1. SCHEMATIC PATHOPHYSIOLOGY
Predisposing Factors: Precipitating Factors:
1) Age ۞ 1) Hypertension ۞
2) Heredity ۞ 2) Cigarette Smoking
3) Race 3) Diabetes Meliitus ۞
4) Sex ۞ 4) Carotid or other Artery Disease ۞
5) Prior Stroke, TIA or heart attack ۞ 5) Atrial Fibrillation
6) Socioeconomic Factors ۞ 6) Other heart disease
7) Sickle cell disease
8) Undesirable levels of cholesterol
9) Poor diet ۞
10) Physical inactivity
11) Obesity
12) Alcohol Abuse
13) Drug Abuse
Atherosclerosis
Formation of Plaque deposits
Thrombosis
Hypertensio Occlusion by major vessel
83

2. If managed: If not managed
Actual:
Possible:
Dx:
Dx: PET scan, MRI,
Cranial CT scan (6/16/08) Lysed or moved thrombus
cerebral angiography,
Capsuloganglionic bleed from the vessel
lumbar puncture, EEG/
Lacunar infarct,
ECG, skull x-ray,
Bilateral Internal Carotid
carotid ultrasonography
Ateriosclerosis
Doppler (6/16/08) Vascular wall becomes
TX: aspirin within 24 weakened and fragile
Mean flow velocities and
hrs, thrombolytics
pulsatility index of both
within 3 hours, carotid
anterior and posterior
stenting, hypothermia,
circulation within normal Leaking of blood from the
anticoagulants, surgical
limits fragile vessel wall
decompression
(hemicraniectomy),
EEG/ECG, skull x-ray,
carotid endartectomy
carotid ultrasonography
Guarded Prognosis
Cerebral Hemorrhage
Sx:, headache,
unconsciousness,
If managed: If not managed nausea/vomiting,
Dx: CT scan, MRI, cerebral angiography, visual
arteriography, disturbances
lumbar puncture, skull x-ray
Tx: chronic hypertensives, surgical
decompression, evacuation and
aspiration, administration of fresh frozen
Mass of blood forms and
plasma with fibrinogen or cryoprecipitate
grows
Decreased
Hematoma evacuation
ICP
Formation of cavity surrounded by dense gliosis 84

3. < 30 ml 30-60 ml > 60 ml
hemorrhage hemorrhage hemorrhage
Good prognosis Intermediate Poor prognosis
prognosis
Vasospasm of
tissue and arteries
Blood seeps into the Formation of small
ventricles and large clots
CEREBRAL
HYPOPERFUSION
Sx: dizziness,
Obstruction of CSF
confusion,
passageway
headache Impaired distribution of
oxygen and glucose
Accumulation of CSF in
the ventricles
Tissue hypoxia and
cellular starvation
Ventricles dilate behind
the point of obstruction Lodges unto
other cerebral Cerebral Ischemia
arteries
Increased ICP
Initiation of ischemic
cascade
If managed: If not managed
Ventriculostomy,
VP shunt, ICP Anaerobic metabolism by
Monitoring mitochondria
Alternative route Unrelieved
for return of CSF obstruction Production of oxygen free
in the circulation radicals and other reactive
Generates large amounts Failure production of oxygen species
of lactic acid adenosine triphosphatase
Compression of
brain tissues will Guarded
Metabolic Acidosis Failure of energy dependent
not occur Prognosis
process
(ion pumping) 85

4. Release of excitatory Damage to the blood
neurotransmitter glutamate vessel endothelium
Influx of calcium
Activates enzymes that Failure of
digest cell proteins, lipids mitochondria
and nuclear material
Further energy
depletion
Transient Ischemic Attack
If managed: If not managed
-t-PA (urokinase,
streptokinase)
-calcium channel Brain sustains an irreversible
blockers cerebral damage
Release of metalloprotrease
(zinc and calcium-dependent enzymes)
Guarded
Prognosis
Break down of collagen, hyaluronic acid and
other elements of connective tissue
Structural integrity loss of brain
tissue and blood vessels
Breakdown of the protective
Blood Brain Barrier
86

5. Cerebral edema
Vascular Congestion
Compression of tissue
Increased intracranial
pressure
Impaired perfusion and
function
Middle Anterior cerebral Posterior Internal Carotid Vertebrobasilar Anteroinferior Posteroinferior
Cerebral Artery artery CerebraI Artery Artery System Cerebellar cerebellar
Lateral Frontal Lobe Occipital lobe; Branches into Cerebellum and Cerebellum Cerebellum
hemisphere, anterior and ophthalmic, PCA, brain stem
frontal, parietal medial portion of anterior choroidal,
and temporal temporal lobe ACA, MCA
lobes, basal
ganglia
87

6. Sx: Sx:
Sx: Sx: Sx: Sx:
contralateral Ipsilateral Sx:
Contralateral Contralateral Mild Alternating
hemiparesis ataxia, facial Ataxia,
hemiparesis or hemiparesis, contralateral motor
with facial paralysis, paralysis of the
hemiplegia, foot and leg hemiparesis, weaknesses,
asymmetry, ipsilateral loss larynx and soft
unilateral deficits greater intention ataxic gait,
contralateral of sensation in palate,
neglect, altered than the arm, tremor, diffuse dysmetria,
sensory face, sensation ipsilateral loss
consciousness foot drop, gait sensory loss, contralateral
alterations, changes on of sensation in
, homonymous disturbances, pupillary hemisensory
homonymous trunk and face,
hemianopsia, contralateral dysfunction, impairments,
hemianopsia, limbs, contralateral on
inability to turn hemisensory loss of double vision,
ipsilateral nystagmus, body,
eyes toward alterations, conjugate homonymous
periods of Horner’s nystagmus,
affected side, deviation of gaze, hemianopsia,
blindness, syndrome, dysarthria,
vision changes, eyes toward nystagmus, nystagmus,
aphasia if tinnitus, Horner’s
dyslexia, affected side, loss of depth conjugate
dominant hearing loss syndrome,
dysgraphia, expressive perception, gaze,
hemisphere is hiccups and
aphasia, aphasia, cortical paralysis,
involved, Mild coughing,
agnosia, confusion, blindness, dysarthria,
Horner’s vertigo, nausea
memory deficits, amnesia, flat homonymous memory loss,
syndrome, and vomiting
vomiting affect, apathy, hemianopsia, disorientation,
carotid bruits
shortened perseveration, drop attacks,
attention span, dyslexia, tinnitus,
loss of mental memory hearing loss,
acuity, apraxia, deficits, visual vertigo,
incontinence hallucinations dysphagia,
coma
88

7. If managed: If not managed:
Palliative care-
Frequent vital sign and
neurovital signs,
intubation, mechanical
ventilation, Continued insufficiency of blood
vasodilators, osmotic flow
diuretics,
ventriculostomy, ICP
monitoring
Further compression of tissues
Poor cerebral perfusion
Coma
Poor improvement
Cerebral Death
Poor
Prognosis
Loss of neural feedback
mechanisms
Cessation of physiologic
functions
89

8. Cardiovascular Pulmonary GUT Other systems
GIT
System System
Relaxation of
intestines and Sx: restlessness,
Loss of cardiac Relaxation of abnormal
muscle function sphincters thermoregulation,
venous valves
mental confusion,
increased secretions,
decreased urinary
output.
Sx: Sx:
bradycardi hypotensio
Loss of bowel
Failure of accessory Loss of lung control
Decreased muscles for breathing movement
cardiac output Neurogenic bladder Loss of sphincter
control
Sx:
apnea
Cardiopulmonary arrest
Systemic Failure
DEATH 90