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Cerebrovascular disease (CVA / Stroke)
1) The document discusses strokes (cerebrovascular accidents or CVAs), their causes, types, symptoms, diagnosis and treatment. 2) Strokes are caused by disturbances in the vascular system and can be ischemic (caused by clot or blockage) or hemorrhagic (caused by bleeding). 3) Common symptoms of strokes include weakness or numbness on one side of the body, speech problems, and visual issues. The specific symptoms depend on the area of the brain affected.
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Cerebrovascular disease (CVA / Stroke)
- 1. Cerebrovascular disease (CVA,Stroke) Submitted to AskTheNeurologist.Com in 2007 Author Anon.
- 2. What is astroke / CVA ? Acute onset of deficit Persists > 24 hours ( see TIA definition) Result of disturbance of vascular system
- 3. TIA’s Current definitionis based on duration less than 24 hours Most last minutes Always ischaemic….hence “I” Warn of impending stroke
- 4. CVA Epidural IschaemicHaemorrhagic Subdural SAH Intracerebral Thrombosis Embolus Carotid / VB Cardiac Aortic arch
- 5. Bleed vs IschaemiaClear vascular territory No obvious territory Herniation rare / late Early signs of herniation Consciousness relatively preserved ( variable) Consciousness usually impaired if large Moderate / no headache Severe headache Acute or hyperacute Hyperacute Ischaemia Bleed
- 6. Clinical features ofCVA’s Depend on part of brain involved Very variable Common syndromes vs very rare
- 7. Common Features ofCVA Hemiparesis Face asymmetry Gaze deviation Dysphasia / aphasia Dysarthria Limb incoordination Ataxia ( +/- vertigo) One sided sensory symptoms
- 8. Features very unlikelyto be due to CVA General weakness Isolated headache Isolated vertigo General confusion Memory disturbance Isolated fall Bilateral complaints Gradual deterioration in consciousness
- 9. When to thinkof a CVA in a patient with decreased consciousness Hyperacute sustained loss of consciousness with no evidence of cardiorespiratory disturbance Unequal pupils ( if no past surgery!) Reacts to pain only on one side Gaze deviation Other causes are more common and usually much more treatable
- 10. The old strokethat got worse A past stroke is a significant risk factor for a future stroke Patients usually improve following stroke Deterioration common with fever or other metabolic / haemodynamic disturbance
- 11. Common differential diagnosesSOL Seizure Metabolic condition especially hypoglycaemia
- 12. Blood pressure followingCVA Rise in BP following stroke is protective Rarely want to decrease BP in acute phase Very high BP may be the cause or the effect!
- 13. Basic work-up PMH( especially risk factors, old strokes) Drugs ( risk factors, “ blood thinning” ) Vital signs including temperature! ECG Bloods for CBC, Biochemistry ( esp. glucose), ESR ? INR ? X-match
- 14. Diagnosis Clinical ismost important CT MRI in selected cases
- 15. Following diagnosis ofischaemic stroke Some patients receive immediate treatment with thrombolysis / stenting Some with suspected embolus may be started on heparin Most started on aspirin alone
- 16. Important issues followingstroke Physiotherapy Family support Identify and treat depression Prevent common complications DVT Infections ( aspiration) Pressure sores
- 17. Searching for atreatable cause Carotid duplex Cardiac echo Angiography
- 18. Secondary prevention Reducerisk factors Anticoagulants / antiplatelets Neurological follow-up
- 19. Case 55year old man with negligible risk factors for cerebrovascular disease Presented to Hadassah Ein Kerem ER with acute, progressive left-sided weakness and right-sided headache 2 days prior to admission felt sudden onset of sharp, right – sided headache associated with left arm numbness and mild articulation difficulty; resolved spontaneously over minutes On morning of admission, recurrence of sharp, severe right sided headache (without pulsatile characteristics) associated with left arm numbness and articulation difficulty
- 20. Examination Fullyconscious & orientated, no neck stiffness Speech Dysarthric Left central facial weakness - Cranial nerves otherwise intact Mild right upper limb global weakness (4/5) Power preserved in lower limbs Reflexes symmetrical with no pyramidal signs Hypoaesthesia left arm Rest of neurological examination unremarkable with no evidence of neglect
- 21. Diffusion Perfusion MismatchOn MRI Diffusion MRI Perfusion MRI
- 22.
- 23. Pre-Stent Angiography StringSign Parenchymography phase
- 24. Angioplasty and StentingPost angioplasty - aneurysm After 1st stent After 3rd stent
- 25. Comparison of preand post –stent Angiogram
- 26. Progress in EROver period of 2 hours deterioration with marked exacerbation of dysarthria and facial weakness, exacerbation of left arm weakness to 3/5 and appearance of left leg weakness 4-/5 with a left Babinski sign
- 27. Following procedure Immediatelyfollowing procedure noticeable improvement in dysarthria and left sided weakness Treatment commenced with LMW heparin, aspirin and clopidogrel. On following morning neurological examination had returned to that noted on arrival to ER: Mild dysarthria with left facial weakness Left arm 4/5 Left leg in tact
- 28. Follow – upPatient discharged on Aspirin 325mg, Clopidogrel 75mg Trans-cranial Doppler and follow-up MRA revealed patency and normal flow in all cervical arteries Follow-up MRI revealed no progression of infarct Patient responded well to rehabilitation and recovered all function being left with mild dysarthr i a, left arm sensory complaints and facial weakness
- 29. Submitted to AskTheNeurologist.Com in 2007 Author Anon.