Cerebrovascular ds

1. Cerebrovascular Disease
Lecture class
Dr Rahul Jankar MD DM,
MGM college

2. Cerebrovascular disease ?
Stroke

3. Definition of Stroke
• Astroke 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 causeof severe physicaldisability.
References : Harrison 18th ed

5. Stroke types
• Stroke is classified into two majortypes:
1. Ischemic stroke:
Brain ischemia due to thrombosis,
embolism or hypoperfusion
2. Hemorrhagic stroke: Brain hemorrhage
due to intracerebral hemorrhage or subarachnoid
hemorrhage.
• Approximately 80 %of strokes are due to ischemic cerebral
infarction and 20 %to brainhemorrhage.

6. Stroke types ?

7. 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 accessto aparticular brain region.
•
Systemichypoperfusion is a more general
circulatory problem, manifesting itself in the brain and
perhaps otherorgans.
• References1: Caplan LR.Basicpathology, anatomy, and pathophysiology of stroke. In: Caplan's Stroke:
AClinical Approach, 4th ed, Saunders Elsevier, Philadelphia 2009.p.22.

8. Hemorrhagic stroke

9. Hemorrhagic stroke: types
•
1. Intracerebral hemorrhage refers to bleeding directly into
the brain parenchyma
2. Subarachnoid hemorrhage refers to bleeding into the
cerebrospinal fluid within the subarachnoid space that
surrounds the brain
• Reference1: Caplan LR.Intracranial branch atheromatous disease: a neglected, understudied, and
underused concept. Neurology 1989; 39:1246.

11. Diagnosis?
• Clinical
• Investigation

12. Clinical ?
• Isthere any neurological deficit ?
• Isthere any risk factor for vascular disease?

13. STROKERISKFACTORS
• Age
• Gender (male >female)
• Race(Afro-Caribbean >Asian > European)
• Heredity
• Previous vascular event, e.g. MI, strokeor
peripheral embolism
• High fibrinogen

14. STROKERISKFACTORS
• High blood pressure
• Heart disease(atrial fibrillation, HF
,
endocarditis)
• Diabetes mellitus
• Hyperlipidaemia
• Smoking,Excessalcohol consumption
• Polycythaemia
• Oral contraceptives

15. • Cerebral infarction is mostly due to
thromboembolic disease
secondary atherosclerosis in
the major arteries.
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.

16. Hemorrhagic stroke : RiskFactor

17. Cincinnati Prehospital StrokeScale
1. Facialdroop: Havethe person smile or show his or herteeth.
•Normal: Both sides of face moveequally
•Abnormal: Oneside of face does notmove aswell asthe other (or at all)
2. Arm drift:
•Normal: Both arms move equally or not atall
•Abnormal: One arm does not move, or one arm drifts down compared with the
other side
3.Speech:
•Normal: Patient usescorrect words with noslurring
•Abnormal: Slurred or inappropriate words ormute
Patients with 1 of these 3 findings asanew event have a72%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,EvensonKR(2005). "Directed useof the Cincinnati Prehospital StrokeScaleby laypersons". PrehospEmergCare9 (3): 292–6

18. Investigations ?
• Imaging

19. 7 questions ?
1. Isthis avascular lesion ?
CT/MRI

20. CTHEAD
• Imaging

21. 7 questions ?
2. Isit ischaemic orhaemorrhagic?
CT/MRI

22. 7 questions ?
3. Isit asubarachnoidhaemorrhage?
CT/MRI

23. SubArachnoid Hemorrhage

24. 7 questions ?
4. Isthere any cardiac source of embolism?
ECG/ECHO

25. ECG:Afib

26. 7 questions ?
5. What is the underlying vasculardisease?
• Duplex ultrasound of carotids
• Magnetic resonance
angiography(MRA)
• CTangiography
(CTA) Contrast
angiography

27. 7 questions ?
6. What are the riskfactors?
Full blood count
Cholesterol
Blood glucose

28. 7 questions ?
7. Isthere an unusualcause?
Rule out
BleedingDisorders/
Thrombophillic
ds/ESR

29. References
• Harrison’s 18thedition
• Davidsons20thed
• Uptodate 20.3
• Emedicine.com