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(A Project of National Medical Centre Karachi)

DISORDER OF NEUROLOGICAL FUNCTION.


(STROKE & TIA)

BY:
SHAHZAD BASHIR
LECTURER, NMC ION.
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OBJECTIVES.
 After the completion of this unit learners will be
able to:

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 Review the major vessels in the cerebral
circulation.

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 Review the, blood brain, & brain cerebrospinal
fluid barrier.
 Explain the degeneration of the nervous tissue
that cause alteration in cerebral blood
flow(Stroke).
 Risk factors & types of stroke.
 Transient Ischemic attacks (TIAS).

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CEREBRAL CIRCULATION

 Cerebral circulation refers to the movement of

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blood through the network of blood vessels
supplying the brain approximately 750 mL/minute.

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 The arteries deliver oxygenated blood, glucose and
other nutrients to the brain and the veins carry
deoxygenated blood back to the heart,
removing carbon dioxide, lactic acid, and other
metabolic products.
 Failure of these safeguards results
in cerebrovascular accidents, commonly known as
strokes.
 The amount of blood that the cerebral circulation
carries is known as cerebral blood flow. 3
ARTERIAL CEREBRAL CIRCULATION

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Arterial
cerebral
circulation

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Anterior Posterior
cerebral cerebral
circulation circulation

Common Vertebral
Carotid Artery 4
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FIGURE 20.20D
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TABLE 20.4 PT 1
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TABLE 20.4 PT 3
BLOOD–BRAIN AND CEREBROSPINAL
FLUID–BRAIN BARRIERS

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 Maintenance of a chemically stable environment
is essential to the function of the brain.

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 Two barriers, the blood–brain barrier and the
CSF–brain barrier, provide the means for
maintaining the stable chemical environment of
the brain.
 Only water, carbon dioxide, and oxygen enter the
brain with relative ease; the transport of other
substances between the brain and the blood is
slow.

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BLOOD–BRAIN BARRIER

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 BBB depends on the unique
characteristics of the brain
capillaries.

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 BBB is an endothelial barrier
present in capillaries that course
through the brain.
 Endothelial cells in brain differ
fundamentally from those in most
peripheral tissues in two ways:
 1.Structurally (Continuous tight
junctions).
 2.Biochemically (Some protein
which serves as a gatekeeper in
BBB)
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STRUCTURAL DIFFERENCES:

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Brain endothelial cells are coupled by tight junctions, severely restricting the
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amount of paracellular flux. Transmembrane junctional proteins, scaffolding
proteins and junction associated proteins involved in mediating the interaction
with the actin cytoskeleton.
THE BIOCHEMICAL BARRIER:

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The most important efflux transporters which so far identified at the blood–
brain barrier belong to the class of ATPbinding-cassette (ABC) transporters14
CONT……
 The blood–brain barrier permits passage of essential
substances while excluding unwanted materials.

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 Large molecules such as proteins and peptides are
largely excluded from crossing the blood–brain

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barrier.
 Acute cerebral lesions, increase the permeability of
the BBB and alter brain concentrations of proteins,
water, and electrolytes.
 Many lipid-soluble molecules cross the lipid layers of
the BBB with ease such as:
 Alcohol, Nicotine, Oxygen, Carbon dioxide
 Some drugs, such as the antibiotic chloramphenicol,
are highly lipid soluble and therefore enter the brain 15
readily.
CEREBROSPINAL FLUID–BRAIN BARRIER
 The ependymal cells covering the choroid plexus are

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linked together by tight junctions, forming a blood–
CSF barrier.
 Lipids and nonpeptide hormones diffuse through the

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barrier rather easily.
 Most large molecules, such as proteins, peptides,
many antibiotics, and other medications, do not
normally get through.
 The choroid epithelium uses (ATP) to secrete actively
many components into the CSF, including proteins,
sodium ions, and a number of micronutrients, such
as vitamins C and B6 (pyridoxine) and folate.
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CONT….
 The choroid cells also generate bicarbonate from
carbon dioxide in the blood.

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 Major function of the CSF, that of providing a
means of removal of toxic waste products from the

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CNS.
 Several specific areas of the brain do not have a
blood–CSF barrier (Fourth ventricle & walls of the
third ventricle)

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STROKE/BRAIN ATTACK
 Stroke is an acute focal neurologic deficit from an

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interruption of blood flow in a cerebral vessel due
to thrombi or emboli or to bleeding into the brain
tissue

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 Types of Stroke:
1. Ischemic stroke, (the most common type 70% to
80% of all strokes.)
2. Hemorrhagic stroke.

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RISK FACTORS
 MAJOR FACTORS:
 Age

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 Sex
 Race
Family history

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 Hypertension
 Smoking,
 Diabetes mellitus,
 Asymptomatic carotid stenosis,
 Sickle cell disease,
 Hyperlipidemia,
 Atrial fibrillation
 MINOR FACTORS:
 Obesity, Physical inactivity, Alcohol and drug abuse,
hypercoagulability disorders, Hormone replacement
therapy, and Oral contraceptive use. 19
ISCHEMIC STROKE
 Caused by cerebrovascular obstruction by

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thrombosis or emboli.

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 CLASSIFICATION OF ISCHEMIC STROKE:
 20% large artery atherosclerotic disease (both
thrombosis and arterial emboli)
 25% small vessel or penetrating artery disease
(Also-called lacunar stroke)
 20% cardiogenic embolism

 30% cryptogenic stroke (undetermined cause)

 5% other, unusual causes32 (i.e., migraine, vessel


dissection, coagulopathy). 20
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The most frequent sites of arterial and cardiac abnormalities
causing ischemic stroke.
CONTI…
 During the evolution of an ischemic stroke, there
usually is a central core of dead or dying cells

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surrounded by an ischemic band of minimally perfused
cells called a penumbra.
 Whether the cells of the penumbra continue to survive

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depends on the successful timely return of adequate
circulation.
 The realization that there is a window of opportunity
during which ischemic but viable brain tissue can be
salvaged has led to the use of thrombolytic agents in the
early treatment of ischemic stroke.

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HEMORRHAGIC STROKE
 The most frequently fatal stroke is a spontaneous

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hemorrhage into the brain substance.
 With rupture of a blood vessel, hemorrhage into the brain
tissue occurs, resulting in edema, compression of the

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brain contents, or spasm of the adjacent blood vessels.
 A cerebral hemorrhage occurs suddenly, usually when
the person is active.
 Vomiting commonly occurs at the onset, and headache
often occurs.
 PREDISPOSING FACTORS:
 Advancing age and hypertension, aneurysm, trauma,
erosion of the vessels by tumors, arteriovenous
malformations, blood coagulation disorders, vasculitis,
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and drugs
TIA (TRANSIENT ISCHEMIC ATTACK)
 A TIA is like a temporary ischemic stroke.
 An artery is temporarily blocked, preventing blood from
reaching a part of the brain less than 24 hours (usually

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less than 1 to 2 hours).
 This lack of blood flow causes that part of the brain to
stop functioning.

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 The symptoms of a TIA are the same as symptoms of an
ischemic stroke.
 In a TIA, the blood vessel opens up again, before any
permanent injury to the brain occurs and the patient
recovers completely.
 Most TIA symptoms last less than 30 minutes.
 People who suffer TIA’s are at HIGH RISK OF
STROKE soon thereafter.
 A TIA should lead to immediate medical evaluation
to determine its cause and a treatment plan to prevent
a stroke from following soon after. 24
PATHOPHYSIOLOGY
Precipitating Factors: Predisposing Factors:
-Hypertension -Life style (sedentary)
-Hyperlipidemia -Vices (Alcohol, smoke)
-Diabetes Mellitus
-Heart Diseases
VASOCONSTRICTION -Age
-Diet
-Atherosclerosis
-Sex
-Arteriosclerosis
-Heredity
-Thrombosis Blockage of the
-Severe dehydration Embolism -Self-medication
blood vessel
High blood pressure, smoking, heart diseases,
diabetes, narrowing of arteries supplying the
Lack of oxygen & Ischemic brain, high cholesterol and an unhealthy
Cerebral Ischemia nutrients supply Stroke lifestyle.

High blood pressure, smoking, and a


Subarachnoid
family history of burst aneurysms.
Hypoxia Hemorrhage
- Cell death
Severe dehydration, severe infection
Altered cerebral Venous Stroke in the sinuses of the head and medical
- Decreased
or genetic conditions that increase a
metabolism
person’s tendency to form blood clots.
Oxygen level
Decreased cerebral Large Artery
Hypertension, diabetes, smoking and
perfusion Strokes
high cholesterol levels.
Intracerebral Transient
hemorrhage Local Acidosis Ischemic Attack Same with Ischemic stroke

Cytotoxic Edema Hypertension, diabetes and smoking.


Small Artery
Stroke
PARALYSIS
Aneurysm Rupture Irregular heart beat (atrial
Embolic strokes
fibrillation), a heart attack
(myocardial infarction), heart
failure or a small hole in the heart
Brain tissue Necrosis called a PFO (Patent Foramen 25
Ovale).

DEATH Severe Cases


COMMON FEATURES OF CVA.

 Hemiperesis

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 Face asymmetry

 Dysphasia/ Aphasia

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 Dysarthia

 Limb incoordination

 Ataxia

 Vertigo

 One sided sensory symptoms.

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DIAGNOSIS AND TREATMENT

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 Complete history thorough physical and
neurologic examination.

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 Cerebral angiography

 CT-Scan

 MRI

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TREATMENT.
Physiotherapy

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 Family Supportive therapy

 Identify & treat depression

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 Prevent common complications
 DVT
 Infection (Aspiration)
 Pressure sores

 Reduce risk factors


 Neurological follow up

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REFERENCES

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 Porth, MC. (6th ED). Pathophysiology.
(2002). Philadelphia. USA. Lippincott

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Willams& Willkins, A Wolters Kluwer
Company

 McPhee, J. S., & Papadakis, A. M. (2011).


Current Medical Diagnosis and Treatment.
(50th ED). Chicago. USA: Mc Graw Hill

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