1. Cerebrovascular diseases 1
Stroke
Cerebrovascular diseases 1
Dr. Mohammed Aziz F.I.B.M.S Neuro . 50

2. Stroke is the third largest killer.
Stroke is one of the major causes of disability, particularly in the elderly. 50

3. Approximately 800,000 people have a stroke each year
about one every 4 seconds 50

4. STROKE
Def: an episode of neurological dysfunction due to a cerebrovasculare diseases which last for more than 24hr. & reach it's peak of defecit in less than 6hr 50

5. CVAs neurological symptoms and signs usually focal acute
localized
acute
sudden onset
result from diseases involving blood vessels. ~ 50

6. 50

7. Transient ischemic attack
Transient ischemic attack TIA:
an episode of neurological dysfunction due to CVD with negative neuroimaging (DWIMRI brain). 50

8. STROKE IN EVOLUTION
An episode of neurological dysfunction due to CVD which last for more than 24hr. continues to deteriorate for more than 6hr. 50

9. Multi-infarct dementia
dementia due to multiple ischemia & infracted areas in the brain. 50

10. 50

11. 50

12. 50

13. 50

14. 50

15. 50

16. 50

17. 50

18. 50

19. 50

20. 50

21. Blood Supply of Brain Arises from aortic arch
2 common carotid arteries
(extracranial)
give rise to external & internal carotid
2 vertebral arteries ~ 50

22. Vertebral Artery Anterior spinal artery
Posterior inferior cerebellar artery 50

23. Basilar Artery Anterior inferior cerebellar artery
Superior cerebellar artery
Posterior cerebral artery
Blood supply to the thalamus, midbrain, pons, medulla, cerebellum 50

24. Types of stroke Occlusive(ischemic) stroke : Hemorrhagic stroke :
due to the closure of a blood vessel -
usually due to atherosclerosis & thrombosis.
Hemorrhagic stroke :
due to bleeding from a blood vessel
usually due to either hypertension or an aneurysm. ~ 50

25. Common Types and Incidence:
Ischemic: Incidence 80%
- mortality 40%
50% - Thrombotic – atherosclerosis
Large-vessel 30% (carotid, middle cerebral)
Small vessel 20% (lacunar stroke)
30% Embolic (heart dis / atherosclerosis)
Young, rapid, extensive.
Hemorrhage: Incidence 20%
- mortality 80%
Intracerebral
subarachnoid. 50

26. Stroke types and incidence:50

27. 50

28. 50

29. 50

30. 50

31. What"s underlying ANATOMY OF STROKE
Is the stroke in the
In the Carotid distribution
anterior circulation OR
Vertebrobasillar distribution
posterior circulation.. 50

32. What is the underlying PATHOLGY OF STROKE.
Atherosclarosis
Hypertention
Embolisation to the brain
Vasculitis
Intravascular coagulation 50

33. Atherosclerosis Is a diseases of large& medium sized A.
Atheroseclarosis starts as deposition of lipids in the subintimal layer which is a F.B for the arterial wall; therefore; fibrosis& Ca++ deposition take place . 50

34. Atherosclerosis
The intima which is move with arterial pulses now lies on stiff layer that can no more withstand the pulse pressure & thus the intimal [atheroseclarotic] ulceration results 50

35. Atherosclerosis
Platelets& fibrin deposit on those ulcers thus thrombus is formed . 50

36. Embolism formation: 50

37. Atherosclerosis
Part of which may detach forming small emboli that lodge in an A. occluding it’s lumen& then dissolve after sec. or min. that precipitating a TIA or thrombus gets larger& expands occluding the A. leading to a stroke 50

38. 50

39. Hypertensive arterial diseases
Affect small arteries & arterioles. 50

40. Hypertensive arterial diseases
This affects small arteries & arterioles which under pressure higher than normal; undergoes muscle wall hypertrophy' this make the A. withstand the pressure to a certain extend; 50

41. Hypertensive arterial diseases
if pressure is still higher; then the arteriolar wall undergoes fibrosis & necrosis; thus it no more tolerate the pressure; therefore; a microaneurysm developeds 50

42. Hypertensive arterial diseases
If the microaneurysm near area of branching; then the branch will occluded leading to infarction of the brain tissue supplied by that branch [peri-aneurysmal infarction 50

43. Hypertensive arterial diseases
Because the vessel wall is weak at the site of aneurysm; it may rupture & leak blood [peri-aneurysmal hemorrhage]. 50

44. Both cases [ischemia & hemorrhage] small pin-head sized areas of infarction are found in brain tissue; this called LACUNAE 50

45. Embolisation to the brain
Either from carotid A.
Or from the heart 50

46. Cardioembolic Sources
High Risk
Medium Risk
Low / Unclear Risk
Atrial fibrillation
Recent anterior MI
Mechanical valve
Rheumatic mitral
stenosis
Thrombus / tumor
Endocarditis
LV hypokinesia / aneurysm
Bioprostetic valve
Congestive failure
Cardiomyopathy
Patent foramen ovale
Atrial septal aneurysm 50

47. Vasculitis
It's inflammation of the vessel wall as part of a systemic diseases e.g.
SLE
Behcet disease 50

48. In travascular coagulation: [thrombophilia]
Causes
Congenital:
prot.C , S, deficiencies.
Activated prot.C resistance.
Acquired:
polycythemia rubra vera.
Essential thrombocythemia
Antiphospholipid Ab syndrome 50

49. Pathophysiology of stroke50

50. Stroke: Ischemia Insufficiency of blood supply
Glucose & O2 deprivation, build-up of wastes
NOT synonymous Anoxia:
O2 deprivation only
Few seconds: little or no damage
6-8 minutes ---> Infarction
neurons & other cells die ~ 50

51. Pathophysiology
Cerebral blood flow ( rCBF): changes after acute ischemia seen by PET scan
Normal = 40 to 50 ml/100 g/min
Necrosis <12 50

52. Pathophysiology
Ischemic Penumbra : area of stunned parenchyma surrounding the ischemic core
Area of rCBF between 12 and 22 ml/100gm/min
Has the potential for recovery ONLY if reperfusion is rapidly established 50

53. The Penumbra 50

54. Local infarction: Cell death ~ 6min central infarct area or umbra,
surrounded by a penumbra of ischemic tissue that may recover 50

55. Ischemic penumbra: 50

56. Saving penumbra area Keep BP high Good oxygenation hypothermia
Euglycemia
Keeping the brain dry 50

57. Cerebral edema 50

58. Risk factors for stroke.
Modifiable
Non modifiable 50

59. Risk factors Modifiable:
Hypertension: Most important modifiable risk factor DM
Heart disease including Atrial fibrillation
Hyperlipidemia
Cigarette Smoking 50

60. Risk factors Modifiable Excessive alcohol consumption
Cocaine and Amphetamine abuse
Previous H/O stroke or TIA
Estrogen –containing drugs e.g oral contraceptive pill
IBD & vasculitis
Sickle cell diseases
Malignancy 50

61. Risk factors Non modifiable: age Race/ethnicity
Gender : Male>Female
Post menopause : Female risk equals male
Family history 50

62. THANK YOU 50