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Cerebrovascular Diseases Alina Valdes, M.D.
Stroke - Background ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Risk Factors for Ischemic Strokes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cerebral Circulation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Physiology ,[object Object],[object Object],[object Object],[object Object],[object Object]
Ischemic Stroke ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Causes of Acute Cerebral Ischemia   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Transient Ischemic Attack (TIA) ,[object Object],[object Object],[object Object]
Stroke - Classes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Clinical Presentations of Acute Stroke ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Left (Dominant) Hemisphere Stroke: Common Pattern ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Right (Non-dominant) Hemisphere Stroke: Common Pattern ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Brain Stem / Cerebellum / Posterior Hemisphere Stroke: Common Pattern ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Small Subcortical Hemisphere or Brain Stem Stroke: Common Pattern ,[object Object],[object Object],[object Object],[object Object]
Differential Diagnosis of Stroke ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Tests for the Emergent Evaluation of the Patient With Acute Ischemic Stroke ,[object Object],[object Object],[object Object],[object Object]
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The NIH Stroke Scale ,[object Object]
IF ANY ITEM IS LEFT UNTESTED, A DETAILED EXPLANATION MUST BE CLEARLY WRITTEN ON THE FORM. ALL UNTESTED ITEMS WILL BE REVIEWED BY THE MEDICAL MONITOR, AND DISCUSSED WITH THE EXAMINER BY TELEPHONE.   Instructions Scale Definition Score 1a. Level of Consciousness: The investigator must choose a response, even if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation . ,[object Object],[object Object],[object Object],[object Object],         ____
1b. LOC Questions: The patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues. ,[object Object],[object Object],[object Object],[object Object],     ____ 1c. LOC Commands: The patient is asked to open and close the eyes and then to grip and release the non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to them (pantomime) and score the result (i.e., follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. ,[object Object],[object Object],[object Object],[object Object],[object Object],       ____
2. Best Gaze: Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored but caloric testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV or VI) score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness or other disorder of visual acuity or fields should be tested with reflexive movements and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy. ,[object Object],[object Object],[object Object],[object Object],[object Object],       ____
3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat as appropriate. Patient must be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia is found. If patient is blind from any cause score 3. Double simultaneous stimulation is performed at this point. If there is extinction patient receives a 1 and the results are used to answer question 11. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],       ____ 4. Facial Palsy: Ask, or use pantomime to encourage the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barrier obscures the face, these should be removed to the extent possible. ,[object Object],[object Object],[object Object],[object Object],       ____
5 & 6. Motor Arm and Leg: The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine) and the leg 30 degrees (always tested supine). Drift is scored if the arm falls before 10 seconds or the leg before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder or hip may the score be "9" and the examiner must clearly write the explanation for scoring as a "9". ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],     ____ ____   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],                       ____ ____  
7. Limb Ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, insure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion may the item be scored "9", and the examiner must clearly write the explanation for not scoring. In case of blindness test by touching nose from extended arm position. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],     ____   ____ ____ ____
8. Sensory: Sensation or grimace to pin prick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas [arms (not hands), legs, trunk, face] as needed to accurately check for hemisensory loss. A score of 2, "severe or total," should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will therefore probably score 1 or 0. The patient with brain stem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic score 2. Patients in coma (item 1a=3) are arbitrarily given a 2 on this item. ,[object Object],[object Object],[object Object],[object Object],[object Object],           ____
9. Best Language: A great deal of information about comprehension will be obtained during the preceding sections of the examination. The patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet, and to read from the attached list of sentences. Comprehension is judged from responses here as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in coma (question 1a=3) will arbitrarily score 3 on this item. The examiner must choose a score in the patient with stupor or limited cooperation but a score of 3 should be used only if the patient is mute and follows no one step commands . ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],                   ____
  10. Dysarthria: If patient is thought to be normal an adequate sample of speech must be obtained by asking patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barrier to producing speech, may the item be scored "9", and the examiner must clearly write an explanation for not scoring. Do not tell the patient why he/she is being tested. ,[object Object],[object Object],[object Object],[object Object],       ____ 11. Extinction and Inattention (formerly Neglect): Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. ,[object Object],[object Object],[object Object],[object Object],[object Object],       ____
Additional item, not a part of the NIH Stroke Scale score. A. Distal Motor Function: The patient's hand is held up at the forearm by the examiner and patient is asked to extend his/her fingers as much as possible. If the patient can't or doesn't extend the fingers the examiner places the fingers in full extension and observes for any flexion movement for 5 seconds. The patient's first attempts only are graded. Repetition of the instructions or of the testing is prohibited.  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],                   ____   ____
Primary Stroke Prevention ,[object Object],[object Object],[object Object],[object Object],[object Object]
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Management of Acute Stroke   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Extensive right-sided cerebral infarction  (left side of picture) demonstrated by unenhanced CT scan, performed 4 days after the onset of stroke. There is no evidence of hemorrhage. High-quality CT scanners allow diagnosis of cerebral infarction within 6-8 hours of onset.
Cerebral embolism  in a patient following cardiac surgery, demonstrated by unenhanced CT scan. The open arrowhead points to a high-density embolus within the distal right internal carotid artery; the filled arrowhead points to a similar embolus in the right middle cerebral artery. There is extensive hypodensity in the right middle cerebral artery distribution, reflecting an extensive area of infarction.
Right-sided facial palsy resulting from stroke.   The patient also had right hemiplegia and complete aphasia. The signs are those of upper motor neuron lesion. The limbs are at first flaccid and areflexic, but after a variable period the reflexes recover and become exaggerated, and an extensor plantar response appears. Weakness in the face and elsewhere may recover gradually over a variable period of time.
Loss of postural stability is common following stroke.   When the non-dominant hemisphere is involved, walking apraxia and loss of postural control are usually apparent. The patient is unable to sit upright and tends to fall sideways. Appropriate support with pillows or cushions should be provided.
Intracerebral Hemorrhage ,[object Object],[object Object],[object Object],[object Object],[object Object]
Causes of Spontaneous Intracerebral Hemorrhage (ICH) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Diagnosis, Management, and Prognosis of ICH ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Hemorrhagic cerebral infarction   demonstrated by unenhanced CT scan one day after the onset of stroke. Note the high-density hemorrhage within the low density of the edematous, infarcted region in the right hemisphere. Hemorrhage is evident from its onset on CT scanning.
Intracranial Aneurysms ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Right cavernous carotid aneurysm   (arrowed), shown on coronal MRI. The signal void at the periphery of the aneurysm represents flowing blood, while the intensity in the central portion may represent either a clot or slowly flowing blood. MRI may demonstrate aneurysms clearly, but is much less successful than CT at demonstrating the presence or absence of blood in the subarachnoid space.
Berry aneurysm on the anterior communicating artery (a).  The angiogram also shows that the anterior cerebral artery (b) is in spasm.
Subarachnoid Hemorrhage ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Hunt and Hess Classification of Subarachnoid Hemorrhage ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Subarachnoid hemorrhage from an anterior communicating artery aneurysm.   This uncontrasted CT scan shows areas of increased density representing blood in the interhemispheric fissure (arrows) and the septum pellucidum (arrowheads). A lesser amount of blood is present in the sylvan fissures and the perimesencephalic cistern.
Vascular Malformations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Left parietal arteriovenous malformation,  shown in an anteroposterior view of an internal carotid angiogram. Bleeding from AVM is usually less severe than that from aneurysms, but their size may lead to other symptoms including epilepsy.
Glasgow Outcome Scale (GOS) ,[object Object],[object Object],[object Object],[object Object],[object Object]
Infarction in CT Imaging of the Brain in Acute Stroke   ,[object Object]
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Infarction in MRI of the Brain in Acute Stroke ,[object Object]
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Hemorrhage in MRI of the Brain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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Cva

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  • 55. Extensive right-sided cerebral infarction (left side of picture) demonstrated by unenhanced CT scan, performed 4 days after the onset of stroke. There is no evidence of hemorrhage. High-quality CT scanners allow diagnosis of cerebral infarction within 6-8 hours of onset.
  • 56. Cerebral embolism in a patient following cardiac surgery, demonstrated by unenhanced CT scan. The open arrowhead points to a high-density embolus within the distal right internal carotid artery; the filled arrowhead points to a similar embolus in the right middle cerebral artery. There is extensive hypodensity in the right middle cerebral artery distribution, reflecting an extensive area of infarction.
  • 57. Right-sided facial palsy resulting from stroke. The patient also had right hemiplegia and complete aphasia. The signs are those of upper motor neuron lesion. The limbs are at first flaccid and areflexic, but after a variable period the reflexes recover and become exaggerated, and an extensor plantar response appears. Weakness in the face and elsewhere may recover gradually over a variable period of time.
  • 58. Loss of postural stability is common following stroke. When the non-dominant hemisphere is involved, walking apraxia and loss of postural control are usually apparent. The patient is unable to sit upright and tends to fall sideways. Appropriate support with pillows or cushions should be provided.
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  • 67. Hemorrhagic cerebral infarction demonstrated by unenhanced CT scan one day after the onset of stroke. Note the high-density hemorrhage within the low density of the edematous, infarcted region in the right hemisphere. Hemorrhage is evident from its onset on CT scanning.
  • 68.
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  • 70. Right cavernous carotid aneurysm (arrowed), shown on coronal MRI. The signal void at the periphery of the aneurysm represents flowing blood, while the intensity in the central portion may represent either a clot or slowly flowing blood. MRI may demonstrate aneurysms clearly, but is much less successful than CT at demonstrating the presence or absence of blood in the subarachnoid space.
  • 71. Berry aneurysm on the anterior communicating artery (a). The angiogram also shows that the anterior cerebral artery (b) is in spasm.
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  • 75. Subarachnoid hemorrhage from an anterior communicating artery aneurysm. This uncontrasted CT scan shows areas of increased density representing blood in the interhemispheric fissure (arrows) and the septum pellucidum (arrowheads). A lesser amount of blood is present in the sylvan fissures and the perimesencephalic cistern.
  • 76.
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  • 78. Left parietal arteriovenous malformation, shown in an anteroposterior view of an internal carotid angiogram. Bleeding from AVM is usually less severe than that from aneurysms, but their size may lead to other symptoms including epilepsy.
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