Atherosclerosis Brain

Dissorders
MARSHELL TENDEAN, MD
DEPARTMENT OF INTERNAL MEDICINE
UKRIDA JAKARTA
Objective :

 To show the burden of atherosclerosis worldwide

 To describe the pathogenesis of atherosclerosis

 To emphasize the atherosclerosis burden ini cerebrovascular disease

 To emphasize the management of patient with atherosclerosis

Introduction

 Atherosclerosis is a condition in which patchy deposits of fatty material

(atheroma or atherosclerotic plaques) develop in the wall of medium
sized and large arteries, leaading to reduced or blocked blood flow.

 It’s a major cause of death and premature disability in developed

societies

 In 2020 it is estimated, atherosclerosis will become the leading global of

total disease burden.

Brain Circ 2015;1:47-52

Endothelial cell role in Atherosclerosis

 Regulation of vasular tone

 Formation of NO (nitric oxide)
 Prostacyclinis and ETS
 Maintain the composition of subendothelial matrix
 Proliferation of smooth muscle cells
 Coagulation
 Fibrinolysis
 Permeability of lipoproteins and plasma protein
 Adhesion and migration of blood cells
Nitric oxide

 A diatomic molecule that has cytoprotective and cytotoxic properites depenting on its
concentration
 The role of nitric oxide to maintain homeostasis :
 Vasodilatation
 Inhibition of platelet adhesion and aggregation
 Reduction of platelet adherence
 Inhibition of small muscle cells proliferation

Circulation Volume 109, Issue 23 suppl

Risk Factor for Atherosclerosis

 Tobaco uses
 High level of Cholesterol ini the blood
 High blood pressure
 Diabetes
 Obsesity
 Physical activity
 Diet
The Endothelial Dysfunction and
Atherosclerosis

Internet Journal of Medical Update, Vol. 4, No. 1, January 2009

 ET-1 (Endothelin 1):
 A potent vasoconstrictor and mitogen for VSMC
 ROS (Reactive Oxygen Species)
 Produced extracellulary of ROS mainly by action of angiotensin II on macrophages and
endothelial cells
 Ros production is also increased after the stimulation of endothelial cells nu TNF-alfa and
cytokines
 Hypercholesterolemia by balancing the degraddation and production of natural anti-oxidant
 ROS which produced by polymorphonuclear cells
Pathogenesis Atherosclerosis
Clinical manifestation of brain atherosclerosis

Stroke Dementia
Stroke

 It refers to cerebrovascular disorders because it affect the brain (=cerebro) and vascular (=
blood vessel)
 Stroke : Non valvular AF, stenosis of the carotid arteries, intracranial atherosclerotic
disease
 In Asia population dominated by : intracranial atherosclerotic disease

Arnillas. Stroke. 2011; 42: S20-S23

The Pathologic Change in Stroke

 The magnitude of flow reduction

 A decrease in cerebral blood flow :

 Zero causes the death of brain tissue within 4-10 minutes

 Less than16-18 mL/ 100 gr tissue cause infarction within an hour

 Less than 20 mL/ 100 g tissues per minute causes ischaemia without infaction unles sprolonged for several
hours per or day

 * Will cause hypoxemia, depletion of Glucose and ATP  cell dysfunction apoptosis and cell death
The Pathogenic change in stroke

 Ischemic stroke :
 Obstruction of the blood vessel

 Hemorrhagic stroke
 Decrease of tissue perfusion
Uncommon cause of stroke :

www.thelancet.com/neurology Vol10 May2011

 (A) Inflammatory mechanisms that promote stroke
 (B) The acute phase of inflammation after stroke
 Intracranial atherosclerotic disease (ICAD)

Types of ICAD
1. Thrombotic type
2. Embolism type
3. Hemodynamic
impair rare
4. Branch
atheromatous
disease

Journal of Stroke 2014;16(1):27-35

Major Risk Factors for ICAD

Journal of Stroke 2014;16(1):27-35

There are three therapeutic strategies for
ICAD :

1. Anti- thrombotics
2. Intervention to prevent thromboembolism
and restore blood flow, and
3. Identification and control of risk factors.
Dementia

 Group of symptoms that occur when brain is damaged by spesific disease :

 Memory problem

 Communication dificulties

 Problems understanding

 Reduced ability to concentrate

 Mood change
Vascular dementia

 Multi infarct :
 In patients who had several sttrokes which may developed chronic cognitive deficit

 Diffuse white matter disease (Binswanger’s) :

 Appears to result from chronic ischemia due to occlusive disease of small, penetrating cerebral
arteries and arterioles
Management :

 Treatment for atherosclerosis may include :

 Therapeutic lifestyle changes, medicine and medical procedures or surgery

 Follow a healthy diet :

 A healthy diet is an important part of a healthy lifesyle. Following a healthy diet can prevent of
reduce high blood pressure and high blood cholesterol and can help you maintain a healthy diet
Therapeutic livestyle changes (TLC)

 Reccomended in patient in high blood cholesterol

 TLC consist of healthy diet, physical activity and weight management

 Reccomendation :
 Less than 7% for daily calories chould come from saturated fat ( found in : some meats, dairy products, chocolate, baked
goods and deep fried and processed foods.

 No more than 25 to 35% of your daily calories should come from all fast, including saturated, trans, monosaturated, and
polysaturated fats.

 You also should have less than 200 mg a day of cholesterol

 Additional stenols or sterols

 Include fishes in diet, eg: tuna, salmon (canned or fresh and mackerel). Two fish meal
every week

 Limit ammount of sodium (Salt)

 Limit drink alcohol (calories)

 Men: not more than two drinks per day

 Woman : not more than one drinks per day

Farmacotherapy for Atherosclerosis
Controling of risk factors :

 Control of blood pressure

 Control of blood sugar

 Control of other risk factors

Medical Procedures and Surgery

 Angioplasty

 DSA (digital substraction angiography)

 Carotid end arterectomy

New Medication for Atheroslerosis
Future Treatment and Directions :

 Vaccines against atherosclerosis using antibodies against oxidized LDL

 Daraplanib an inhibitor of the enzyme Lp-PLA (lipoprotenin associated phospholipase

A2) which releases pro inflamatory molecules (lyzophosphatidilcoline) from oxidized
LDL particles

 Metothrexate
Conclusion :

 Atherosclerosis is a burden world wide.

 Determination of risk factors for atherosclerosis are detrimental.

 Atherosclerosis were manifests as cerebrovascular disease.

 Approach in changging the modifiable risk factors are main concern.