cerebrovascular accident/ stroke

1. Stroke / Cerebro-Vascular
Accident (CVA)
By,
Ms. Ekta S Patel
Assistant Professor

2. Introduction:
× Cerebrovascular accident: The sudden
death of some brain cells due to lack
of oxygen when the blood flow to the
brain is impaired by blockage or
rupture of an artery to the brain. A CVA
is also referred to as a stroke.

3. Definition:

4. × “Focal neurological
deficit due to a local
disturbance in blood
supply to the brain. Its
onset is usually
abrupt, but may
extend over a few
hours or longer.”
WHO,
1971

5. × Its an focal neurological
deficit resulting from
cerebrovascular
disease and lasting
more than 24 hours or
causing earlier death.

6. Stroke is not
diagnosis, but a
clinical syndrome
with numerous
causes.

7. Classification:
CVA
Ischemic stroke
(87%)
Primary
hemorrhagic
stroke (13%)

8. Ischemic stroke (87%)
Atherosclerotic disease (20%)
(Large artery thrombosis
stroke)
Lunar stroke (small penetrating
artery thrombosis stroke) (25%)
Cardiogenic embolic stroke (20%)
Cryptogenic (30%)
Other (5%)

9. Primary
hemorrhagic
stroke (13%)
Subarachnoid
hemorrhage
(7%)
Intra-cerebral
hemorrhage
(8%)

10. Etiology:
× Smoking
× High blood pressure
(hypertension)
× Obesity
× High cholesterol levels
× Diabetes
× Excessive alcohol intake
× Atrial fibrillation.
Ischemic
stroke

11. × Being overweight
× Drinking excessive amounts of
alcohol
× Smoking
× A lack of exercise
× Stress
× Brain aneurysm
Hemorrhagic
stroke

13. Pathophysiology

15. Neuronal death following ischemia will be a result of necrotic,
apoptotic and necroptotic mechanisms depending on the severity of
insult.
Further, the opening of mitochondrial permeability transition pore
releases various proapoptotic molecules including cytochrome C that
activate apoptotic cell death.
Reperfusion aggravates the neuronal damage by forming free radicals
that damage the membranes, proteins and DNA.
This impairs the neuronal homeostasis leading to activation of several
calcium dependent pathways that include proteases and nucleases.
Activation of glutamate receptors following ischemic stroke leads to
excitotoxicity and calcium influx.

18. Common sites of hemorrhagic
stroke:

19. × Putamen: 35 % - 50%
× Subcortical white matter 30%
× Thalamus: 10%-15%
× Pons 5%-12%
× Cerebellar white matter <5%

20. Common sites of ischemic
stroke

21. Clinical Manifestation Of
Specific Cerebral Artery
Involvement

22. Middle cerebral artery involvement:
× Contra lateral paralysis (hemiplegia)
× Contralateral anesthesia loss of
proprioception, fine tough, localization
(hemiperesis.)
× Aphasia (Difficulty in communication )
× Dysmetria (difficulty in coordination)
× Conjugate gaze paralysis (inability to
move eyeball in some direction)

23. Anterior cerebral artery involvement
× 1. occlusion of stem
× 2. occlusion of distal anterior communicating
artery:
× Contralateral sensory and motor deficit of foot
and leg
× Contralateral weakness of proximal upper
extremities
× Urinary incontinence
× Apraxia (difficulty in movement on command)
×

24. × Personality changes: flat affect, loss of
spontaneity and distractibility
× Possible cognitive impairment

25. Posterior cerebral artery involvement
1. Thalamogeniculate branch occlusion
× Contralateral sensory loss
× Temporary hemiparesis
× Homonymous hemianopsia
× 2. paramedin branch occlusion: central
midbrain and thalamus:
× Webber’s syndrome
× Contralateral hemiplegia

26. × Incomplete homonymous heminopsia
× Dysphasia (Difficulty in generation of
speech)
× Disorientation
× Visual disturbances
× Dyscalculia: objects and inability to
count
× Possible memory loss

27. Vertebrobasilar artery involvement
× Bilateral motor and sensory deficit of
all extermities
× Ipsilateral Horner’s syndrome: miosis,
ptosis, decrease sweating
× Hoarsness
× Dysphagia
× Nystagmus, diplopia, blindness
× Nausea and vomiting
× Ataxia

28. Common symptoms

29. Motor
× Hemiparesis
× Hemiplagia
× Dysphagia
× Dysarthria (slurred speech)

30. Bowel and bladder
× Frequency, urgency, urinary
incontnance
× Constipation

31. Language
× Non fluent aphasia (motor /expressive
aphasia)
× Fluent aphasia (sensory/ receptive
aphasia)
× Alexia: inability to understand written
words
× Agraphia : inability to express self in
written

32. Sensory perceptual
× Diminished response to superficial
sensation : touch, pain, hot, cold
× Diminished proprioseption: knowledge
of body parts in environment
× Visual defects

33. × Perceptual deficit:
o Unilateral neglect syndrome: fail to
report, respond or orient to meaningful
stimuli.
o Apraxia : inability to perform learned or
familiar movement on commands
o Agnosia: loss of ability to identify objects
or people
o Anosognosia: unaware of existance.

35. × Depression
× Memory loss
× Short attention of span
× Early distractibility
× Loss of reasoning, judgment and
abstract thinking ability.

36. Diagnostic Evaluation:

40. × Physical examination
× Neurological examination
× Detailed history collection

41. × CT
× MRI
× MRA- MR Angiography
× Carotid ultrasound
× Transcranial doppler
× Cerebral angiography
× Transthoracic echocardiography
× Transesophageal echocardiography
× ECG
× Ambulatory ECG monitoring
× Prothombotic states

42. Medical managemet
× Hypervolemic- hemodilution therapy:
× The therapy is designed to decrease the
hematocrit and the viscosity of blood,
subsequently increasing CBF.
× The patient must have a documented SAH
and have a baseline neurologic status
compatible with aggressive intervention to
qualify for the therapy.

43. × The infusion technique is begun with
5% albumin and continued for 3 to 7
days
× The dosage is gradually tapered
before discontinuation.
× Effectiveness of the therapy is
measured through improvement in
neurologic function and regional CBF
measurements.

44. × Thrombolytic: (reteplase, urokinase, rt-
PA)
× recombinant tissue plasminogen activator:
(rt-PA)
× Treated within 3 hours of stroke
symptoms onset
× 0.9 mg/kg
× Initial 10% given IV bolus over 1minute
remaining infused over 60 min.

45. × Anticoagulant or aspirin should not be
given in first 24hours after rt-PA
treatment.

46. × Antiplatelet
× Anticoagulant
× Antihypertensive

47. Surgical management
× Carotid endarterectomy

48. Superficial temporal artery – middle temporal artery
anastomosis

49. Clot extraction (MERCI) Mechanical embolus removal
in cerebral embolism

51. aneurysm clipping and coiling

52. Thank You