><ul><li>Opiate antagonists - GABA-A agonists </li></ul></ul><ul><ul><li>Antioxidants - Neuroperfusion </li></ul></ul><ul><ul><li>Mild hypothermia - Blood substitutes </li></ul></ul><ul><ul><li>- Kinase inhibitors </li></ul></ul>
  35. 36. AÉrÉÑuÉåïSÉå AqÉ×iÉÉlÉÉqÉç
  36. 39. <ul><li>Treatment is planned according to – </li></ul><ul><li>Causation of illness </li></ul><ul><li>Pathological factors involved & </li></ul><ul><li>Clinical presentation </li></ul>
  37. 40. Remember……. <ul><li>Stroke is preventable </li></ul><ul><li>Neural damage after stroke is progressive </li></ul><ul><li>There is a therapeutic window for optimal treatment </li></ul><ul><li>Stroke is an emergency </li></ul><ul><li>Effective therapies currently exist </li></ul><ul><li>New therapies are currently being developed </li></ul>
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