Cerebrovascular disease

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Cerebrovascular disease

• David Dayya, D.O., M.P.H.
• St. Barnabas Hospital

2
Epidemiology

• 3rd leading cause of death and disability in the
  developed world. Exceeded only by Heart disease
  and Cancer
• Declining incidence with better treatment of
  hypertension and reduction in smoking
• 500,000/Year, approximately ¼ die

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Major risk factors

• Hypertension ( Systolic or diastolic)
• Smoking
• Atrial Fibrillation
• Myocardial Infarction
• Hyperlipidemia
• Diabetes
• Congestive Heart Failure
• Acute Alcohol abuse
• TIA gt70 occlusion of the carotid arteries
• Oral contraceptives when combined with smoking in
  women
• Hypercoagulopathy
• High RBC count and Hemoglobinopathy
• Age, Gender, Race, Prior Stroke, and Heredity

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Classification of Stroke

• Ischemic (75 of stroke, Embolic or Thrombosis)
• Hemorrhagic

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Definitions of Stroke

• Transient Ischemic Attack
• Completed Stroke
• Stroke in evolution
• RIND ( Reversible Ischemic Neurological Deficit)

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TIA

• Brief episodes of focal neurological deficits
  lasting 2-3 minutes to at most a few hours but no
  longer than 24 hours leaving no residual deficits
  with complete functional recovery.

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Completed Stroke

• Acute, sustained functional neurological deficit
  lasting from days to permanent. There is neuronal
  necrosis or infarction in at least a part of area
  supplied by the affected artery. Brain Attack

8
Stroke in evolution

• An unusual condition in which a restricted
  neurological deficit spreads relentlessly over a
  small period of time, usually hours, to involve
  adjacent functional areas supplied by the
  affected artery.

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Anatomy Cerebral and Carotid circulation review
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Brain Anatomy
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Presentation depends on the affected vessel and
whether or not there is any further complicating
factors.
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Stroke Syndromes

• ICA occlusion
• ACA occlusion
• MCA occlusion
• PCA occlusion
• Vertebrobasilar occlusion (AICA, PICA, SCA)
• Lacunar Infarct
• Spinal stroke

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Anterior Circulation TIAs and stroke

• Anterior or Middle Cerebral artery involvement
• amaurosis fugax (monocular blindness)
• Face-hand-arm-leg contralateral hemiparesis
• Aphasia/dysarthria

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MCA occlusion

• Similar to ICA-MCA occlusion
• Contralateral hemiplegia in face-arm-hand
• Dominant hemisphere aphasia
• Nondominant Right hemisphere confusion, spatial
  disorientation, sensory and emotional neglect

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ACA occlusion

• Sensorimotor deficit in contralateral foot and
  leg
• Brocas or anterior conduction aphasia in dominant
  hemisphere is possible (deep frontal lobe nuclei)
• TIAs rarely affect ACA distribution

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Posterior Circulation TIA and Stroke

• Vertigo
• Diplopia/ dysconjugate gaze, ocular palsy
  homonymous hemianopsia
• Sensorimotor deficits - Ipsilateral face and
  contralateral limbs, drop attack (rarely TIA)
• Dysarthria
• ataxia

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Vertebro-Basilar posterior circulation occlusion

• Emboli less frequent in the posterior circulation
  but more common anterior.
• Various syndromes depending on the site of
  occlusion.
• VA-PICA syndrome HA, ataxia, nausea/vomiting,
  paralysis in tongue and swallowing all
  ipsilateral, Ipsilateral face and contralateral
  body. Horner's Syndrome.
• PICA-AICA-SCA acute cerebellar infarction.

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Vertebro-Basilar posterior circulation occlusion

• BA trunk (V-B junction or basilar apex - PCA
  junction).
• V-B junction lower extremity paraplegia or
  tetraplegia, conjugate or dysconjugate gaze
  paralysis, constricted pupils, respiratory
  depression, coma.
• Basilar apex PCA junction results in
  hemiplegia-diplegia, pupillary and occulomotor
  paralysis, visual field defects, stupor and coma.
• PCA (distal branches) quadrantic or homonymous
  hemianopsia
• PCA (proximal branches) Thalamus involvement
  hence memory loss and sensorimotor hemiplegias.

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Spinal Stroke

• Rare
• Anterior spinal artery
• Assoc. with prolonged hypotension and intraspinal
  mass lesions.

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Hemorrhagic stroke

• Subarachnoid Hemorrhage
• Intracerebral Hemorrhage
• Vascular rupture
• In general patients with hemorrhagic stroke
  present seriously ill. Deteriorate more rapidly
  and have H.A., N/V, and decreased consciousness
  as prominent signs.

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Hemorrhagic Stroke

• Intracerebral hemorrhage
  (including hypertensive atherosclerotic
  hemorrhage, Lobar hemorrhages, Hemorrhage from
  vascular malformations, and uncommonly bleeding
  into brain tumors, blood dyscrasias or
  anticoagulants, and inflammatory vasculopathies.)

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Subarachnoid Hemorrhage

• Rupture of an artery with bleeding unto the
  surface of the brain
• 1 cause Aneurysm, AVM (85 from congenital
  berry aneurysm, 10 cause not found)
• 25 of patients may have warning leak
  symptoms

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Subarachnoid hemorrhage

• Worst H.A. in the patients life radiates to face
  and neck. Progresses to maximal intensity
  immediately after onset.
• Phonophobia or photophobia

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Subarachnoid Hemorrhage

• Physical signs
• Nuchal rigidity
• Altered mental status
• Poor sign if associated with transient loss of
  consciousness, may represent a complicating
  factor such as seizure or cardiac dysrythmia
• Papilledema
• May not have a neurological deficit

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Intracerebral hemorrhage

• Rupture of an artery with bleeding into the brain
  parenchyma
• 1 cause Hypertension, Amyloid angiopathy
• These patients can present with any of the signs
  and symptoms of ischemic stroke
• Hypertensive atherosclerotic hemorrhage usually
  involves basal ganglia, thalamus, cerebellum, and
  pons. Often large and catastrophic found in
  hypertensives 60 of time. Degenerative-atheroscle
  rotic vascular injury.
• Lobar hemorrhages smaller (frontal-temporal-pariet
  al-occipital)

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DDX Stroke

• Focal seizures
• Glaucoma
• Benign Vertigo or Menieres disease
• Cardiac syncope or syncope from other causes
• Migraine HA
• Intracranial neoplasm
• Subdural hematoma
• Epidural hematoma
• Hyperglycemia (NHH, DKA), Hypoglycemia

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DDX Stroke

• Postcardiac arrest ischemia
• Drug overdose
• Meningitis, Encephalitis
• Trauma
• Anoxic encephalopathy
• Hypertensive encephalopathy

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Diagnosis

• ABCs
• History and Physical exam (including a risk
  factor assessment and a thorough description of
  symptoms/deficits, medications, PMHx, PSHx, time
  of onset, duration. A thorough neurological exam.
• EKG, monitor, pulse oximetry
• Labs (CBC, electrolyte, glucose, ABG, PT/PTT,
  Urine drug screen, LP)
• CT or MR head scan
• Echocardiography, EEG
• Carotid Duplex Ultrasonography
• MRA or Angiography

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Management of Acute Stroke

• Medical management
• Surgical management
• Prognosis

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Medical Management

• Prevention, Lifestyle Modification
• Early Recognition with Rapid Transport/Pre-arrival
  Notification
• ABCs, O2, IV, (Hyperbaric Chamber)
• Rapid Evaluation for Fibrinolytic therapy (TPA)
• Anticoagulation (Aspirin, Heparin and Warfarin)
• Calcium channel blockers (Nimodipine)
• Antioxidants to inhibit the role of excitatory
  neurotoxins and Nitric acid synthase

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Anticoagulants Indications in the acute setting

• Repetitive TIAs clustered together within a
  single day or a few days
• Acutely progressive weakness in stroke

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Acute anticoagulation

• Initiate with Heparin, start warfarin
  concurrently using INR guidelines
• With acute stroke may use ASA concurrently if
  depending on comorbidities with Heparin caution
  with Warfarin.
• Contraindications include SBP gt 170, Diastolic gt
  100, Uremia, Bleeding diathesis, Intracranial
  bleeding

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Thrombolytics

• Intra-arterial and intravenous
• TPA
• Only TPA approved for ischemic stroke if given
  within 3 hours of onset of signs and symptoms
  Class I AHA recommendation
• 30 more likely to have minimal or no disability
  at 3 months ( NINDS trial)
• 3 vs. 0.3 increase in frequency of intracranial
  hemorrhages
• 6.4 vs. 0.6 increase in the frequency of all
  symptomatic hemorrhage

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Thrombolytic contraindications

• Contraindicated in B.P. gt 185/110, AMI, Seizure,
  Hemorrhage, LP within 7 days, arterial puncture
  at incompressible site, surgery within 14 days,
  bleeding diathesis, within 3 months of head
  trauma, history of intracranial hemorrhage, minor
  or rapidly improving stroke symptoms

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Acute or Chronic Prophylactic Anti platelet
therapy

• Role of ASA 81mg vs 325mg
• Role of Plavix or Ticlodipine

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Chronic prophylactic anticoagulation

• Indicated in Acute Ant. Wall M.I. With mural
  thrombus formation. ( continue Heparin/Warfarin
  until thrombus dissolves. INR
• Chronic Atrial Fibrillation with any or all of
  the following risk factors, CHF within 3 months,
  HTN, previous thromboembolism, LV dysfunction
  and/or enlarged left atrium, Chronic valvular
  disease. A-fib without any of the following risk
  factors may be treated with chronic ASA therapy.
• Same contraindications

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Chronic management

• Multidisciplinary approach
• Psychiatric Services
• PT/OT/Speech-Language
• VNS/Home health attendant
• Skilled nursing facility
• Social Services
• Family support groups

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Carotid Endarterectomy

• Good general Health
• Hypertension controlled
• Internal carotid stenosis 70-99 (2.8 vs. 16.8
  incidence for postoperative ipsilateral stroke
  after 3 years)
• Ipsilateral stroke or TIA within 3-6 months
• Surgeon with morbidity/mortality lt 2
• Worse outcome if used to treat evolving stroke

• Multiple coexisting comorbid conditions
• Hypertension poorly controlled
• Internal carotid artery either completely or
  lt 70 occluded
• No history of ipsilateral TIA or stroke
• Inexperienced surgeon

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Future

• Possible role for HBO in the acute setting?
• Stem cell research and neuronal regeneration?
  Myelin Project.