Cerebrovascular Disease Ian A. Cook, M.D. Case for Discussion •58 yo WM, former smoker, develops sudden onset of dysarthria •Two weeks previously, had awakened with clumsiness in using his right (dominant) hand; this persisted for a few hours, then resolved •What thoughts are you considering? Source: Murray CJL, Lopez AD, eds. The Global Burden of Disease. Boston: Harvard School of Public Health, World Health Organization, World Bank, 1996. Global Burden of Disease 2.6 HIV 10 2.7 Diarrheal diseases 9 3.0 War injuries 8 3.0 Tuberculosis 7 3.1 Lower respiratory infections 6 4.2 Chronic obstructive pulmonary disease 5 4.4 Cerebrovascular disease 4 5.1 Road traffic accidents 3 5.7 Unipolar major depression 2 5.9 Ischemic heart disease 1 % Total Cause Rank Projection 2020 Terms •Cerebrovascular disease - any brain abnormality arising from pathologic processes in the vessels •occlusion via embolism or thrombosis •vessel rupture •viscosity problems •small vessel disease, developmental
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Cerebrovascular Disease with clumsiness in using his right ... · PDF fileStroke Syndrome •Sudden appearance of a nonconvulsive neurologic deficit •apoplexy •cerebrovascular
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CerebrovascularDisease
Ian A. Cook, M.D.
Case for Discussion•58 yo WM, former smoker, develops
sudden onset of dysarthria•Two weeks previously, had awakened
with clumsiness in using his right(dominant) hand; this persisted for afew hours, then resolved•What thoughts are you considering?
Source: Murray CJL, Lopez AD, eds. The Global Burden of Disease. Boston:Harvard School of Public Health, World Health Organization, World Bank, 1996.
•Cerebrovascular disease - anybrain abnormality arising frompathologic processes in the vessels•occlusion via embolism or thrombosis•vessel rupture•viscosity problems•small vessel disease, developmental
•The brain depends on a continuoussupply of oxygenated blood,maintained by a series ofbaroreceptors & vasomotor reflexescontrolled by the brain stem•LOC in 10 sec•irreversible damage in 4-5 min
•Infarction, ischemic necrosis,encephalomalacia•arterial obstruction is the usual cause of focal ischemic
damage• focal + diffuse ischemia with circulatory collapse or
Stroke Syndrome•Risk Factors•hypertension•heart disease•atrial fibrillation•diabetes•smoking•hyperlipidemia•hypercoagulable states
Ischemic Stroke
•Global - no collateral flow soirreversible destruction begins in4-8 min at normal body temp.•Focal - collaterals mean that there
may be some oxygen & glucoseavailable
Ischemia-modifying Factors•Effects depend upon location•Circle of Willis•ophthalmic artery•Depend upon speed of occlusion•gradual narrowing allows collateral
channels to open•Viscosity, hypotension
Pathophysiology I
•Loss of oxygen and glucose•Changes in cellular metabolism
and collapse of energy-producingprocesses and cell membranedisintegration
Pathophysiology II•ATP depletion, incr extracelluar K, incr in
intracellular Ca, cellular acidosis•Free fatty acids are activated and destroy
phospholids of membranes•Prostaglandins, leukotrienes, free radicals
accumulate•Lactic acid from anerobic conditions is
•Thrombolytic agents•tisue plasminogen activator t-PA•streptokinase•IV within 3 hrs of onset - benefit•IV within 6 hrs - much less benefit•NO hemorrhage by CT
•Begin within a few days of strokein all but most ill patients•Passive ROM to avoid contracture•Regain strength, teach new
strategies for movement•Neuroplasticity ....
Prevention
•ASA•control HTN, atrial fibrillation•avoid oversedation with deep sleep•treat anemia, polycythemia•avoid rapid diuresis•obsess during surgical procedures
Primary Intracranial Hemorrhage•Chronic hypertension•Bleeding into tissue, rarely into
subarachnoid space except withaneurysms•CT scans - blood shows as white
acutely; less dense 2-3 after wks•Skip the LP
Intracranial Hemorrhage•Apoplexy•“obese, plethoric hypertensive male who,
while sane and sound, falls senseless tothe ground, breathes stertorously, anddies in a few hours”•30-35% die in 1-30 days•In survivors, surprising degree of
recovery
Intracranial Hemorrhage•ICU care - hyperventilate to keep pCO2 to