Cerebrovascular Disease

Stroke Statistics
 15% of adults > age 50 cannot name a
single symptom of stroke

 13 hours after onset of symptoms is the

median time to presentation

 58% of stroke patients don’t present during

the first 24 hours after onset

 52% of stroke patients in the ED are

unaware that they are experiencing a stroke
 Stroke Knowledge
 MYTHS
– Can’t prevent stroke
– Can’t treat stroke
– Stroke affects the heart
– Stroke affects the elderly
– Recovery happens for a
few months after stroke
 FACTS
– Stroke is preventable
– Stroke is treatable
– Stroke is a brain attack
– Stroke affects anyone
– Stroke recovery occurs
throughout life
Stroke Symptoms
 Sudden numbness or weakness of face, arm or leg,
especially on one side of the body

 Sudden confusion, trouble understanding or

speaking

 Sudden trouble seeing in one or both eyes

 Sudden trouble walking, dizziness, loss of balance

or coordination

 Sudden severe headache with no known cause

Other Symptoms
 Sudden nausea, fever and vomiting,
distinguished from a viral illness by rapid onset
(minutes or hours vs. days)

 Brief loss of consciousness or period of

decreased consciousness
(fainting, confusion, convulsions or coma)
TIA: The First Clue
Transient Ischemic Attack

 “Sudden, focal neurologic deficit lasting less

than 24 hours, confined to an area of the
brain or eye perfused by a specific artery.”

 Based on assumption that TIAs do not

cause infarction or other permanent brain
injury.

 Time criterion is arbitrary.

Problems with TIA Definition

 Most TIAs last seconds to 10 minutes, with

symptoms lasting greater than 1 hour in only 25%
of patients

 Less than 15% of patients with symptoms lasting

> 1 hour resolve within 24 hours

 Following TIAs, evidence of infarction is found in

20% by CT imaging and almost 50% with MRI

 The “24-hour” rule leads to complacency and

delay.
Tissue Definition of TIA
 “A TIA is a brief episode of neurologic
dysfunction caused by focal brain or retinal
ischemia, with clinical symptoms typically
lasting less than one hour, and without
evidence of acute infarction.”

 Parallel to distinction between angina and

myocardial infarction (i.e. depends on the
absence of tissue injury rather than the
resolution of symptoms)
Advantages
 Acknowledges that transient neurologic
symptoms may cause permanent brain injury

 Supports rapid intervention to diagnose and

treat acute brain ischemia

 More accurately reflects the presence or

absence of brain infarction

 Avoids assigning an arbitrary time criterion to

define TIA
TIA - Differential Diagnosis
 Anxiety (panic attack)  Migraine
 Hyperventilation  Orthostatic hypotension
 Neuropathy (focal)  Syncope
 Neuropathy (ischemic)  Arrhythmias (ischemia)
 Vertigo  Seizures
 Disequilibrium  Conversion disorder
Stroke: The Initial Symptoms
 Definition of Stroke
 Sudden brain damage
 Lack of blood flow to the brain caused by a
clot or rupture of a blood vessel

Ischemic = Clot
(makes up approximately
87 percent of all strokes)

Hemorrhagic = Bleed
Thrombotic

- Bleeding around brain

- Bleeding into brain
© 2011 National Stroke Association
Clinical Presentations of Stroke

 Focal ischemia (85%)

– Embolism
– Thrombosis

 Hemorrhage (15%)
– Epidural
– Subdural
– Intraparenchymal
Cerebral Ischemia
Embolism Thrombosis
 Preceded by TIAs
 Abrupt onset  Abrupt onset
 Small vascular area  Large vascular area
 Focal deficit  More complex symptoms
– Pure aphasia
– Pure hemianopia
 Acute CT normal  Acute CT normal
 High recurrence risk
Cerebral Hemorrhage
Epidural hemorrhage Subdural hemorrhage
 Smooth onset  Smooth onset

 Arterial origin  Venous origin

 Mass effect causes  May be recurrent

coma over hours  Fluctuating, falsely
 Similar (but slower localizing signs
in evolution) to
hemorrhage in
basal ganglia
Remember Lacunar Strokes
Lacunar Strokes

 15 – 20% of ischemic strokes

– Small penetrating branches of circle of
Willis, MCA, or vertebrobasilar artery
– Atherothrombotic or lipohyalinotic
occlusion
 Infarct of deep brain structures
– Basal ganglia, cerebral white matter,
thalamus, pons, and cerebellum
– From 3 mm to 2 cm
Presentation of Lacunar Stroke

 Risk factors
– Diabetes
– Hypertension
– Polycythemia

 Variable course progressing over days

– Fluctuating; progressing in steps; or remitting
– Preceded by TIAs in 25%
– Without headache or vomiting
Lacunar Stroke Syndromes

 Well-defined syndromes
– Pure motor hemiparesis (with dysarthria)
– Pure sensory stroke (loss or paresthesias)
– Dysarthria-clumsy hand (with contralateral
face and tongue weakness)
– Ataxia-hemiparesis (contralateral face and
leg weakness)
– Isolated motor-sensory stroke
Lacunar Stroke Outcome

 Management
– Long-term blood pressure control
– Empiric anti-platelet therapy
– Omega-3 oil 1 gm TID to improve viscosity

 Prognosis
– Good recovery of function
– Other lacunes develop
Prevention Pearls
Reducing Primary Risk - 1

 Obstructive sleep apnea

 Homocysteine  folate, B6, B12
 Hypertension – morning BP surge
 Smoking  50% risk reduction in 1 yr
 Hyperlipidemia  statins
 Migraine  triptans
 Drugs – cocaine, ephedra, PPA
Reducing Primary Risk - 2

 Asymptomatic carotid stenosis

– Endarterectomy for > 60% stenosis
– Risk reduction for 3% to 1% per year
– Benefit related to surgical risk
 Nonvalvular atrial fibrillation
– Aspirin for patients < 65 years, healthy
– Warfarin for patients > 65 years or
having other stroke risk factors
Reducing Secondary Risk

Reducing risk of recurrence

 TIA with ipsilateral carotid stenosis 
endarterectomy for > 70% stenosis
 Cardiogenic embolism  warfarin
 Lacunar infarcts  aspirin, dipyridamole
 Cryptogenic infarcts (40% embolic) 
anticoagulation?
Reducing Risk in Children

 Sickle cell disease

– Screen with transcranial doppler q 6 mo
– Transfusion therapy for 2 abnormal studies
 Congenital heart disease
 Arterial dissections (trauma)
 Prothrombotic disorders
 Mitochondria disorders (MELAS)
Decreasing Salt Intake

 Reducing salt intake by 3 g per day

lowers blood pressure; the effect is
doubled with a 6 gm/day reduction
and tripled with a 9 gm/d reduction.

 Reduction in stroke risk parallels

reduction in salt intake.
Using Statins

 Pooled results after 5 years

 Pravastatin or Simvastatin 40 mg/day
 Changes in cholesterol levels
– Total cholesterol decreased 20%
– LDL cholesterol decreased 28%
– HDL cholesterol increased 5%
– Triglycerides decreased 13%
Using Statins

 Reducing LDL cholesterol by 1 mmol/L

– 22% stroke reduction in patients with
known vascular disease

– 6% stroke reduction in patients without

known vascular disease

– 28% reduction in thromboembolic stroke

 Acute Stroke Treatments

 Ischemic stroke (brain clot)

– Clot busting medication: tPA (tissue
plasminogen activator)
– Clot-removing devices: Merci Retriever,
Penumbra
 Hemorrhagic stroke (brain bleed)
– Clipping
– Coiling

© 2011 National Stroke Association

 Stroke Recovery

 10 percent of stroke survivors recover almost

completely
 25 percent recover with minor impairments
 40 percent experience moderate to severe
impairments requiring special care
 10 percent require care within either a skilled-care
or other long-term care facility
 15 percent die shortly after the stroke
© 2011 National Stroke Association
 Types of Stroke
Rehabilitation
Physical therapy (PT)
– Walking, range of movement
Occupational therapy (OT)
– Taking care of one’s self
Speech language therapy
– Communication skills, swallowing, cognition
Recreational therapy
– Cooking, gardening
© 2011 National Stroke Association