1. Cerebrovascular disease
Halmat M. Jaafar
(MSc. Clinical pharmacy)
Hawler Medical University/ College of Pharmacy
Department of Pharmacology

2. Out line of this lecture
What is Cerebrovascular disease?
Epidemiology.
Etiology
Classification of Cerebrovascular disease.
Causes of Cerebrovascular disease
Clinical presentation
Management of cerebrovascular disease

3. Cerebrovascular disease
Cerebrovascular disease is a broad term encompassing many disorders of the blood vessels of the central nervous system (CNS).
These disorders result from either inadequate blood flow to the brain (i.e., cerebral ischemia) with subsequent infarction of the involved portion of the CNS or hemorrhages into the parenchyma or subarachnoid space of the CNS and subsequent neurologic dysfunction.
This group of disorders is the third leading cause of deaths among adults in the United States.

4. Types of Stroke
Ischemic
Hemorrhagic

5. TRANSIENT ISCHEMIC ATTACK
A transient ischemic attack (TIA) describes the clinical condition in which a patient experiences a temporary focal neurologic deficit such as slurred speech, aphasia, weakness or paralysis of a limb, or blindness. These symptoms appear rapidly and are temporary, lasting less than 24 hours (usually only 2–15 minutes).

6. TRANSIENT ISCHEMIC ATTACK
The clinical presentation depends on the portion of the cerebrovascular tree affected by diminished or absent blood flow.
TIAs frequently result from small clots breaking away from larger, distant blood clots. These emboli are then dissolved by the fibrinolytic system, allowing re-establishment of blood flow and return of neurologic function.

7. STROKE vs TIA
Transient ischemic attack (TIA): A clinical syndrome characterized by an acute loss of focal brain or monocular function with symptoms lasting less than 24 hrs and which is thought to be due to inadequate cerebral or ocular blood supply, without ischemic changes
Stroke: Clinical syndrome characterized by an acute loss of focal brain or monocular function with symptoms lasting greater than 24 hrs and which is thought to be due to inadequate cerebral or ocular blood supply.

8. CEREBRAL INFARCTION
A cerebral infarction is a permanent neurologic disorder characterized by symptoms similar to a TIA. The patient with a cerebral infarction presents with neurological deficits caused by the death of neurons in a focal area of the brain. The two primary causes of infarction and persistent ischemia are atherosclerosis of cerebral blood vessels and an embolus to cerebral arteries from a distant clot.

9. A stable infarction describes the condition in which the neurologic deficit is permanent, will not improve, and will not deteriorate.
An improving infarction is marked by return of previously lost neurologic function over the course of several days or weeks.
A progressing infarction is one in which the patient’s neurologic status continues to deteriorate after the initial onset of focal deficits.
CEREBRAL INFARCTION

10. Ischemic Stroke 85% of strokes
Arterial occlusion of an intracranial vessel leads to hypoperfusion of the brain region it supplies
Two etiological types
Thrombotic
Embolic

11. Cerebral hemorrhage involves escape of blood from blood vessels into the brain and its surrounding structures. The leakage of blood causes clinical symptoms similar to those associated with a TIA or cerebral infarction.
In a cerebral hemorrhage, the initial neurologic deficits are attributable to the direct irritant effects of blood that is in direct contact with brain tissue.
Primary causes of a cerebral hemorrhage include cerebral artery aneurysm, arteriovenous malformation, hypertensive hemorrhage, and trauma.
The terms apoplexy, stroke, and paralytic stroke are commonly
used by laypersons to describe a sudden neurologic affliction that
usually is related to the cerebral blood supply. The term stroke
is used to describe a cerebral vascular event when neurologic
deficits persist for at least 24 hours.
CEREBRAL HEMORRHAGE

12. Primary causes of a cerebral hemorrhage include cerebral artery aneurysm, arteriovenous malformation, hypertensive hemorrhage, and trauma.
The terms apoplexy, stroke, and paralytic stroke are commonly used to describe a sudden neurologic affliction that usually is related to the cerebral blood supply.
The term stroke is used to describe a cerebral vascular event when neurologic deficits persist for at least 24 hours.
CEREBRAL HEMORRHAGE

13. Hemorrhagic Stroke Two types
Intracerebral hemorrhage(ICH)
Subarachnoid hemorrhage(SAH)
Higher mortality rates when compared to ischemic stroke

14. Annually, approximately 700,000 individuals in the United States experience a cerebral infarction, and approximately 160,000 will die as a result of the stroke.
Cerebrovascular disease is the third most common cause of death in adults and is one of the more commonly encountered causes of neurologic dysfunction
Third most common cause of death after cancer and ischeamic heart disease
EPIDEMIOLOGY

15. There are important racial and ethnic differences in incidence and mortality rates for ischemic stroke. The precise reasons for these differences are unclear, but genetic, geographic, dietary, and cultural factors have been considered.
In addition, the incidence of risk factors for stroke such as hypertension, diabetes, and hypercholesterolemia differ among racial groups.
ischemic stroke 85% is the most common type of infarction and Hemorrhagic stroke 15%.
EPIDEMIOLOGY

16. There are important racial and ethnic differences in incidence and mortality rates for ischemic stroke. The precise reasons for these differences are unclear, but genetic, geographic, dietary, and cultural factors have been considered.
In addition, the incidence of risk factors for stroke such as hypertension, diabetes, and hypercholesterolemia differ among racial groups.
United States, ischemic stroke is the mostcommontype of infarction.
EPIDEMIOLOGY

17. Primary causes of a cerebral hemorrhage include cerebral artery aneurysm, arteriovenous malformation, hypertensive hemorrhage, and trauma.
The terms apoplexy, stroke, and paralytic stroke are commonly used to describe a sudden neurologic affliction that usually is related to the cerebral blood supply.
The term stroke is used to describe a cerebral vascular event when neurologic deficits persist for at least 24 hours.
CEREBRAL HEMORRHAGE

18. management of cerbrovascular disease

19. management of cerebrovascular disease
Goals of Therapy
• The immediate goal of therapy is to reestablish adequate blood flow to affected cerebral vessels.
Longer-range objectives are to prevent reoclusion, decrease the risk of future symptomatic TIAs, and prevent cerebral infarction.
management of cerebrovascular disease

20. History
Ask for onset and progression of neurological symptoms – completed stroke or stroke in evolution
History of previous TIAs
History of hypertension & diabetes mellitus
History of heart conditions like arrhythmias & prosthetic valves
History of seizures, migraine, anticoagulant therapy& oral contraceptive use
History of any hypercoagulable disorders like sickle cell anemia & polycythemia vera
Substance abuse: cocaine, amphetamines

21. • Rapid recognition of stroke symptoms and immediate initiation of treatment are essential to
the management of ischemic or hemorrhagic stroke.
• Proper education regarding the symptoms of stroke is essential for any patient at increased risk
for stroke. Patients should be instructed to seek immediate medical attention if they experience
any weakness or paralysis, speech impairment, numbness, blurred vision or sudden vision
loss, or altered level of consciousness.
Patient Assessment

22. • Prognosis after ischemic stroke depends on factors including age, hypertension, coma, cardiopulmonary complications, hypoxia, and neurogenic hyperventilation. Neurologic deficits in
stroke patients are not considered stable or fixed until at least 8 to 12 months have elapsed.
Patient Assessment

23. Stroke Warning Signs
Sudden weakness, paralysis, or numbness of the face, arm and the leg on one or both sides of the body
Loss of speech, or difficulty speaking or understanding speech
Dimness or loss of vision, particularly in only one eye
Unexplained dizziness (especially when associated with other neurologic symptoms), unsteadiness, or sudden falls
Sudden severe headache and/or loss of consciousness

24. Symptoms

25. Investigation Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Cerebral Angiography: identify responsible blood vessel
Electrocardiogram (ECG): underlying heart conditions
Echocardiogram: blood clot from heart
Carotid Duplex: carotid artery stenosis
Heart monitors, blood work and many more tests!!
Investigation

26. primary prevention in AF

27. Drugs used in primary prevention

28. Treatment of acute stroke

29. Treatment of acute stroke

30. Treatment of hemorrhagic stroke

31. QUETIONS