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CEREBROVSCULAR
DISEASES
By
Mohamed Saad
Professor of Neurology
Mansoura University
Cerebral arterial circulation :
Aortic arch
Common carotid
Internal carotid
M.C.A. A.C.A.
The vertebrobasilar system
Aortic arch
Subclavian Subclavian
Vertebral Vertebral
Basilar
P.C.A. P.C.A.
A., M. & P. Cerebral arteries
A.C.A. A.C.A.
P.Com.A. P.Com.A.
P.C.A. P.C.A.
V.B. A.
STROKE
70 – 80 % 0f all strokes
Pathogenesis of cerebral
infarction
Sudden thrombotic or embolic
occlusion of a cerebral artery
Causes of occlusion of a cerebral
artery :-
Cardioembolic causes(20%).
Extracranial
Intracranial
Small artery disease
Microatheroma
Lipohyalinosis
Other arteriopathies
Dissiction
Arteritis
Cardioemolic Causes
Atrial fibrillation
Mitral stenosis
Endocarditis
Myocardial infarction
Atrial myxoma
Prothetic valve
Mitral valve prolapse
Cong. heart disease
Cariomyopthy
Cardiac surgery
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Hematological disorders
Polycythemia
Thrombocythemia
Leukemia
Sickle cell disease
Hypercoagulable states
Risk factors for cerebral infarction
Increasing age
Male gender
African-American race
A prior stroke
Hypertension
Diabetes mellitus
Heart disease
TIAs
Raised hematocrite
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Modifiable risk factors
(by changing life style)
Cigarette smoking
Hyperlipidemia
Physical inactivity
Obesity
Stressful life
Clinical features of ischemic stroke
Negative in quality.
Rapidly developing.
Maximum at onset.
Focal neurological S. & S.
Caroid Vertebrobasilar
Unilat. S. & S. Unilat. Or bilat. S.& S.
e.g. +
Hemiplegia, hemihyop Disturbance of cranial
esthesia, hemianopia, nerves and cerebellum
and aphasia ( lt. sided) e.g. crossed hemiplgia
Investigations of ischemic stroke
- Transcranial doppler.
- Angiography
Prognosis depends upon :
Rehabilitation.
Prevention.
Acute treatment
Emergency care.
- Care of respiration.
- Care of circulation.
Thrombolytic therapy.
Neuroprotective therapy.
Prevention of complications.
Care of respiration
IV Labetalol or Na Nitroprusside
- Nimodipine (Nimotop).
- Naloxone (Narcan).
- Piracetam (Nootropil).
Prevention of complications
- Brain edema.
- Pneumonia.
- Seizures.
- D.V.T.
- Electrolyte disturbances.
- Pressure sores.
- Urosepsis.
- Depression
Rehabilitation
Should start as soon as the diagnosis
of stroke is established
Physiotherapy.
Speech therapy.
Occupational therapy.
Prevention of stroke recurrence
Antiplatelets.
Anticoagulants.
Carotid endarterectomy.
Antiplatelets
- Lipid lowering.
- Control of diabetes.
- Treatment of hypertension.
Transient Ischemic Attacks
(TIAs)
Acute focal loss of brain function
with symptoms lasting less than
24 hours and which is thought to
be due to inadequate cerebral
blood flow.
Pathogenesis of TIAs
Convulsions.
Symptoms of vertebrobasilar TIAs
Alternating hemiparesis or hemisensory
symptoms.
Dysartheria, dysphagia, diplopia, vertigo,
impalance, vomiting, loss of consciousness
or vital signs alterations.
Drop attacks.
Homonymus hemianopia.
Investigations of TIAs
Duplex carotid ultrasound.
Echocardiography.
Transcranial doppler.
Cerebral angiography.
Treatment of TIAs
Anticoagulants.
Antiplatelets.
Endarterectomy.
The putamin.
The thalamus.
The cerebellum.
The pons.
Clinical manifestations
- Seizures.
Manifestations related to the site of the
hematoma.
Putaminal hemorrhage
CP varies:
- From slight hemiparesis
& dysarthria.
- To sever coma and
deceribrate rigidity.
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Lobar hemorrhage
Frontal hematomas
hemiparesis more in u.l.
Parietal hematomas
sensorimotor deficit + hemianopia.
Dominant temporal hematomas
fluent aphasia.
Occipital hematomas
homonymous hemianopia.
Thalamic hemorhage
Immediate prognosis:
Grave (1/3 of the patients die in 1 to 30 days).
Late Prognosis:
Better restoration of function than ischemic stroke.
Treatment of ICH
Emergency care:
To prevent airway obstruction, hypoventilation and
aspiration.
Control of blood pressure:
Correction of bl. Pr. Is mandatory, but cautiously and slowly.
Control of intracranial pressure:
By hyperventilation, I.v. mannitol & dexamethasone
Prevention of complications:
As seizures, pneumonia, D.V.T., urosepsis, bed sores etc.
Surgical evacuation of the hematoma:
Subarachnoid hemorrhage
(SAH(
A) Spontaneous:
due to
a- Rupture of IC aneurysm.
b- Rupture of IC AVM.
B) Traumatic:
due to
Head trauma (rare cause).
Clinical picture of SAH
Premonitoring symptoms.
Onset.
Clinical manifestations.
Age and sex
- Both sexes are affected.
Usually absent or
- Periodic headache.
- Recurrent ophthalmoplegia.
- Seizures.
Onset
- Sudden.
C) Focal manifestations.
Manifestations of rapidly
increasing intracranial pressure
Headache.
Vomiting.
Change of conscious.
Convulsions.
Moderate pyrexia.
Surgical:
Excision or clipping of the aneurysm
or feeding vessel.
Embolization or radiotherapy.
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