Cerebrovascular

Disease
• Most common and devastating disorders of CerebrovascularDse:
Stroke
• Stroke: 2nd leading cause of death worldwide
• Stroke causes prox. 200,000 death in each year in USA
• Cerebral ischemia: reduction in blood flow thatlast longer than
several seconds
• If this long for few minutes, it will cause infarct or Death of brain
tissues
• If quickly restored, neurological signs and symptoms resolve back
within 24 hours, it’s Transient IschemicAttack
• Or if the signs and symptoms last for >24hrs and the infarctis
demonstrated, it’s stroke.
Stroke: a cerebrovascular Accident defined asan
abrupt onset of a neurological deficit that is
attributable to a focal vasculardisease.

STROKE classification

Ischemic stroke Hemorrhagic stroke

Thrombotic Embolic Intracerebral Subarachnoid

stroke stroke hemorrhage hemorrhage
 Ischemic Stroke
• Lacunar (small Vessel Dse) 20%
• Perforating Arteries obstruction, microatheromas, microembolis
• Basal ganglia
• Very isolated lesion: pure motor or puresensory stroke
• Intracranial Atherosclerosis: 50%
• Extracranial Atherosclerosis
• Hemodynamic – more common in the InternalCarotid artery
• Cardioembolism (20%)
• Atrial Fibrillation (mostCommon)
• Valvular Heart Disease
• Congenital Heart Failure
• Cryptogenic or unknown
• Classically: Hx of TIA

• Penumbra – ischemic but

reversibly dysfunctional tissue
surrounding a core area of
infarction.
• Saving the ischemic penumbra is
the goal of revascularization
therapy
Hemorrhagic Stroke
• Intracerebral hemorrhage: uncontrolled hypertension with greater
bleeding in the substances of brain
• 15% of stroke
• Classic symptoms: sudden
onset of headache, vomiting
and elevated BP
• Focal neurological deficits
progress over minutes
• May present with agitationand
lethargy, then progress to
stupor or coma
Subarachnoid Hemorrhage
• Aneurysm (>40 yrs)
• AV malformation (<40yrs)
• Greater in between the piaand
arachnoid matters
• Bleeding into the space between the
inner layer and the middle layer of the
tissue covering the brain
• Cause sudden, severe headache, often
followed by a brief episode of
unconsciousness.
Symptoms of Stroke:
• Loss of Sensory and/or motor Function on one side of the body
• Change in vision, gait, or ability to speak orunderstand
• Sudden severe headache
• Dizziness
• Confusion
• Loss of balance or coordination
• Nausea/vomiting
• Seizure
• Painful stiff neck
Pre Hospital Assesment:
• Rapid identification of potential
Stroke patient
• Pre arrival notification of receiving
facility – early mobilization of stroke
team
• Cincinnati Stroke Scale/ “FAST”
• Facial Droop
• Have patient look up at you andsmile
• Arm drift
• Have pt. lift arms up and hold them out
with eyes closed for 10seconds
• Speech
• Have patient to repeat any phrase yousay
• Time
National Institute ofHealth Stroke Scale
• Systemic tool designed to measure neuro deficits most often seen
with stroke
• Helps to determine the severity ofstroke
• 0 - 1 => normal
• 1 - 4 => minor Stroke
• 5 – 15 => moderate Stroke
• >20 Severe Stroke
Stroke Mimickers
• Seizure
• Intracranial Tumor
• Hyponatremia or hypoglycemia
• Migraine
• Metabolic encephalopathy
• Anxiety
• Parkinson’s dse
• Peripheral vertigo
• Bells palsy
Diagnostics
• History and Physical Examination
• Neurological Examination
• Imaging/ Lab
• CTScan
• MRI
• Angiography/ Venography
• ECG
• Transcranial Doppler
• Blood tests: CBC,Serum Elec., PTT,LipidProfile
Medical Management
• Ascertain Clinical Diagnosis of TIA/Stroke (Hx and PEare very
important)
• Exclude Common stroke Mimickers
• Provide basic emergent supportive care (ABCs ofResuscitation)
• Monitor neuro VS, BP,MAP, RR,Temperature andPupils
• Perform Stroke Scales
• Perform risk stratification using the ABCD2scale
• Monitor and Manage BP; treat if MAP>130

• Medications:
• Tissue Plasminogen Activator:
• Dissolve blood clot and restore bloodflow
• Antithrombotic Tx
• Platelet inhibitors
• Anticoagulants

• Also, Statins to reduce cholesterol level inblood

• With neuroprotection
Management
• BPmanagement
• Should be kept within higher normallimits
• Blood Glucose Level
• Within physiological level
• Body Temperature
• Antipyretics or Coolingdevices

Sever Stroke Considerations

• Ischemic
• BPmanagement
• Recognize sings of increased ICP
• Non cardio embolic: antiplatelet or combination, neurospecialist forposterior circulation
stroke, ifcerebellar infarct refer to neurosurgery
• Hemorrhagic:
• Medical Compression: mannitol, furosemide or Hypertonicsaline
• Long term strict BPcontrol
• Neurosurgical control
• ICPmonitoring
• Goal: reduce mortality
Neuroprotective interventions
5 ‘H’
• Hypotension
• Hypoxemia
• Hypoglycemia
• Hyperglycemia
• Hyperthermia

Prevention
• Diet (low Fat, High Fiber)
• Quit smoking and Alcohol intake
• Control Diabetes
• Maintain healthy weight
• Exercise