1. Cerebrovascular diseases

2. Definitions:
-Stroke :it is acute onset of neurological deficit that persist for at least 24h.
-Minor stroke : it is deficits that last for longer than 24h but resolve completely.
-stroke in evolution: actively progressing as a direct consequence of the underlying vascular disorder.
-TIA :neurological deficit that resolve completely within 24h.
Stroke either due to ischemia 85% or hemorrhage 15% .

3. Pathophysiology :
acute occlusion of an intracranial vessel causes reduction in blood flow, fall in CBF to zero lead to death of tissue within 4-10 min. tissue surrounding the core region of infarction is ischemic but reversibly dysfunction and referred to ischemic penumbra . Saving the ischemic penumbra is the goal of thrombolytic therapy .

4. Risk factors : -nonmodifiable: modifiable -Age -Hypertension -Sex -D.M
-Race ethnicity Smoking
-Hereditary Alcohol Intake
-Obesity
-Drugs abuse
-Food intake

5. Causes : -common causes:
-Thrombosis : lacunars stroke -large vessel stroke -dehydration
-Embolic occlusion: -artery to artery like carotid bifurcation and aortic arch.
Cardioembolic : AF, mural thrombus, MI, dilated cardiomyopathy,

6. Uncommon causes: -hypercoagulable diseases. -venous sinus thrombosis.
-fibromuscular dysplagia.
-vasculitis.
-Cardiogenic
-drugs.
-moya-moya disease.
-eclampsia.

7. Clinical manifestations :
-1-Middle cerebral art. Stroke: it is the commonest art. Involved by imbolic rather than thrombosis.
-A- superior division stroke:
-contralateral hemiparesis contralateral hemisensory loss.
-no homonymous hemianopia expressive aphasia if dominant.
-B-inferior division stroke:
-contralateral homonymous hemianopia.
-agraphesthasia &asteriognosis.
-anosognosia.
-neglect contralateral space &limb.
-wernicke aphasia if dominant.
-acute confusion.
-C- stem of MCA:
-contralateral hemiplegia & sensory loss affecting face, arm &leg.
-global aphasia.

8. -2- ACA stroke: -4-PCA syndrome: -impaired maturation center.
-contralateral paralysis & sensory loss affecting the leg.
-impaired maturation center.
-contralateral grasp reflex & sucking R.
-abulia.
-3-internal carotid art. Stroke:
-one fifth of ischemic stroke.
-may be asymptomatic.
-symptomatic similar to that of MCA stroke.
-4-PCA syndrome:
-homonymous hemianopia with or without macular sparing.
-anomic aphasia.
-alexia without agraphia.
-Visual agnosia.
-Cortical blindness.
-memory impairment.
-prosognosia.

9. -5- Basilar art. Syndrome :
-brief anatomy.
-hemiplegia or quadriplegia coma is common.
-unilateral or bilateral 6th N. palsy.
-locked in syndrome unilateral or bilateral 3th N.palsy.
Paralysis upward or downward gaze.
-6-PICA syndrome :
-epsilateral cerebellar ataxia horner syndrome.
-facial sensory loss nausea & vomiting.
-nystagmus vertigo.
-contralateral loss pain &tempru dysphasia & dysartheria
-excessive salivation .
-7- Associated symptome :
-seizures.
-headache.

10. Small vessel stroke:
-lipohyalinotic or atherothrobotic occlusion of small art.
-Hypertention & age .
-20% of all stroke.
-1-pure motor hemiparesis:
-2-pure sensory stroke:
-3-ataxic hemiparesis:
-4-dysarthria-clumsy hand syndrome:
-5-pure motor hemiparesis & brocas aphasia:

11. Investigative studies :
-A- blood tests :
1-blood count.
2-ESR.
3-serology for syphilis.
4-RBS.
5-serum lipids.
-B-ECG.
-C-echo study.
-D-CT or MRI:
-E-carotid Doppler.
-F-LP.
-G-Angiography.
-H-EEG.

12. DDx: 1-vascular disorders: 2-structural brain lesion: 3-metabolic:
-ICH
-SAH
-subdural or epidural hematoma.
-saggital sius thrombosis.
2-structural brain lesion:
-tumors.
-abscess.
3-metabolic:
-hypoglycemia.
-hyperosmolar nonketotic hyperglycemia.

13. Treatment:
1-medical support: the immediate goal is to optimize cerebral perfusion in the surrounding ischemic penumbra.
1-Blood pressure: when 220/120 mmhg ??
2-Glucose: <11.1mml/L (200mg/dl).
3-Fever.
4-Prevent complicaion:
5-Antiedema drugs:
2-Thrombolysis: rTPA.
-Indications:
-C/I:
3-Anticoagulation:

14. -A-symptomatic carotid stenosis.
4-Antiplatelets:
-aspirin.
-ticlopidine &clopidogrel.
-compination.
5-surgical therapy:
-A-symptomatic carotid stenosis.
-B-asymptomatic carorid stenosis.
6-Rehabilitation:
1-early physical therapy.
2-speech therapy.
3-education of pat. &family.
4-prevente complication of immobility.

15. Intracranial hemorrhage:
-it is classified by their location & the underlying vascular pathology.
-it is incidence 15% of CVA.
Causes:
1-head trauma.
2-hypertensive H.
3-transformation of prior stroke.
4-metastatic brain tumor.
5-coagulopathy.
6-drugs.
7-AVM.
8-aneurysm.
9-amyliod angiopathy.
10-vasculitis.
11-vasculopathy.
12-cavernous angioma.

16. Risk factors: -age. higher in young subjects. -male gender.
-hypertension.
-DM.
-smoking.
-high alcohol intake.
-very low cholesterol <160mg/dl.

17. Pathophysiology: ICH has 3 main phases.
-arterial rupture & hematoma formation.
-haematoma enlargement.
-peri-hematoma oedema.
-ICH result from rupture of small penetrating art.
-early oedema is due to the vasogenic oedema. peak 4-5 days.
-delayed oedema is both vasogenic &cytotoxic. Last 2-4weeks.

18. Diagnosis : 1-Imaging noncontrast CT. 2-Routine investigation.
-CBP & ESR B. urea. & creatinine.
-Electrolyte S. cholesterol.
-PT & PTT ECG.
-U/S.
3-If young patients. Send to the following.
-ANA & antidouble strand DNA.
-Antiphospholipid ABS.
-VDRL.
4- EEG.

19. Treatment: 1-admition to stroke unit.
2-reducing ICH Mannitol Steriod.
3-hdrocephalus.
4-cerebellar hematoma >3cm.
5-large lobar hematoma.
6-hypertension BP >180/105mmhg.
7-seizures.
8-prevention of aspiration Nasogastic tube.
9-prevention of complication .
10-hematoma growth.

20. Hypertensive hemorrhage:
-brief pathophysiolgy.
-common sites in order. Putamen, thalamus, deep ceebellum & pons.
-almost occurs when the patients are awake &stressed.
-develop over 30-90min.
-abrupt onset of focal neurological deficits.
Thalamic hemorrhage :
-contralateral hemipligia &hemisensory loss.
-horner syndrome .
-homonymous field defect.
-Paralysis of vertical gaze.
-absent of light R.
-absence of convergence.

21. Cerebellar hemorrhage:
Pontine hemorrhage:
-occurs over min.
-deep coma.
-quadriplegia.
-pin-piont pupils.
-hyperpyrexia.
-severe hypertension.
-hyperpnea & hyperhydrosis.
-impiarment of dolls maneuver.
Cerebellar hemorrhage:
-usually develop over h.
-occipital headache &vomiting.
-dizziness &vertigo.
-ataxia of giat.
Impaired of gaze.
-dysartheria & dysphagia.

22. SAH: Clinical manifestations:
-excluding head trauma the most common cause of SAH is rupture of aneurysm.
-saccular aneurysm occurs in 2% of adults .
-the most common location are terminal ICA, MCA bifurcation, & top of basilar art.
-mycotic aneurysm.
Clinical manifestations:
-most unruptured aneurysm are completely asymptomatic.
-the hallmark feutures.
-sudden onset loss of coniousness.
-neck stiffness &vomiting.
-cranial N. palsy.
-subhyliod hemorrhage.
-hemiparesis, aphasia &abulia.

23. Delayed neurological deficits:
1-Rerupture:
2-Hydrocephalus:
3-Vasospasm:
4-Hyponatremia:
Laboratory evaluation & Imaging:
-the hallmark is blood in the CSF.
-noncontrast CT of brain.
-if CT fail , LP done.
-what are the finding of CSF.
-four vessel angiography.
-ECG finding.
-monitoring of electrolytes.

24. Tretment: -Early aneurysm repair prevent rerupture.
-protecting the airway.
-managing BP.
-treat vasospasm.
-decrease raised ICP.
-bed rest in quiet room & given stool softeners.
-treat seizures.
-managing hyponatremia.
-prevent of complication.
-neurosurgical consultation.