DISEASE OVERVIEW:CEREBROVASCULAR DISEASE Cerebrovascular disease (CVD) includes all disorders in which an area of the brain is transiently or permanently affected by ischemia or bleeding and one or more of the cerebral blood vessels are involved in the pathological process. Classification: o Ischemic Stroke cerebrovascular accident (CVA) or brain attack is a sudden loss of function resulting from disruption of the blood supply to the part of the brain. Risk Factors: y Hypertension y Heart disease y History of TIA y Increase hematocrit y Age (older) y Alcohol use y Smoking y Diabetes Mellitus Symptoms occur suddenly and may include muscle weakness, paralysis, lost or abnormal sensation on one side of the body, difficulty speaking, confusion, problems with vision, dizziness, and loss of balance and coordination. Diagnostic Exam: y Physical Examination history of event and identification of which artery is blocked based on symptoms. y CT Scan - helps distinguish an ischemic stroke from a hemorrhagic stroke, a brain tumor, an abscess, and other structural abnormalities. y Blood sugar levels to rule out hypoglycaemia which can cause similar symptoms. y Electrocardiography (ECG) to look for abnormal heart rhythms.
Blood tests to check for anemia, polycythemia, blood clotting disorders, vasculitis, and some infections (such as heart valve infections and syphilis) and for risk factors such as high cholesterol levels or diabetes. Managements: y First priority is to restore the person's breathing, heart rate, blood pressure (if low), and temperature to normal. y Maintain adequate tissue oxygenation: May require airway support and ventilatory assistance. Check for possible aspiration pneumonia. y Intravenous line for medication and fluids. y Acetaminophen or Ibuprofen for fever increase in body temperature by even a few degrees can dramatically worsen brain damage due to an ischemic stroke. y Mannitol to reduce swelling and increased pressure in the brain y Thrombolytic (Fibrinolytic) Drugs drug called tissue plasminogen activator (tPA) is given intravenously to break up clots and help restore blood flow to the brain. Before tPA is given, CT is done to rule out bleeding in the brain. y Antiplatelet Drugs and Anticoagulants Antiplatelet drugs make platelets less likely to clump and form clots. Anticoagulants inhibit proteins in blood that help it to clot (clotting factors). y Surgical interventions like: Carotid Endarterectomy (CEA) surgical removal of the atheromatous plaque. Reserved for patients with an ulcerated lesion or clot that occludes > 70% of blood flow in the carotid artery. A general anesthetic or a local anesthetic (to numb the neck area) may be used. If people remain awake during the operation, the surgeon can better evaluate how the brain is functioning. The surgeon makes an incision in the neck over the area of the artery that contains the blockage and an incision in the artery. The blockage is removed, and the incisions are closed. For a few days afterwards, the neck may hurt, and swallowing may be difficult. Most people can stay in the hospital 1 or 2 days. Heavy lifting should be avoided for about 3 weeks. After several weeks, people can resume their usual activities. y
Carotid endarterectomy can trigger a stroke because the operation may dislodge clots or other material that can then travel through the bloodstream and block an artery. However, after the operation, the risk of stroke is lower for several years than it is when drugs are used. It also reestablishes the blood supply to the affected area, but it cannot restore lost function because some brain tissue is dead. Stent Placement - A wire mesh tube (stent) with an umbrella filter may be placed in the carotid artery. The stent helps keep the artery open, and the filter catches blood clots and prevents them from reaching the brain and causing a stroke. After a local anesthetic is given, a catheter is inserted through a small incision into a large artery near the groin or in the arm and is threaded to the internal carotid artery in the neck. A dye that can be seen on x-rays (radiopaque dye) is injected, and x-rays are taken so that the narrowed area can be located. After the stent and filter are placed, the catheter is removed. o Hemorrhagic Stroke - include bleeding within the brain (intracerebral hemorrhage) and bleeding between the inner and outer layers of the tissue covering the brain (subarachnoid hemorrhage). Intracerebral Hemorrhage Non-traumatic or spontaneous intracerebral hemorrhage (ICH) occurs when a diseased blood vessel within the brain bursts, allowing blood to leak inside of the brain (the name means within the cerebrum or brain). The sudden increase in pressure within the brain can cause damage to the brain cells surrounding the blood. If the amount of blood increases rapidly, the sudden build up in pressure can lead to unconsciousness or even death. Intracerebral hemorrhage usually occurs in selected parts of the brain including the basal ganglia, cerebellum, brainstem or cortex. y Risk Factors: Chronic Hypertension weakens the small artery that causes it to burst. Use of Cocaine Alcohol consumption High doses of anti-couagulants and antiplatelets y Signs and Symptoms: Severe headache may be present or absent.
Weakness, paralysis, loss of sensation, and numbness, often affect only one side of the body. Dysarthria difficulty in speaking Vision may be impaired or lost Nausea, vomiting, seizures, and loss of consciousness are common and may occur within seconds to minutes ICP Diagnostic Exam: Neurological exam may indicate increased intracerebral pressure such as swelling of the optic nerve or changes in eye movement. Localized abnormalities in the brain function are detected by observing abnormal reflexes or movement. CT Scan and MRI - helps distinguish an ischemic stroke from a hemorrhagic stroke, a brain tumor, an abscess, and other structural abnormalities. Blood sugar levels to rule out hypoglycaemia which can cause similar symptoms. Blood tests to check for anemia, polycythemia, blood clotting disorders, vasculitis, and some infections (such as heart valve infections and syphilis) and for risk factors such as high cholesterol levels or diabetes. Management: o First priority is to restore the person's breathing, heart rate, blood pressure (if low), and temperature to normal. o Maintain adequate tissue oxygenation: May require airway support and ventilatory assistance. Check for possible aspiration pneumonia. o Intravenous line for medication and fluids. o Acetaminophen or Ibuprofen for fever increase in body temperature by even a few degrees can dramatically worsen brain damage due to an ischemic stroke. o Mannitol to reduce swelling and increased pressure in the brain o Anticoagulants (such as heparin and warfarin), thrombolytic drugs, and antiplatelet drugs (such as aspirin) are not given because they make bleeding worse.
o Tracheal intubation is indicated in patients with decreased level of consciousness or other risk of airway obstruction o Surgery: Surgery to remove the accumulated blood and relieve pressure within the skull, even if it may be life-saving, is rarely done because the operation itself can damage the brain. Also, removing the accumulated blood can trigger more bleeding, further damaging the brain and leading to severe disability. However, this operation may be effective for hemorrhage in the pituitary gland or in the cerebellum. In such cases, a good recovery is possible. A catheter may be passed into the brain vasculature to close off or dilate blood vessels, avoiding invasive surgical procedures. Aspiration by stereotactic surgery or endoscopic drainage may be used in basal ganglia hemorrhages, although successful reports are limited. Subarachnoid Hemorrhage - A subarachnoid hemorrhage is bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the tissue covering the brain (meninges). y Risk Factors: Head injury Aneurysm or weakened blood vessels Hypertension Smoking y Signs and Symptoms: Headache, which may be unusually sudden and severe (sometimes called a thunderclap headache) Facial or eye pain Double vision Loss of peripheral vision Weakness or paralysis on one side of the body (most common) Loss of sensation on one side of the body
Difficulty understanding and using language (Aphasia) Within 24 hours, blood and cerebrospinal fluid around the brain irritate the layers of tissue covering the brain (meninges), causing a stiff neck as well as continuing headaches, often with vomiting, dizziness, and low back pain. Diagnostic Exams: o Computed tomography (CT) is done to check for bleeding. o A spinal tap (lumbar puncture) is done if CT is inconclusive or unavailable. It can detect any blood in the cerebrospinal fluid. A spinal tap is not done if doctors suspect that pressure within the skull is increased. o Cerebral angiography is done as soon as possible to confirm the diagnosis and to identify the site of the aneurysm or arteriovenous malformation causing the bleeding. Management: o Bed rest with no exertion is essential o Analgesics such as opioids (but not aspirin or other nonsteroidal anti-inflammatory drugs, which can worsen the bleeding) are given to control the severe headaches. o Stool softeners are given to prevent straining during bowel movements. o Nimodipine, a calcium channel blocker, is usually given by mouth to prevent vasospasm and subsequent ischemic stroke. o Doctors take measures (such as giving drugs and adjusting the amount of intravenous fluid given) to keep blood pressure at levels low enough to avoid further hemorrhage and high enough to maintain blood flow to the damaged parts of the brain. o A piece of plastic tubing (shunt) may be placed in the brain to drain cerebrospinal fl