Cerebrovascular Disease Nicholas Cascone, PA-C
Stroke – general characteristics 3 rd most common cause of death in US Higher incidence in men, blacks, geriatrics Risk factors: HTN, dyslipidemia, DM, tobacco, OCPs, EtOH 80% ischemic/20% hemorrhagic; 2/3rds of ischemic are thrombotic, rest are embolic
Stroke – clinical features Anterior circulation: Anterior cerebral artery: hemiparesis in contralateral leg > arm/face Middle cerebral artery: hemiparesis in face/arm > leg, homonymous hemianopia, aphasia if in dominant hemisphere Posterior circulation: Posterior cerebral artery: visual changes, pain if thalamic Cerebellar: ataxia, vertigo/nausea, drop attack
Stroke – clinical features Thrombotic stroke – often preceded by TIAs in same distribution Embolic stroke – abrupt, occur without warning; common sources are atrial fibrillation, valvular vegetations in endocarditis, rheumatic heart dz Hemorrhagic – largely due to HTN, deficits more diffuse and widespread
Stroke – labs and imaging Imaging: non-contrast CT to differentiate hemorrhagic from ischemic Also carotid Doppler, echocardiography, cerebral angiography, MRI EKG Lumbar puncture CBC, ESR, coagulation studies, lipids, glucose
Stroke – treatment Thrombolytic therapy within 3 to 12 hours if no contraindications Contraindications include recent bleeding, anticoagulation, HTN, increased intracranial pressure, many others Prevention of subsequent stroke: Antiplatelet therapy for thrombotic, anticoagulation for embolic Hemorrhagic: management of HTN, antiedema therapy with mannitol Endarterectomy in qualified patients with 70%+ stenosis of common/internal carotid
TIA – general characteristics More frequent in geriatrics, patients with vascular disease Sudden onset of focal neurological deficit lasting less than 24 hours 1/3 of TIA patients will have a stroke within 5 years
TIA – clinical features TIAs in carotid distribution present with muscle weakness/sensory loss, amaurosis fugax/visual changes, aphasia Carotid bruits may be present TIAs in posterovertebral distribution present with diplopia, ataxia, vertigo, CN palsies, drop attacks DDx: gerealized/partial seizure, migraine, syncope, space-occupying lesion
TIA – labs and imaging Arteriography or MRA Cardiac workup for arrhythmia/murmurs Imaging for source of embolus: echocardiography, EKG, carotid Doppler Hematologic workup for coagulopathy
TIA – treatment Thrombotic – antiplatelet therapy Embolic – anticoagulation Moderate- to high-grade carotid stenosis –endarterectomy Health maintenance – control of HTN, control of dyslipidemia, control of Afib, cessation of EtOH and tobacco
Subarachnoid hemorrhage – etiology and presentation Usually d/t ruptured berry aneurysm, occasionally d/t arteriovenous malformation Presents with “worst headache of life”, nausea/vomiting, ALOC, fever, meningeal irritation Aneurysmal leak occurs in 40%, with atypical headache, focal neurological signs
Subarachnoid hemorrhage – labs and imaging, treatment CT is initial study CSF if safe; increased opening pressure and xanthochromia or frank blood When safe, cerebral angiography to identify intact aneurysms Supportive treatment inclues bed rest, sedation, antiemetics, stool softeners, careful management of HTN