Cerebrovascular Accident

It is the rapidly developing loss of brain functions due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. Strokes can be classified into two major categories: ischemic and hemorrhagic. Ischemic strokes are those that are caused by interruption of the blood supply, while hemorrhagic strokes are the ones which result from rupture of a blood vessel or an abnormal vascular structure. About 87% of strokes are caused by ischemia, and the remainder by hemorrhage. Some hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"). It is unknown how many hemorrhages actually start as ischemic stroke.

Ischemic stroke
In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: 1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally)

These four entities predict the extent of the stroke. no cause identified. the stroke episode is classified as total anterior circulation infarct (TACI). also known as the Bamford or Oxford classification) relies primarily on the initial symptoms. The Oxford Community Stroke Project classification (OCSP. There are various classification systems for acute ischemic stroke. (3) occlusion of a small blood vessel. on this basis. 3. Hemorrhagic stroke Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. in shock) 4. e.2. Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin).g. this constitutes 30-40% of all ischemic strokes. Systemic hypoperfusion (general decrease in blood supply. a stroke is classified as being due to (1) thrombosis or embolism due to atherosclerosis of a large artery. lacunar infarct (LACI) or posterior circulation infarct (POCI). the underlying cause. partial anterior circulation infarct (PACI). (4) other determined cause. the area of the brain affected. Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular . (2) embolism of cardiac origin. A distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the brain). Embolism (obstruction due to an embolus from elsewhere in the body. based on the extent of the symptoms. Venous thrombosis. (5) undetermined cause (two possible causes. see below). The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is based on clinical symptoms as well as results of further investigations. or incomplete investigation). and the prognosis.

g. Most forms of stroke are not associated with headache. corticospinal tract. and dorsal column (medial lemniscus). in intracranial hemorrhage. SIGNS AND SYMPTOMS Stroke symptoms typically start suddenly. symptoms may include: y y y hemiplegia and muscle weakness of the face numbness reduction in sensory or vibratory sensation . Subtypes: If the area of the brain affected contains one of the three prominent central nervous system pathways³the spinothalamic tract. over seconds to minutes. subdural hematoma (in the subdural space) and subarachnoid hemorrhage (between the arachnoid mater and pia mater). The main types of extra-axial hemorrhage are epidural hematoma (bleeding between the dura mater and the skull). For example. Most of the hemorrhagic stroke syndromes have specific symptoms (e. the more functions that are likely to be lost.system). apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage. headache. The symptoms depend on the area of the brain affected. previous head injury). Some forms of stroke can cause additional symptoms. the affected area may compress other structures. and in most cases do not progress further. The more extensive the area of brain affected.

In most cases. Depending on the part of the brain affected. taste. In addition to the above CNS pathways. pupil reactivity to light decreased sensation and muscle weakness of the face balance problems and nystagmus altered breathing and heart rate weakness in sternocleidomastoid muscle with inability to turn head to one side y weakness in tongue (inability to protrude and/or move from side to side) If the cerebral cortex is involved. However. swallow. the brainstem also consists of the 12 cranial nerves. hearing. the CNS pathways can again be affected. but also can produce the following symptoms: y aphasia (inability to speak or understand language from involvement of Broca's or Wernicke's area) y y y y apraxia (altered voluntary movements) visual field defect memory deficits (involvement of temporal lobe) hemineglect (involvement of parietal lobe) . since these pathways also travel in the spinal cord and any lesion there can also produce these symptoms. or vision (total or partial) drooping of eyelid (ptosis) and weakness of ocular muscles decreased reflexes: gag. A stroke affecting the brain stem therefore can produce symptoms relating to deficits in these cranial nerves: y y y y y y y altered smell. the presence of any one of these symptoms does not necessarily indicate a stroke. the defect in the brain is usually on the opposite side of the body. the symptoms affect only one side of the body (unilateral).

especially metallothionein. Intriguingly. usually strokerelated. headache. these cells can be saved. the patient may have the following: y y y trouble walking altered movement coordination vertigo and or disequilibrium  PATHOPHYSIOLOGY Neurons and glia die when they no longer receive oxygen and nutrients from the blood or when they are damaged by sudden bleeding into or around the brain. Drugs that buffer the zinc and reduce the level of free zinc are already being tested to reduce brain cell death after stroke. . deficit) If the cerebellum is involved.  ASSOCIATED SYMPTOMS Loss of consciousness. These damaged cells can linger in a compromised state for several hours. This released zinc is a major player in the ensuing death of the brain cells. hypersexual gestures (with involvement of frontal lobe) y anosognosia (persistent denial of the existence of a. they begin to fill up with free zinc ions which are released from some of their proteins. which can release 7 zinc ions per molecule. With timely treatment. when the brain cells suffer the ischemia. and vomiting usually occurs more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing the brain.y disorganized thinking. confusion.

If symptoms are maximal at onset. . the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke.

however in physiological terms.Deahydration Dehydration is defined as an excessive loss of body fluid. The former can lead to seizures. hypertonic or hypernatremic (primarily a loss of water). despite the name. There are three main types of dehydration: hypotonic or hyponatremic (primarily a loss of electrolytes. as water and solutes (mainly sodium) are usually lost in roughly equal quantities to how they exist in blood plasma. and isotonic or isonatremic (equal loss of water and electrolytes). It is literally the removal of water from an object. the most commonly seen type of dehydration by far is isotonic (isonatraemic) dehydration which effectively equates with hypovolemia. intravascular water shifts to the extravascular space. dehydration. sodium in particular). but the distinction of isotonic from hypotonic or hypertonic dehydration may be important when treating people who become dehydrated. . does not simply mean loss of water. Neurological complications can occur in hypotonic and hypertonic states. while the latter can lead to osmotic cerebral edema upon rapid rehydration. exaggerating intravascular volume depletion for a given amount of total body water loss. In humans. Physiologically. it entails a deficiency of fluid within an organism. In hypotonic dehydration.

dizziness when standing due to orthostatic hypotension. swelling of the tongue and. Blood tests may show hyperalbuminemia. unconsciousness. and sunken eyes. elevated body temperatures. Dehydration symptoms generally become noticeable after 2% of one's normal water volume has been lost. Mild dehydration also has been shown to negatively impact people·s moods. and rapid onset of fatigue. decreased urine volume. low endurance. there may be no urine output at all. possibly along with loss of appetite and dry skin. . irritability. SIGNS AND SYMPTOMS Symptoms may include headaches similar to what is experienced during a hangover. which includes water losses between 1% and 2%. one experiences thirst and discomfort. Initially. lack of tears when crying. abnormally dark urine. decreased blood pressure (hypotension). fainting. a sudden episode of visual snow. dry mouth. Athletes may suffer a loss of performance of up to 30% and experience flushing. and dizziness or fainting when standing up due to orthostatic hypotension. In moderate to severe dehydration. fatigue. observed in the experiment are comparable to mild dehydration experienced by people in their everyday lives. sunken fontanel (soft spot) in infants. rapid heart rates. Experiments by the USDA's Agricultural Research Service has shown that dehydration is associated with confusion. headache. and negative moods. Symptoms of mild dehydration include thirst. in extreme cases. unexplained tiredness. death. muscle cramps (especially leg cramps). Other symptoms in these states include lethargy or extreme sleepiness. Mild dehydration. This can be followed by constipation. and in some cases can cause insomnia. Untreated dehydration generally results in delirium. seizures.

and may feel tingling in one's limbs (paresthesia).The symptoms become increasingly severe with greater water loss. dehydration can be caused by a wide range of diseases and states that impair water homeostasis in the body. one may become groggy or sleepy. while body temperature may rise because of decreased sweating. These include: . experience headaches or nausea.  DIFFERENTIAL DIAGNOSIS In humans. Numerous studies have shown that for terminally ill patients who choose to die. when supplemented with adequate pain medication. urination will be greatly reduced and may become painful. One's heart and respiration rates begin to increase to compensate for decreased plasma volume and blood pressure. At around 5% to 6% water loss. and delirium may begin. In people over age 50. the body·s thirst sensation diminishes and continues diminishing with age. Many senior citizens suffer symptoms of dehydration. Dehydration along with hyperthermia results in old people dying during extreme hot weather. dehydration becomes the major problem in an otherwise selflimited illness. muscles may become spastic. Losses greater than 15% are usually fatal. deaths by terminal dehydration are generally peaceful and not associated with suffering. Diseases of the gastrointestinal tract can lead to dehydration in various ways. Often. vision may dim. Fluid loss may even be severe enough to become lifethreatening. skin may shrivel and wrinkle (decreased skin turgor). With 10% to 15% fluid loss.

g. amphetamine.[9] o Patient refusal of nutrition and hydration .. especially in a hot and/or dry environment o Prolonged exposure to dry air. caffeine and other stimulants o Excessive consumption of alcoholic beverages y Infectious diseases o o o o Cholera Gastroenteritis Shigellosis Yellow fever y Malnutrition o Electrolyte disturbance   Hypernatremia (also caused by dehydration) Hyponatremia. e.2 lb)).y External or stress-related causes o Prolonged physical activity with sweating without consuming adequate water. especially from restricted salt diets o o Fasting Recent rapid weight loss may reflect progressive depletion of fluid volume (the loss of 1 L of fluid results in a weight loss of 1 kg (2. in high-flying airplanes (5%² 12% relative humidity) o o o o o o o o Blood loss or hypotension due to physical trauma Diarrhea Hyperthermia Shock (hypovolemic) Vomiting Burns Lacrimation Use of methamphetamine.

or fluid shift (ascites. and capillary leak states such as burns and sepsis). As dehydration progresses. the more water must be consumed to replace it and avoid dehydration. increased output (renal. The decrease in total body water causes reductions in both the intracellular and extracellular fluid volumes. effusions. especially in diabetes mellitus o o Glycosuria Uremia y y y Diabetes insipidus Acute emergency dehydration event Foodborne illness  PATHOPHYSIOLOGY The negative fluid balance that causes dehydration results from decreased intake. hypovolemic shock ultimately ensues. GI. resulting in end organ failure and death. consumption of water .  PREVENTION Dehydration is best avoided by drinking sufficient water. or insensible losses). Since the body cannot tolerate large deficits or excesses in total body water. Clinical manifestations of dehydration are most closely related to intravascular volume depletion. The greater the amount of water lost through perspiration.o Inability to swallow (obstruction of the oesophagus) Other causes of obligate water loss y Severe hyperglycemia.

This is particularly true in hot environments or for those older than 65. one should also be drinking some water frequently). A person's body. the water loss can increase by an order of magnitude or more through perspiration. through the skin by perspiration (100ml) and by diffusion through the skin (350ml). all of which must be promptly replaced. Drinking water beyond the needs of the body entails little risk when done in moderation. it is not possible to drink enough water to stay hydrated. the losses may be great enough to exceed the body's ability to absorb water from the gastrointestinal tract. if one is perspiring. or through the kidneys as urine (1000-2000ml. to determine how much fluid is lost during the workout. in these cases. during an average day in a temperate climate such as the United Kingdom.5 litres of water. during exercise. a move to a cooler environment. drinking when one is thirsty is sufficient to maintain hydration. since the kidneys will efficiently remove any excess water through the urine with a large margin of safety. For an exercise session.must be roughly concurrent with the loss (in other words. In extreme cases. relying on thirst alone may be insufficient to prevent dehydration from occurring. about 900ml of which is obligatory water excretion that gets rid of solutes). Some water (about 150-200ml. however. This can be through the lungs as water vapor (about 350ml). In warm or humid weather or during heavy exertion.) . loses approximately 2. etc. and the only way to avoid dehydration is to either pre-hydrate or find ways to reduce perspiration (through rest. an accurate determination of how much fluid is necessary to consume during the workout can be made by performing appropriate weight measurements before and after a typical exercise session. For routine activities in which a person is not perspiring to any large degree. in the absence of diarrhea) is also lost through the bowels. However.

When large amounts of water are being lost through perspiration and concurrently replaced by drinking. inhibiting the thirst mechanism before solute levels can be replenished. Plain water restores only the volume of the blood plasma.  TREATMENT The treatment for minor dehydration often considered the most effective is drinking water and stopping fluid loss. correction of a dehydrated state is accomplished by the replenishment of necessary water and electrolytes (rehydration.A useful rule of thumb for avoiding dehydration in hot or humid environments or during strenuous activity involves monitoring the frequency and character of urination. if urine is deeply colored or urination occurs only after many hours or not at all. Solid foods can contribute to fluid loss from vomiting and diarrhea. chances are that dehydration is not occurring. If water is being lost through mechanisms such as vomiting or diarrhea. an imbalance can develop very quickly into a medical emergency. During sports events such as marathons. maintaining proper electrolyte balance becomes an issue. athletes take frequent water stops and water breaks to avoid dehydration. water intake may not be adequate to maintain proper hydration. through . Drinking fluids that are hypertonic or hypotonic with respect to perspiration may have grave consequences (hyponatremia or hypernatremia. In more severe cases. principally) as the total volume of water turnover increases. If one develops a full bladder at least every 3²5 hours and the urine is only lightly colored or colorless.

it is the treatment of choice for mild dehydration. Pure water injected into the veins will cause lysis of erythrocytes. Fluids containing a proper balance of replacement electrolytes are given orally or intravenously with continuing assessment of electrolyte status. Solutions used for intravenous rehydration must be isotonic or hypotonic. Some research indicates that artificial hydration to alleviate symptoms of dry mouth and thirst in the dying patient may be futile. As oral rehydration is less painful. In the case of serious lack of fresh water (e. and easier to provide.g.oral rehydration therapy or fluid replacement by intravenous therapy). at sea or in a desert). complete resolution is the norm in all but the most extreme cases. nor does the consumption of alcohol. . drinking seawater or urine does not help. less expensive. For severe cases of dehydration where fainting. or other severely inhibiting symptom is present (the patient is incapable of standing or thinking clearly).. emergency attention is required. less invasive. unconsciousness.

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