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